A cost-effectiveness analysis of prescribing strategies in the management of gastroesophageal reflux disease

OBJECTIVE: Patients who have uncomplicated gastroesophageal-reflux disease (GERD) typically present with heartburn and acid regurgitation. We sought t o determine the cost-effectiveness of H-2-receptor antagonists (H2RAs) and proton-pump inhibitors (PPIs) as first-line empiric therapy for patients wi th typical symptoms of GERD. METHODS: Decision analysis comparing costs and benefits of empirical treatm ent with H2RAs and PPIs for patients presenting with typical GERD was emplo yed. The six treatment arms in the model were: 1) Lifestyle therapy, includ ing antacids; 2) H(2)RA therapy, with endoscopy performed if no response to H2RAs; 3) Step up (H(2)RA-PPI) Arm: H(2)RA followed by PPI therapy in the case of symptomatic failure; 4) Step down arm: PPI therapy followed by H(2) RA if symptomatic response to PPI, and antacid therapy if response to H(2)R A therapy; 5) PPI-on-demand therapy: 8 wk of treatment for symptomatic recu rrence, with no more than three courses per year; and 6) PPI-continuous the rapy. Measurements were lifetime costs, quality-adjusted life years (QALYs) gained, and incremental cost effectiveness. RESULTS: Initial therapy with PPIs followed by on-demand therapy was the mo st cost-effective approach, with a cost-effectiveness ratio of $20,934 per QALY gained for patients with moderate to severe GERD symptoms, and $37,923 for patients with mild GERD symptoms. This therapy was also associated wit h the greatest gain in discounted QALYs. The PPI-on-demand strategy was mor e effective and less costly than the H(2)RA followed by PPI strategy or the other treatment arms. The results were not highly sensitive to cost of the rapy, QALY adjustment from GERD symptoms, or the success rate of the lifest yle arm. However, when the success rate of the PPI-on-demand arm was less t han or equal to 59%, the H(2)RA-PPI arm was the preferred strategy. CONCLUSION: For patients with moderate to severe symptoms of GERD, initial treatment with PPIs followed by on-demand therapy is a cost-effective appro ach. (C) 2000 by Am. Cell. of Gastroenterology.