What is heartburn worth? A cost-utility analysis of management strategies

OBJECTIVE: To determine the best treatment strategy for the management of p atients presenting with symptoms consistent with uncomplicated heartburn. METHODS: We performed a cost-utility analysis of 4 alternatives: empirical proton pump inhibitor, empirical histamine,receptor antagonist, and diagnos tic strategies consisting of either esophagogastroduodenoscopy (EGD) or an upper gastrointestinal series before treatment. The time horizon of the mod el was 1 year. The base case analysis assumed a cohort of otherwise healthy 45-year-old individuals in a primary care practice. MAIN RESULTS: Empirical treatment with a proton pump inhibitor was projecte d to provide the greatest quality-adjusted survival for the cohort. Empiric al treatment with a histamine, receptor antagonist was projected to be the least costly of the alternatives. The marginal cost-effectiveness of using a proton pump inhibitor over a histamine(2)-receptor antagonist was approxi mately $10,400 per quality-adjusted life year (QALY) gained in the base cas e analysis and was less than $50,000 per QALY as long as the utility for he artburn was less than 0.95. Both diagnostic strategies were dominated by pr oton pump inhibitor alternative. CONCLUSIONS: Empirical treatment seems to be the optimal initial management strategy for patients with heartburn, but the choice between a proton pump inhibitor or histamine,receptor antagonist depends on the impact of heartb urn on quality of life.