Gambling with gastroesophageal reflux disease: should we worry about the QALY?

The gain in quality-adjusted life months by switching to esomeprazole in those with continued reflux symptoms in primary care: EncomPASS--a cluster-randomized trial

OBJECTIVES

Proton pump inhibitors (PPIs) are effective in gastroesophageal reflux disease (GERD), but their cost effectiveness is unknown. This is usually determined by cost/quality-adjusted life year (QALY) gained, but whether PPI therapy improves QALYs has not been assessed in a randomized trial. The PPI acid suppression symptom (PASS) test is a five-item questionnaire that identifies patients with persistent acid-related symptoms. We evaluated whether a PASS test-based management strategy of changing GERD therapy to esomeprazole in those with continued symptoms on another PPI or H(2) receptor antagonist therapy would be cost effective. We expressed the data in terms of cost per quality-adjusted life months (QALM), as this was a 4-week trial.

METHODS

This is a multicenter, cluster-randomized, open-label study in primary care physician centers across Canada. Primary care physician centers were randomized to intervention or control arms. Patients on acid-suppressing medication were identified from primary care records and asked to complete the PASS test. PASS test failures at baseline assessment continued current therapy in control practices or switched to esomeprazole 20 or 40 mg daily (the dose was at the clinician's discretion) for 4 weeks in intervention practices. A planned secondary end point was QALM gain, measured using the validated Euroqol (EQ-5D) completed at baseline and 4 weeks. Medication use was also assessed by questionnaire. Canadian unit generic costs were applied to all GERD drugs, except to esomeprazole and lansoprazole, wherein proprietary costs were used (all costs in Canadian $). Data were analyzed using bootstrap sampling.

RESULTS

A total of 1,564 patients were recruited from 134 intervention sites and 92 control sites. Data were evaluable for 808 intervention and 445 control patients. The mean (±standard deviation) QALM at 4 weeks in the intervention group was 0.885±0.164 compared with 0.814±0.179 in the control group, resulting in a mean 0.071 (95% CI=0.091-0.051) QALM gain (P<0.0001). Esomeprazole was cost effective for PASS test failures, with a mean cost of $763 (95% CI=456-1,414) per QALM gain.

CONCLUSIONS

Esomeprazole was associated with a statistically significant gain in QALMs and was cost effective in primary care patients with persistent acid-related symptoms identified by the PASS test.

The health economics of Helicobacter pylori infection

Economic considerations are becoming increasingly important as health care becomes more expensive. Evidence for effectiveness is usually gained from randomised controlled trials (RCTs) but often there is insufficient evidence of the costs of alternative strategies in trials. Often, therefore, economic models are needed to extrapolate data from a variety of sources to give an indication of which strategy is cost effective. Helicobacter pylori (H. pylori) testing and treating in a wide variety of upper gastrointestinal diseases is a good example of the application of economic analyses to health care interventions. H. pylori eradication in peptic ulcer disease is very effective with systematic reviews giving a number needed to treat of around two compared to no therapy. RCTs have also suggested that treating H. pylori is also more effective and less expensive than continuous H(2) receptor antagonist therapy and is therefore the dominant strategy in treating peptic ulcer disease. The impact of H. pylori eradication in infected patients with functional dyspepsia is less dramatic, with systematic reviews suggesting a number needed to treat of 14. Economic models suggest that in Europe H. pylori eradication is cost-effective compared to offering no treatment (e.g. in the UK we can be 95% certain this approach is cost effective if you are willing to pay $51/month free from dyspepsia). In the USA it is less certain that this is a cost-effective approach due to the higher cost of eradication therapy. H. pylori test and treat has been proposed as an alternative to early endoscopy in patients with uninvestigated dyspepsia. We have conducted an individual patient data meta-analysis of five RCTs that has addressed the cost effectiveness of this approach. Endoscopy was slightly more effective than H. pylori test and treat at relieving dyspepsia at one year but was not cost-effective as it cost $9000/dyspepsia cure at one year. Population H. pylori test and treat has been proposed as a strategy to prevent noncardia gastric cancer. RCTs have suggested this approach may be cost saving but more data are needed on whether H. pylori eradication will reduce gastric cancer mortality before this strategy can be recommended.