Cost effectiveness of omeprazole and ranitidine in intermittent treatment of symptomatic gastro-oesophageal reflux disease

Prioritizing health system and disease burden factors: an evaluation of the net benefit of transferring health technology interventions to different districts in Zimbabwe

INTRODUCTION

Health-care technologies (HCTs) play an important role in any country's health-care system. Zimbabwe's health-care system uses a lot of HCTs developed in other countries. However, a number of local factors have affected the absorption and use of these technologies. We therefore set out to test the hypothesis that the net benefit regression framework (NBRF) could be a helpful benefit testing model that enables assessment of intra-national variables in HCT transfer.

METHOD

We used an NBRF model to assess the benefits of transferring cost-effective technologies to different jurisdictions. We used the country's 57 administrative districts to proxy different jurisdictions. For the dependent variable, we combined the cost and effectiveness ratios with the districts' per capita health expenditure. The cost and effectiveness ratios were obtained from HIV/AIDS and malaria randomized controlled trials, which did either a prospective or retrospective cost-effectiveness analysis. The independent variables were district demographic and socioeconomic determinants of health.

RESULTS

The study showed that intra-national variation resulted in different net benefits of the same health technology intervention if implemented in different districts in Zimbabwe. The study showed that population data, health data, infrastructure, demographic and health-seeking behavior had significant effects on the net margin benefit for the different districts. The net benefits also differed in terms of magnitude as a result of the local factors.

CONCLUSION

Net benefit testing using local data is a very useful tool for assessing the transferability and further adoption of HCTs developed elsewhere. However, adopting interventions with a positive net benefit should also not be an end in itself. Information on positive or negative net benefit could also be used to ascertain either the level of future savings that a technology can realize or the level of investment needed for the particular technology to become beneficial.

Cost minimization of on-demand maintenance therapy with proton pump inhibitors in nonerosive gastroesophageal reflux disease

On-demand proton pump inhibitor maintenance therapy is one of the suggested strategies for patients with nonerosive gastroesophageal reflux disease who achieve symptom remission after 4 weeks of continuous treatment. This review evaluates the difference in cost and quality of life of six on-demand proton pump inhibitor maintenance strategies in patients with nonerosive gastroesophageal reflux disease. This was performed by decision analysis and Markov modeling of costs (from the perspective of the healthcare service and society) and utility up to 12 months. Median utility scores associated with each proton pump inhibitor ranged from 0.731 to 0.745 quality-adjusted life years and were not statistically different. Annual expected cost, however, was statistically different among the different drugs and the following cost-minimization ranking was obtained for median costs to the healthcare service and society, respectively: rabeprazole (euro 181, euro 295), pantoprazole (euro 223, euro 341), lansoprazole (euro 249, euro 370), omeprazole 10 mg (euro 297, euro 412), esomeprazole (euro 295, euro 419) and omeprazole 20 mg (euro 405, euro 528). Unit cost of proton pump inhibitors was the major determinant of cost to the healthcare service, while the number of productivity days lost due to symptoms was the major determinant of cost to society. In Italy, on-demand use of rabeprazole for maintenance therapy of nonerosive gastroesophageal reflux disease incurs the least cost in comparison with the other proton pump inhibitors evaluated.

WITHDRAWN: Initial management strategies for dyspepsia

BACKGROUND

This review considers management strategies (combinations of initial investigation and empirical treatments) for dyspeptic patients. Dyspepsia was defined to include both epigastric pain and heartburn.

OBJECTIVES

To determine the effectiveness, acceptability, and cost effectiveness of the following initial management strategies for patients presenting with dyspepsia (a) Initial pharmacological therapy (including endoscopy for treatment failures). (b) Early endoscopy. (c) Testing for Helicobacter pylori (H. pylori )and endoscope only those positive. (d) H. pylori eradication therapy with or without prior testing.

SEARCH STRATEGY

Trials were located through electronic searches and extensive contact with trialists.

SELECTION CRITERIA

All randomised controlled trials of dyspeptic patients presenting in primary care.

DATA COLLECTION AND ANALYSIS

Data were collected on dyspeptic symptoms, quality of life and use of resources. An individual patient data meta-analysis of health economic data was conducted

MAIN RESULTS

Twenty-five papers reporting 27 comparisons were found. Trials comparing proton pump inhibitors (PPI) with antacids (three trials) and histamine H2-receptor antagonists (H2RAs) (three trials), early endoscopy with initial acid suppression (five trials), H. pylori test and endoscope versus usual management (three trials), H. pylori test and treat versus endoscopy (six trials), and test and treat versus acid suppression alone in H. pylori positive patients (four trials), were pooled. PPIs were significantly more effective than both H2RAs and antacids. Relative risks (RR) and 95% confidence intervals (CI) were; for PPI compared with antacid 0.72 (95% CI 0.64 to 0.80), PPI compared with H2RA 0.63 (95% CI 0.47 to 0.85). Results for other drug comparisons were either absent or inconclusive. Initial endoscopy was associated with a small reduction in the risk of recurrent dyspeptic symptoms compared with H. pylori test and treat (OR 0.75, 95% CI 0.58 to 0.96), but was not cost effective (mean additional cost of endoscopy US$401 (95% CI $328 to 474). Test and treat may be more effective than acid suppression alone (RR 0.59 95% CI 0.42 to 0.83).

AUTHORS' CONCLUSIONS

Proton pump inhibitor drugs (PPIs) are effective in the treatment of dyspepsia in these trials which may not adequately exclude patients with gastro-oesophageal reflux disease (GORD). The relative efficacy of histamine H2-receptor antagonists (H2RAs) and PPIs is uncertain. Early investigation by endoscopy or H. pylori testing may benefit some patients with dyspepsia but is not cost effective as part of an overall management strategy.

Gastro-oesophageal acid-related disease, co-morbidity and medical care cost

OBJECTIVE

To analyse the incremental medical care cost of gastro-oesophageal acid-related disease (GERD), and its interactive effects with other diagnoses.

METHODS

A retrospective cohort study was conducted. Six hundred GERD patients were randomly selected and 600 non-GERD patients were selected, matched by age, gender, prescription pharmaceutical benefits and insurance status. Information on demographics, direct medical care cost (DMC) (inpatient, ambulatory and pharmaceuticals) and health service utilization was obtained from a large, not-for-profit managed-care organization across 3 years (1996-1998). DMCs were compared between GERD and non-GERD groups using the bootstrap method. Random coefficient log linear regression models were used to analyse incremental cost and assess its association with other diagnoses.

RESULTS

The mean annual DMC for the GERD group was $4906, as compared to $2054 for the non-GERD group. The increase in the DMC in the GERD group was attributable to increased co-morbidity. Age and gender had no effect on total cost for the GERD population. Among costs of services, the GERD group had a 2.00-fold higher cost associated with outpatient services, a 1.70-fold higher cost associated with inpatient services, and a 2.70-fold higher cost associated with pharmacy.

CONCLUSIONS

GERD is a chronic disease often associated with other diagnoses that significantly affect total DMC. Although the direct cost of treating GERD is low, patients with GERD had significantly higher total medical care cost than those without GERD. The addition of one more disease to a person's existing group of diseases has an important long-term health cost impact.

Functional heartburn, nonerosive reflux disease, and reflux esophagitis are all distinct conditions—A debate: Pro

Gastroesophageal reflux disease (GERD) traditionally has been approached as a spectrum-continuum, suggesting that patients may progress over time and develop a more severe esophageal mucosal involvement. The spectrum-continuum conceptual model had a profound impact on the research priorities in GERD, as well as on proposed diagnostic algorithms and therapeutic strategies. Natural course studies in GERD are almost always retrospective and commonly afflicted with a plethora of shortcomings. Factors that affect quality of natural course studies in GERD include the following: index endoscopy results are taken at face value; antireflux treatment is consumed until index endoscopy and/or offered during the follow-up phase; pathophysiologic, anatomic, and genetic factors are overlooked; and lack of confirmation of the durability of the new esophageal mucosal finding. Functional heartburn is common and likely to affect a large subset of patients presenting with heartburn. Evidence to support progression of functional heartburn to nonerosive reflux disease (NERD), erosive esophagitis, or Barrett's esophagus is very scarce. The largest population-based or longest-duration natural course studies report that only 10% of patients progress from NERD to erosive esophagitis over time. The other GERD patients remained within their respective phenotypic presentations of GERD.

Efficiency of potent gastric acid inhibition

The evidence regarding the efficiency of potent gastric acid inhibition is exposed after a systematic search and a critical evaluation of its quality, using a specific score. The aim was to review alternative options, in economic terms, especially related with gastro-oesophageal reflux disease. The results show that the superiority of the proton pump inhibitors over the histamine H2 receptor antagonist is clear in moderate and severe oesophagitis and in patients with persistent or severe symptoms. This evidence is clearly related with the intensity of the gastric inhibition. An associated benefit is the improvement of the quality of life obtained with this potent gastric acid inhibition profile.

Clinical response (remission of symptoms) in erosive and non-erosive gastro-oesophageal reflux disease

Complete remission of symptoms and prevention of symptomatic recurrence are among the main therapeutic aims in gastro-oesophageal reflux disease (GORD). In this context, a potent pharmacologic inhibition of gastric acid secretion plays a central role. The goal of antisecretory treatment in GORD is to maintain an intragastric pH greater than 4.0 for the longest possible time. This is best achieved by the administration of proton pump inhibitors (PPIs). Tolerability and safety of different PPIs are similar and consistently high, but therapeutic efficacy may differ among them. Esomeprazole appears to achieve an intragastric pH greater than 4.0 for a larger number of hours compared with any other PPI. This is associated with a greater therapeutic efficacy of esomeprazole compared with omeprazole, lansoprazole and pantoprazole in both complete remission of symptoms and prevention of symptomatic recurrence in GORD. This review provides evidence-based recommendations for the treatment of GORD-related symptoms in clinical practice.

An update on the available treatments for non-erosive reflux disease

Non-erosive reflux disease is defined as the presence of troublesome reflux symptoms, such as heartburn and regurgitation, in the absence of endoscopically-visible damage of the oesophageal mucosa. In comparison with erosive oesophagitis, non-erosive reflux disease is the most common clinical manifestation of gastro-oesophageal reflux disease. Pathophysiologically, it is not a homogeneous disease as only approximately two-thirds of patients have truly acid-related symptoms. This explains the fact that patients with non-erosive reflux disease consistently show a poorer response to proton pump inhibitor treatment than patients with erosive oesophagitis. Nevertheless, profound acid inhibition by proton pump inhibitors is the recommended first-line treatment in patients suffering from this condition, both in the initial phase and for long-term care. Non-responders to proton pump inhibitor therapy should be subjected to a thorough examination and treated on an individual basis. Emerging data on the long-term course of reflux disease under routine clinical care have led to the adoption of new therapeutic strategies that would have been unthinkable only a few years ago.

Can economic evaluations be made more transferable?

Several commentators have identified the lack of generalisability and transferability of economic evaluation results. The aims of this study were: (a) to develop a checklist to assess the level of generalisability and transferability of economic evaluations; (b) to assess the generalisability and transferability of economic evaluations between the UK and France using the checklist; (c) to identify reasons for any lack of transferability and generalisability; (d) to assess how the transferability and generalisability of economic evaluations can be improved; and (e) to outline ways in which databases of economic evaluations and journals can assist in this area. The checklist was developed using previous work and the templates of the NHS EED and CODECS databases. A sub-checklist of essential items was then derived. Validation of the two checklists was undertaken with Health Economists participating in the EURONHEED project. Economic evaluations involving the UK and France were then located and assessed using the checklist. A summary score for each study was calculated based on the percentage of correctly reported (applicable) points, and the results in the empirical analysis compared to identify differences. The extended checklist includes 42 items, and the sub-checklist 16 items. Twenty-five economic evaluations met the inclusion criteria for the empirical analysis. In the extended checklist the mean score was 66.9+/-13.6%. The results for the sub-checklist were very similar. The analysis revealed that costing, assessments of generalisability by the author(s), assessment of data variability, discounting, study population, and the reporting of effectiveness are areas that need more attention. Differences in cost-effectiveness results are often accounted for by price or organisational differences. The developed checklists are useful in assessing the generalisability and transferability of economic evaluations. In order to improve the generalisability and transferability of economic evaluations authors need to be more explicit and detailed in describing and reporting their studies. If they are to provide added value to their users, international databases of economic evaluations should systematically assess the generalisability and transferability of studies. Further research is in progress on producing a weighted version of the checklist.

Initial management strategies for dyspepsia

BACKGROUND

This review considers management strategies (combinations of initial investigation and empirical treatments) for dyspeptic patients. Dyspepsia was defined to include both epigastric pain and heartburn.

OBJECTIVES

To determine the effectiveness, acceptability, and cost effectiveness of the following initial management strategies for patients presenting with dyspepsia: (a) Initial pharmacological therapy (including endoscopy for treatment failures). (b) Early endoscopy. (c) Testing for Helicobacter pylori (H. pylori )and endoscope only those positive. (d) H. pylori eradication therapy with or without prior testing.

SEARCH STRATEGY

Trials were located through electronic searches and extensive contact with trialists.

SELECTION CRITERIA

All randomised controlled trials of dyspeptic patients presenting in primary care.

DATA COLLECTION AND ANALYSIS

Data were collected on dyspeptic symptoms, quality of life and use of resources. An individual patient data meta-analysis of health economic data was conducted

MAIN RESULTS

Twenty-five papers reporting 27 comparisons were found. Trials comparing proton pump inhibitors (PPI) with antacids (three trials) and histamine H2-receptor antagonists (H2RAs) (three trials), early endoscopy with initial acid suppression (five trials), H. pylori test and endoscope versus usual management (three trials), H. pylori test and treat versus endoscopy (six trials), and test and treat versus acid suppression alone in H. pylori positive patients (four trials), were pooled. PPIs were significantly more effective than both H2RAs and antacids. Relative risks (RR) and 95% confidence intervals (CI) were; for PPI compared with antacid 0.72 (95% CI 0.64 to 0.80), PPI compared with H2RA 0.63 (95% CI 0.47 to 0.85). Results for other drug comparisons were either absent or inconclusive. Initial endoscopy was associated with a small reduction in the risk of recurrent dyspeptic symptoms compared with H. pylori test and treat (OR 0.75, 95% CI 0.58 to 0.96), but was not cost effective (mean additional cost of endoscopy US$401 (95% CI $328 to 474). Test and treat may be more effective than acid suppression alone (RR 0.59 95% CI 0.42 to 0.83).

AUTHORS' CONCLUSIONS

Proton pump inhibitor drugs (PPIs) are effective in the treatment of dyspepsia in these trials which may not adequately exclude patients with gastro-oesophageal reflux disease (GORD). The relative efficacy of histamine H2-receptor antagonists (H2RAs) and PPIs is uncertain. Early investigation by endoscopy or H. pylori testing may benefit some patients with dyspepsia but is not cost effective as part of an overall management strategy.

Systematic review: the efficacy of intermittent and on-demand therapy with histamine H2-receptor antagonists or proton pump inhibitors for gastro-oesophageal reflux disease patients

AIM

To perform a systematic review on the efficacy of intermittent and on-demand therapy with either histamine H2-receptor antagonists or proton pump inhibitors for patients with erosive oesophagitis or symptomatic heartburn.

METHOD

We conducted randomized-controlled trials of non-continuous therapy in gastro-oesophageal reflux disease patients.

RESULTS

Fourteen studies met inclusion criteria. Because of variation in outcome measures statistical pooling of results was not possible. Results were analysed qualitatively. Four studies evaluated intermittent therapy of treatment 3 days a week with omeprazole 20 mg or daily with ranitidine which were not efficacious compared to a daily proton pump inhibitor. Famotidine 10 and 20 mg, ranitidine 75 mg and cimetidine 200 mg were efficacious in five on-demand studies for relief of symptomatic heartburn episodes. In three of four studies, evaluating only non-erosive (endoscopy-negative) gastro-oesophageal reflux disease patients, esomeprazole 20 and 40 mg and omeprazole 10 and 20 mg a day were efficacious using willingness to continue as an endpoint. Lansoprazole 30 mg and omeprazole 20 mg maintained symptom control in 60-70% of healed oesophagitis patients.

CONCLUSIONS

Intermittent proton pump inhibitor or H2-receptor antagonist therapy is not effective in maintaining control in oesophagitis patients. H2-receptor antagonists are effective for relief of heartburn episodes. On-demand proton pump inhibitor therapy may work in a proportion of non-erosive gastro-oesophageal reflux disease patients.

Maintenance Therapy in Gastro-oesophageal Reflux Disease

Gastro-oesophageal reflux disease (GORD) is a chronic condition. Symptom control and the maintenance of healing of erosive oesophagitis, if present, are important topics. In patients responding to a proton pump inhibitor (PPI) and showing no treatment symptoms it is appropriate to consider long-term treatment strategies, whether continuous, intermittent or on demand. Maintenance PPI therapy is well tolerated for up to 10 years of continuous use. Furthermore, tachyphylaxis does not occur during long-term maintenance PPI therapy. Previous concerns about risks of long-term PPI therapy in Heliobacter pylori-negative or H. pylori-positive patients have not materialized, while no cases of intestinal metaplasia with dysplasia or adenocarcinoma were found. The choice between medical and surgical therapy should depend upon informed patient preference. The optimal candidate for antireflux surgery is a young patient, with typical GORD symptoms, with erosive oesophagitis, with previous complete symptom resolution on acid-suppression therapy and unable to undergo continuous therapy, or alternatively in patients with regurgitation predominating over heartburn as long as the surgical procedures are conducted by an expert surgical team. Endoscopic therapy for erosive GORD should currently be regarded as experimental. The endoscopic procedures are safe, although they remain untested in patients with severe erosive oesophagitis and/or significant hiatal hernia.

Variability of cost-effectiveness estimates for pharmaceuticals in Western Europe: lessons for inferring generalizability

OBJECTIVES

It has long been suggested that, whereas the results of clinical studies of pharmaceuticals are generalizable from one jurisdiction to another, the results of economic evaluations are location dependent. There has been, however, little study of the causes of variation, whether differences in study results among countries are systematic, or whether they are important for decision making.

METHODS

A literature search was conducted to identify economic evaluations of pharmaceuticals conducted in two or more European countries. The studies identified were then classified by methodological type and analyzed to assess their level of variability and to identify the main causes of variation. Assessments were also made of the extent to which differences in study results among countries were systematic and whether they would lead to a different decision, assuming a range of values of the threshold willingness-to-pay for a life-year or quality-adjusted life-year (QALY).

RESULTS

In total 46 intercountry drug comparisons were identified, 29 in multicountry studies and 17 in comparable single country studies that were considered to be sufficiently similar in terms of methodology. The type of study (i.e., trial-based or modeling study) had some impact on variability, but the most important factor was the extent of variation across countries in effectiveness, resource use or unit costs, allowed by the researcher's chosen methodology. There were few systematic differences in study results among countries, so a decision maker in country B, on seeing a recent economic evaluation of a new drug in country A, would have little basis on which to predict whether the drug, if evaluated, would be more or less cost-effective in his or her country. Given the extent of variation in cost-effectiveness estimates among countries, the importance of this for decision making depends on decision makers' thresholds in willingness-to-pay for a QALY or life-year. If a cost-effectiveness threshold (i.e., willingness-to-pay) for a life-year or QALY of dollar 50,000 were assumed, the same conclusion regarding cost-effectiveness would be reached in most cases.

CONCLUSION

This review shows that cost-effectiveness results for pharmaceuticals vary from country to country in Western Europe and that these variations are not systematic. In addition, constraints imposed by analysts may reduce apparent variability in the estimates. The lessons for inferring generalizability are not straightforward, although the implications of variation for decision making depend critically on the cost-effectiveness thresholds applying in Western Europe.

Systematic review: Is there excessive use of proton pump inhibitors in gastro-oesophageal reflux disease?

BACKGROUND

Proton-pump inhibitors are often recommended for continuous use in gastro-oesophageal reflux disease, but this may not be necessary in all patients.

AIM

To ascertain the level of evidence for alternative strategies for proton-pump inhibitor treatment in gastro-oesophageal reflux disease.

METHODS

We searched for observational or interventional studies examining alternatives to continuous proton-pump inhibitor treatment in gastro-oesophageal reflux disease.

RESULTS

Non-randomized studies suggest that some patients with gastro-oesophageal reflux disease, including some with erosive oesophagitis, may be adequately maintained on proton-pump inhibitor therapy given less frequently than once daily. However, the results may not be generalizable. Four high quality randomized-controlled trials compared 'on-demand' proton-pump inhibitor and placebo treatment in endoscopy-negative reflux disease; all found this effective for most patients. One high quality randomized-controlled trial found intermittent courses of a proton-pump inhibitor or H2-receptor antagonist in erosive oesophagitis or endoscopy-negative reflux disease adequate for almost half of the patients studied. Up to 80% of patients on continuous high-dose proton-pump inhibitor treatment for gastro-oesophageal reflux disease can be 'stepped down' to less intensive therapy.

CONCLUSIONS

On-demand proton-pump inhibitor treatment may be appropriate in endoscopy-negative reflux disease. In gastro-oesophageal reflux disease, patients taking more than once daily or high-dose proton-pump inhibitor treatment, a step down to once daily or standard dose therapy should be attempted.

Review article: diagnosis and management of night-time reflux

Symptoms of gastro-oesophageal reflux disease (GERD) range from mild to severe and, when they occur during night-time hours, can interfere with sleep patterns and reduce overall quality of life. The clinical presentation of GERD is characterized by oesophageal as well as supra-oesophageal symptoms, including otolaryngologic and pulmonary complications. However, GERD may be overlooked as the cause of a patient's supra-oesophageal symptoms because these complaints can occur in the absence of oesophageal symptoms or endoscopic changes. The role of available tools used for GERD diagnosis, including endoscopy, oesophageal pH monitoring and an empirical course of proton pump inhibitor therapy, is discussed. Interventions available to achieve the therapeutic goals of symptom relief and prevention include specific lifestyle modifications and over-the-counter as well as prescription pharmacological agents. Patient-initiated, as-needed treatment may not be the best choice for managing persistent night-time reflux because it requires patient arousal from sleep. Proton pump inhibitor therapy remains the treatment of choice for patients with more severe symptoms and those with erosive oesophagitis. Few studies have specifically evaluated the role of pharmacological agents in the management of night-time reflux and comparisons are difficult due to the variability in study design and endpoints assessed.

Personal view: rationale and proposed algorithms for symptom-based proton pump inhibitor therapy for gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease and non-erosive reflux disease are chronic, highly prevalent conditions requiring long-term treatment that is both effective and practical. On-demand therapy with a proton pump inhibitor may meet that need. It is becoming a mainstay of long-term treatment because it reduces the risk of over- and under-treatment, is cost-effective and user friendly. Epidemiological and clinical observations speak also in its favour. However, for the anticipated benefits of on-demand therapy to accrue in clinical practice, on-demand treatment algorithms are required. These algorithms must specify the initial evaluation and treatment of candidates, and follow-up protocols for an on-demand strategy. Our group has developed such algorithms, which are presented here.

Seizure-free Days Observed in Randomized Placebo-controlled Add-on Trials with Levetiracetam in Partial Epilepsy

PURPOSE

We examined the effect of adjunctive levetiracetam (LEV; 1,000 to 3,000 mg/day) on the number of seizure-free days gained per quarter in adult patients with refractory partial-onset epilepsy.

METHODS

The treatment effect was studied in a meta-analysis using individual patient data of a subpopulation of patients (n = 846) emerging from the three randomized, double-blind, placebo-controlled, phase III trials (n = 904).

RESULTS

Adding LEV effectively increased the number of days without seizures by 5.19 days per quarter [95% confidence interval (CI), 3.63-6.76; p = 0.0001; titration and stable dose periods].

CONCLUSIONS

LEV adjunctive treatment shows a clear benefit in terms of seizure-free days gained for patients with refractory epilepsy. This gain is significant for the pooled and for each LEV dose compared with placebo.

The economic and quality-of-life impact of symptomatic gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is one of the most common complaints in general medical practice. Symptoms of GERD have a high prevalence, which greatly affects health economics and patient health-related quality of life (HRQOL). The majority of patients who present with reflux symptoms lack esophageal mucosal injury and thus have symptomatic GERD. There appear to be no differences in either symptoms or HRQOL measures between patients with or without positive endoscopy. Although most pharmacoeconomic and HRQOL assessments have focused on erosive GERD patients, available data suggest that the impact of symptomatic GERD on HRQOL is significant and equivalent to that associated with erosive disease. Proton pump inhibitors (PPIs) improve HRQOL to a greater extent than either histamine(2)-receptor antagonists or prokinetics in patients with GERD, with PPI-based step-down or "on-demand" strategies yielding the most cost-effective benefit to health. Additional HRQOL and outcomes research focused on patients with symptomatic GERD, ideally using disease-specific assessment tools, is needed. Furthermore, these management strategies must be implemented in real world settings to validate their effectiveness and firmly establish claims of reduced need for diagnostic testing and decreased direct medical costs.

Intermittent and on-demand use of proton pump inhibitors in the management of symptomatic gastroesophageal reflux disease

The epidemic of gastroesophageal reflux disease (GERD) in industrialized nations is currently spreading to less-developed ones, with more than half of the patients having symptomatic or mild erosive GERD. The long-term management of GERD has been dominated by daily maintenance treatment with proton pump inhibitors (PPI) to prevent relapse. It is common, however, for many patients with mild disease and infrequent symptom relapses to use a PPI only when symptoms demand. Patients with symptomatic or mild erosive GERD are therefore ideal for on-demand or intermittent treatment. The efficacy of such a strategy of intermittent treatment, or treatment of symptoms on demand, has recently been evaluated in four randomized controlled studies. These trials demonstrate that such therapeutic strategies reduce symptoms, improve quality of life, and are cost effective. In clinical practice, the author has found these treatment strategies suitable for approximately 60% of newly diagnosed patients with GERD for the long-term management of symptomatic GERD of mild or moderate severity.

Decision making in gastroesophageal reflux disease. What are the critical issues?

This article has identified several crucial decision points in the management of GERD. Although there seems to be a strong epidemiologic association with esophageal adenocarcinoma, the clinical and economic benefits of screening endoscopy are not clear. Given the low incidence of this cancer, it is conceivable that screening programs in these patients, such as colon cancer screening and breast cancer screening, may provide a greater health benefit at a lower incremental cost. Surveillance endoscopy in BE is another contentious issue, with the surveillance interval and cost-effectiveness hinging on the cancer risk. As more precise estimates of cancer risk, accounting for publication bias, are derived, the economics of surveillance will require further evaluation. Finally, several, management strategies seem to improve outcomes for patients with uninvestigated GERD, but the incremental costs of the more effective step-down approach seem minimal. More important than the initial strategy may be the ability to implement a systematic approach to care that ensures that patients attempt step-down when symptoms are resolved and do not remain on potent therapy indefinitely when it is not necessary. The results of prospective effectiveness trials are anticipated to validate the findings of these economic analyses.

Patient-centred endpoints in economic evaluations of gastro-oesophageal reflux disease

AIM

To perform a systematic review of the economic literature on gastro-oesophageal reflux disease to evaluate (a) the use of patient-centred effectiveness end-points, or (b) the use of patient-centred economic end-points, and the influence of these end-points on the outcome of the model.

METHODS

Three electronic databases (EMBASE, BIOSIS and Medline) were used, together with a manual search of meeting abstracts for relevant articles. The quality of the studies was determined by the Drummond criteria.

RESULTS

Our initial search identified 179 articles and a manual search revealed 78 abstracts and articles. A total of 47 studies (36 fully published articles and 11 abstracts) met the seven Drummond criteria for inclusion in our evaluation.

CONCLUSIONS

This systematic review demonstrates that many of the published economic evaluations available today take the perspective of the third-party payer and focus on pharmaceutical costs relevant to the third-party payer. Our study also demonstrates that there are a number of costs of illness determinations, such that pharmaceutical costs account for only a small proportion of the total costs of managing gastro-oesophageal reflux disease. Future economic analyses should consider an evaluation of the patient's desire for complete symptom relief by including cost-utility assessments or willingness to pay data.