Impact of gastroesophageal reflux disease on work absenteeism, presenteeism and productivity in daily life: a European observational study

Cost-effectiveness of proton pump inhibitors versus laparoscopic Nissen fundoplication for patients with gastroesophageal reflux disease: a systematic review of the literature

BACKGROUND

Gastroesophageal reflux disease is a common condition in Western countries. It is unknown whether medical or surgical treatment is more cost-effective. This study was conducted to determine whether laparoscopic Nissen fundoplication or treatment by proton pump inhibitors is the most cost-effective for gastroesophageal reflux disease in the long term.

METHODS

Medline, EMBASE, and Cochrane databases were searched for articles published between January 1990 and 2010. The search results were screened by two independent reviewers for economic evaluations comparing costs and effects of laparoscopic Nissen fundoplication and proton pump inhibitors in adults eligible for both treatments. Cost and effectiveness or utility data were extracted for both treatment modalities. The quality of the economic evaluations was scored using a dedicated checklist, as were the levels of evidence.

RESULTS

Four publications were included; all were based on decision analytic models. The economic evaluations were all of similar quality and all based on data with a variety of evidence levels. Surgery was more expensive than medical treatment in three publications. Two papers reported more quality-adjusted life-years for surgery. However, one of these reported more symptom-free months for medical treatment. In two publications surgery was considered to be the most cost-effective treatment, whereas the other two favored medical treatment.

CONCLUSIONS

The results with regard to cost-effectiveness are inconclusive. All four economic models are based on high- and low-quality data. More reliable estimates of cost-effectiveness based on long-term trial data are needed.

Gastroesophageal reflux in cirrhotic patients without esophageal varices

AIM: To evaluate the esophageal motility and abnormal acid and bile reflux incidence in cirrhotic patients without esophageal varices (EV).

METHODS: Seventy-eight patients with liver cirrhosis without EV confirmed by upper gastroesophageal endoscopy and 30 healthy control volunteers were prospectively enrolled in this study. All the patients were evaluated using a modified protocol including Child-Pugh score, upper gastrointestinal endoscopy, esophageal manometry, simultaneous ambulatory 24-h esophageal pH and bilirubin monitoring. All the patients and volunteers accepted the manometric study.

RESULTS: In the liver cirrhosis group, lower esophageal sphincter pressure (LESP, 15.32 ± 2.91 mmHg), peristaltic amplitude (PA, 61.41 ± 10.52 mmHg), peristaltic duration (PD, 5.32 ± 1.22 s), and peristaltic velocity (PV, 5.22 ± 1.11 cm/s) were all significantly abnormal in comparison with those in the control group (P < 0.05), and LESP was negatively correlated with Child-Pugh score. The incidence of reflux esophagitis (RE) and pathologic reflux was 37.18% and 55.13%, respectively (vs control, P < 0.05). And the incidence of isolated abnormal acid reflux, bile reflux and mixed reflux was 12.82%, 14.10% and 28.21% in patients with liver cirrhosis without EV.

CONCLUSION: Cirrhotic patients without EV presented esophageal motor disorders and mixed acid and bile reflux was the main pattern; the cirrhosis itself was an important causative factor.

[Use of health resources and loss of productivity in gastroesophageal reflux disease: results of a cross-sectional study in a primary care setting in Spain]

OBJECTIVE

To evaluate healthcare resource use and productivity in patients with gastro-esophageal reflux disease (GERD) and the influence of disease severity on these two factors.

DESIGN

Sub-analysis of the Spanish population of a multinational study with a 4-month retrospective period for the identification and selection of patients, and a clinical visit to obtain clinical information and data on use of healthcare resources, carried out between October 2007 and January 2008.

POPULATION

A total of 477 patients attending a Primary Care centre, with a medical consultation for GERD.

MAIN VARIABLES

Use of healthcare resources, changes in productivity based on the Work Productivity and Activity Impairment Questionnaire for GERD patients (WPAI-GERD).

RESULTS

Despite having received pharmacological treatment at the baseline visit, after a median of 5.1 months follow-up (range 2.1-8.1), up to 15.9% (95% CI; 12.8-19.5) patients still showed clinically relevant GERD symptoms. Direct medical costs per year associated with diagnostic tests and medical consultations in patients with or without clinically relevant GERD symptoms were 666 € (SD: 2,097 €) and 370 € (SD: 2,060 €), respectively. The mean annual cost of reduced productivity (17%) was 5,316 € (SD: 8,615 €). This cost was 4 times higher for patients with clinically relevant GERD symptoms than for patients with no relevant symptoms (15,188 € [SD: 11,206 €] vs 3,926 € [SD: 7,232 €]).

CONCLUSION

Patients with GERD use significant healthcare resources, attributable to associated medical costs and marked reduction in productivity, even though they receive pharmacological treatment.

Structured management strategy versus usual care for gastroesophageal reflux disease: rationale for pooled analysis of five European cluster-randomized trials

BACKGROUND

Gastroesophageal reflux disease (GERD) has a major impact at the primary care level and there is a need to evaluate whether the diagnosis and therapeutic management of GERD in Europe needs to be improved.

METHODS

This project was designed to test the hypothesis that a new primary care management strategy would improve outcomes for patients with GERD, compared with usual care, in Europe. The analysis pools five separate cluster-randomized studies conducted in Austria, Italy, Norway, Spain and Sweden. These studies used a strategy based on the self-administered GerdQ questionnaire to stratify adult patients with symptoms of heartburn or regurgitation according to the frequency and impact of symptoms. A score of ≥8 indicates a high probability of suffering GERD. Patients with a GerdQ impact score ≤2 were treated with generic proton-pump inhibitors according to local guidance, and patients with an impact score ≥3 were treated with esomeprazole 40 mg once daily.

RESULTS

In total, 2400 patients were enrolled across the five studies. The protocols were modified by individual countries according to their local guidelines/requirements. In Norway, the new management strategy was compared with traditional routine endoscopy and 24-hour pH-metry, and encompassed proton-pump inhibitor reimbursement restrictions. Outcome measures differed by country, but included control of GERD symptoms, self-rated health status and work productivity, treatment changes, specialist referrals and physician adherence. GERD-related use of healthcare resources was also evaluated.

CONCLUSION

The pooled analysis will determine whether a locally adapted primary care management strategy for GERD, using GerdQ as a patient-tailored diagnostic and therapeutic evaluation tool, is beneficial compared with usual care across five countries with different standard approaches to GERD management and control.

[Study of the clinical profile and management of patients with gastroesophageal reflux disease in primary care in Spain]

OBJECTIVE

To assess the clinical profile and management of patients with gastroesophageal reflux disease (GERD) in primary care.

METHODS

A multinational, multicenter study was performed comprising a 4-month retrospective phase for the screening, selection and assessment of patients who had consulted for any GERD-related cause (index visit), and a cross-sectional phase in which clinical data were recorded and the following questionnaires were administered: the Reflux Disease Questionnaire and the Gastroesophageal Reflux Disease Impact Scale (GIS).

RESULTS

Among the 24 participating Spanish centers, 2.7% of the patients (95% CI: 2.6-2.9) had consulted at least once because of GERD. Approximately 50% of the patients showed frequent (2 or more days a week) or moderate to severe symptoms of heartburn, acid regurgitation or chest pain. Although the patients received effective pharmacological treatment at the index visit, clinically relevant GERD symptoms persisted in 16% after a median follow-up of 5 months. These symptoms were associated with a strong disease impact as evaluated with the GIS.

CONCLUSION

GERD represents a substantial burden for primary care physicians. Although effective drugs are used for the treatment of this condition, clinically relevant symptoms persist in a substantial proportion of patients.