Medical or surgical therapy for erosive reflux esophagitis: cost-utility analysis using a Markov model

Economic evaluation of proton pump inhibitors in patients with gastro-oesophageal reflux disease: a systematic review

OBJECTIVES

Our aim was to systematically review the cost-effectiveness of proton pump inhibitor (PPI) therapies and surgical interventions for gastro-oesophageal reflux disease (GORD).

DESIGN

The study design was a systematic review of economic evaluations.

DATA SOURCES

We searched PubMed, Embase, Scopus, and Web of Science for publications from January 1990 to March 2023. Only articles published in English were eligible for inclusion.

ELIGIBILITY CRITERIA

Studies were included if they were full economic evaluations comparing PPIs with surgical or alternative therapies for GORD. Excluded were narrative reviews, non-peer-reviewed articles, and studies not reporting cost-effectiveness outcomes.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data on study design, comparators, time horizon, and cost-effectiveness outcomes. The quality of studies was assessed using the Joanna Briggs Institute (JBI) checklist for economic evaluations.

RESULTS

A total of 25 studies met the inclusion criteria. Laparoscopic Nissen fundoplication (LNF) was found to be cost-effective in long-term horizons, while PPIs were preferred for short- to medium-term outcomes. Differences in healthcare settings and methodological approaches influenced the study findings.

CONCLUSIONS

Strategic purchasing decisions for GORD treatment should consider the time horizon, healthcare setting, and cost structures. LNF may provide better long-term value, but PPIs remain effective for managing symptoms in the short term.

STUDY REGISTRATION

PROSPERO, CRD42023474181.

Splenic artery angioembolization for high-grade splenic injury: Are we wasting money?

BACKGROUND

Non-operative management (NOM) is accepted treatment of splenic injury, but this may fail leading to splenectomy. Splenic artery embolization (SAE) may improve rate of salvage. The purpose is to determine the cost-utility of the addition of SAE for high-grade splenic injuries.

METHODS

A cost-utility analysis was developed to compared NOM to SAE in patients with blunt splenic injury. Sensitivity analysis was completed to account for uncertainty. Utility outcome was quality-adjusted life years (QALY).

RESULTS

For patients with grade III, IV and V injury NOM is the dominant strategy. The probability of NOM being the more cost-effective strategy is 87.5% in patients with grade V splenic injury. SAE is not the favored strategy unless the probability of failure of NOM is greater than 70.0%.

CONCLUSION

For grade III-V injuries, NOM without SAE yields more quality-adjusted life years. NOM without SAE is the most cost-effective strategy for high-grade splenic injuries.

Anti-reflux Surgery Versus Proton Pump Inhibitors for Severe Gastroesophageal Reflux Disease: A Cost-Effectiveness Study in Korea

Background/Aims

The economic burden for gastroesophageal reflux disease (GERD) has recently increased in Asian countries. This study investigates the cost-effectiveness between anti-reflux surgery and medication, with proton pump inhibitors (PPIs) for GERD in Korea.

Methods

We used a decision tree and Markov model to obtain the costs and quality-adjusted life years (QALYs) of the surgical and medical strategies. Our target cohort was the severe GERD patients aged 50 years old who required a continuous double dose of PPIs. The time horizon was 10 years and all estimates were discounted at 5% per year. The incremental cost-effectiveness ratio of the anti-reflux surgery compared with medication with PPIs was calculated. Sensitivity analyses were performed on all relevant variables.

Results

The cost-utility analysis indicated anti-reflux surgery was more cost-effective than medication among severe GERD patients over a 10-year period. The model predicted that the surgical strategy had a cost savings of $551 and the QALYs had a gain of 1.18 as compared with the medical strategy. The break-even point in costs of the anti-reflux surgery over the medication was estimated to be 9 years. Sensitivity analyses using the varying parameter assumptions demonstrated the robustness of the study results.

Conclusions

This study showed anti-reflux surgery was less expensive and more effective therapy over the PPI medication after 9 years of follow-up. This suggests the surgical strategy is a cost-effective alternative to PPI medication among patients who need long-term management for GERD in Korea.

Early referral for esophageal pH monitoring is more cost-effective than prolonged empiric trials of proton-pump inhibitors for suspected gastroesophageal reflux disease

INTRODUCTION

The most cost-effective diagnostic algorithm for gastroesophageal reflux disease (GERD) remains controversial. We hypothesized that prompt referral for esophageal pH monitoring is more cost-effective than prolonged empiric courses of proton-pump inhibitors (PPIs).

DISCUSSION

A cost model was created based on a cohort of 100 patients with possible GERD who underwent pH monitoring. The additional costs incurred from pH monitoring were compared to the potential savings from avoiding unnecessary PPI usage in patients with a negative pH study. The costs of PPI therapy reach equivalence with pH monitoring after 6.4 to 23.7 weeks, depending on the PPI regimen. A total of 21,411 weeks of PPIs were prescribed beyond the recommended 8-week trial, of which 32 % were for patients who had a negative 24-h pH monitoring study. If the sensitivity of pH monitoring was 96 %, early referral for pH monitoring would have saved between $1,197 and $6,303 per patient over 10 years. This strategy remains cost-effective as long as the sensitivity of pH monitoring is above 35 %. Prompt referral for pH monitoring after a brief empiric PPI trial is a more cost-effective strategy than prolonged empiric PPI trials for patients with both esophageal and extraesophageal GERD symptoms.

Cost-effectiveness of laparoscopic fundoplication versus continued medical management for the treatment of gastro-oesophageal reflux disease based on long-term follow-up of the REFLUX trial

Background

Laparoscopic fundoplication surgery has been shown to be a cost-effective alternative to continued medical management over 1 year for patients with gastro-oesophageal reflux disease (GORD). The longer-term cost-effectiveness is, however, uncertain. This study evaluated the long-term health benefits, costs and cost-effectiveness of laparoscopic fundoplication compared with continued medical management in patients with GORD.

Methods

Individual patient data were used from the 5-year follow-up of the REFLUX trial, a large multicentre, pragmatic, randomized trial in which 357 patients with GORD for at least 12 months at trial entry were allocated randomly to early laparoscopic fundoplication or continued medical management. Health outcomes were expressed in quality-adjusted life-years (QALYs). A UK National Health Service perspective was used for costs.

Results

The group randomized to surgery experienced better health outcomes in each year of follow-up, but the difference narrowed over time. At 5 years, the surgery group had experienced 0·216 (95 per cent confidence interval 0·021 to 0·412) more QALYs but also accrued €1832 (1214 to 2448) more costs. The incremental cost-effectiveness ratio was €8481 per QALY gained. The probability that surgery is the most cost-effective intervention was 0·932 at a threshold of €24 134/QALY (£20 000/QALY). Results were robust to most sensitivity analyses, except where patients with missing data randomized to surgery were assumed to have worse health outcomes.

Conclusion

Laparoscopic fundoplication is a cost-effective alternative to continued medical management over 5 years. No evidence was found to suggest that the cost-effectiveness of laparoscopic fundoplication diminishes over time.

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.

Cost-utility of laparoscopic Nissen fundoplication versus proton pump inhibitors for chronic and controlled gastroesophageal reflux disease: a 3-year prospective randomized controlled trial and economic evaluation

BACKGROUND

Very few randomized controlled trials (RCTs) have compared laparoscopic Nissen fundoplication (LNF) to proton pump inhibitors (PPI) medical management for patients with chronic gastroesophageal reflux disease (GERD). Larger RCTs have been relatively short in duration, and have reported mixed results regarding symptom control and effect on quality of life (QOL). Economic evaluations have reported conflicting results.

OBJECTIVES

To determine the incremental cost-utility of LNF versus PPI for treating patients with chronic and controlled GERD over 3 years from the societal perspective.

METHODS

Economic evaluation was conducted alongside a RCT that enrolled 104 patients from October 2000 to September 2004. Primary study outcome was GERD symptoms (secondary outcomes included QOL and cost-utility). Resource utilization and QOL data collected at regular follow-up intervals determined incremental cost/QALY gained. Stochastic uncertainty was assessed using bootstrapping and methodologic assumptions were assessed using sensitivity analysis.

RESULTS

No statistically significant differences in GERD symptom scores, but LNF did result in fewer heartburn days and improved QOL. Costs were higher for LNF patients by $3205/patient over 3 years but QOL was also higher as measured by either QOL instrument. Based on total costs, incremental cost-utility of LNF was $29,404/QALY gained using the Health Utility Index 3. Cost-utility results were sensitive to the utility instrument used ($29,404/QALY for Health Utility Index 3, $31,117/QALY for the Short Form 6D, and $76,310/QALY for EuroQol 5D) and if current lower prices for PPIs were used in the analysis.

CONCLUSIONS

Results varied depending on resource use/costs included in the analysis, the QOL instrument used, and the cost of PPIs; however, LNF was generally found to be a cost-effective treatment for patients with symptomatic controlled GERD requiring long-term management.

A non-homogeneous discrete time Markov model for admission scheduling and resource planning in a cost or capacity constrained healthcare system

Healthcare resource planners need to develop policies that ensure optimal allocation of scarce healthcare resources. This goal can be achieved by forecasting daily resource requirements for a given admission policy. If resources are limited, admission should be scheduled according to the resource availability. Such resource availability or demand can change with time. We here model patient flow through the care system as a discrete time Markov chain. In order to have a more realistic representation, a nonhomogeneous model is developed which incorporates time-dependent covariates, namely a patient's present age and the present calendar year. The model presented in this paper can be used for admission scheduling, resource requirement forecasting and resource allocation, so as to satisfy the demand or resource constraints or to meet the expansion or contraction plans in a hospital and community based integrated care system. Such a model can be used with both fixed and variable numbers of admissions per day and should prove to be a useful tool for care managers and policy makers who require to make strategic management decisions. We also describe an application of the model to an elderly care system, using a historical dataset from the geriatric department of a London hospital.

Laparoscopic fundoplication compared with medical management for gastro-oesophageal reflux disease: cost effectiveness study

OBJECTIVE

To describe the long term costs, health benefits, and cost effectiveness of laparoscopic surgery compared with those of continued medical management for patients with gastro-oesophageal reflux disease (GORD).

DESIGN

We estimated resource use and costs for the first year on the basis of data from the REFLUX trial. A Markov model was used to extrapolate cost and health benefit over a lifetime using data collected in the REFLUX trial and other sources.

PARTICIPANTS

The model compared laparoscopic surgery and continued proton pump inhibitors in male patients aged 45 and stable on GORD medication.

INTERVENTION

Laparoscopic surgery versus continued medical management.

MAIN OUTCOME MEASURES

We estimated quality adjusted life years and GORD related costs to the health service over a lifetime. Sensitivity analyses considered other plausible scenarios, in particular size and duration of treatment effect and the GORD symptoms of patients in whom surgery is unsuccessful. Main results The base case model indicated that surgery is likely to be considered cost effective on average with an incremental cost effectiveness ratio of pound2648 (euro3110; US$4385) per quality adjusted life year and that the probability that surgery is cost effective is 0.94 at a threshold incremental cost effectiveness ratio of pound20 000. The results were sensitive to some assumptions within the extrapolation modelling.

CONCLUSION

Surgery seems to be more cost effective on average than medical management in many of the scenarios examined in this study. Surgery might not be cost effective if the treatment effect does not persist over the long term, if patients who return to medical management have poor health related quality of life, or if proton pump inhibitors were cheaper. Further follow-up of patients from the REFLUX trial may be valuable.

TRIAL REGISTRATION

ISRCTN15517081.

Medium- and long-term outcome of laparoscopic redo fundoplication

BACKGROUND

For a small subset of patients, laparoscopic fundoplication fails, typically resulting in recurrent reflux or severe dysphagia. Although redo fundoplications can be performed laparoscopically, few studies have examined their long-term efficacy.

METHODS

Using a prospectively maintained database, the authors identified and contacted 41 patients who had undergone redo laparoscopic fundoplications at the University of Washington between 1996 and 2001. The median follow-up period was 50 months (range, 20-95 months). Current symptoms were compared with those acquired and entered into the authors' database preoperatively. Patients also were asked to return for esophageal manometry and pH testing.

RESULTS

All redo fundoplications were performed laparoscopically. There were no conversions. The most common indication for redo fundoplication was recurrent reflux. The most common anatomic abnormality was a herniated wrap. Heartburn improved in 61%, regurgitation in 69%, and dysphagia in 74% of the patients. Complete resolution of these symptoms was achieved, respectively, in 45%, 41% and 38% of these same patients. Overall, 68% of the patients rated the success of the procedure as either "excellent" or "good," and 78% said they were happy they chose to have it. For those who underwent reoperation for gastroesophageal reflux disease, distal esophageal acid exposure according to 24-h pH monitoring decreased after redo fundoplication from 15.7% +/- 18.1% to 3.4% +/- 3.6% (p = 0.041).

CONCLUSION

Although not as successful as primary fundoplication, a majority of patients can expect durable improvement in their symptoms with a laparoscopic redo fundoplication.

Health economic evaluation of therapeutic strategies in patients with idiopathic achalasia: results of a randomized trial comparing pneumatic dilatation with laparoscopic cardiomyotomy

BACKGROUND

We have prospectively collected information concerning the costs incurred during the management of patients allocated to either forceful dilatation or to an immediate laparoscopic operation because of newly diagnosed achalasia.

METHODS

Fifty-one patients with newly diagnosed achalasia were randomized to either pneumatic dilatation to a diameter of 30-40 mm or to a laparoscopic myotomy to which was added a posterior partial fundoplication. Follow-ups were scheduled at 1, 3, 6, and 12 months after inclusion. At each follow-up visit a study nurse interviewed the patients regarding symptoms and their quality of life (QoL) and a health economic questionnaire was completed. In the latter questionnaire, patients were asked to report the presence and character of contacts with the healthcare system since the last visit.

RESULTS

In the dilatation group six patients (23%), including the patient who was operated on because of perforation, were classified as failures during the first 12 months of follow-up compared to one (4%) in the myotomy group (p = 0.047). Five of those classified as failures in the dilatation group subsequently had a surgical myotomy and the sixth patient was treated with repeated dilatations. The patient classified as failure in the myotomy group was treated with endoscopic dilatation. The initial treatment cost and the total costs were significantly higher for laparoscopic myotomy compared to a pneumatic dilatation-based strategy (p = 0.0002 and p = 0.0019, respectively). When the total costs were subdivided into the different resources used, we found that the single largest cost item for pneumatic dilatation was that for hospital stay and that for laparoscopic myotomy was the actual operative treatment (operating room time). The cost-effectiveness analysis, relating to the actual treatment failures, revealed that the cost to avoid one treatment failure (incremental cost-effectiveness ratio) amounted to 9239 euros.

CONCLUSION

The current prospective, controlled clinical trial shows that despite a higher level of clinical efficacy of laparoscopic myotomy to prevent treatment failure in newly diagnosed achalasia, the cost effectiveness of pneumatic dilatation is superior, at least when a reasonable time horizon is applied.

A comparison of the cost effectiveness of pharmacotherapy or surgery (laparoscopic fundoplication) in the treatment of GORD

BACKGROUND

Gastro-oesophageal reflux disease (GORD) causes some of the most frequently seen symptoms in both primary and secondary care. An estimated 4-5 patients (age range 18-60 years) per 10,000 (0.045% of the general population) are receiving maintenance proton pump inhibitors (PPIs) for oesophagitis and reflux. The treatment of reflux disease represents significant prescription drug costs to the UK NHS. An alternative to lifelong pharmacotherapy is surgical treatment of reflux using the laparoscopic fundoplication technique to effect a cure. A multicentre study (REFLUX trial) comparing laparoscopic fundoplication with medical management (PPIs) among patients with GORD is currently underway in the UK. This study includes data collection to contribute to a cost-effectiveness analysis.

OBJECTIVE

To generate some preliminary estimates of the cost effectiveness of surgical and medical management of GORD to guide UK NHS decision making before the REFLUX trial reports.

METHODS

A Markov model was developed in Excel. Probabilistic sensitivity analysis was employed to assess the uncertainty associated with the point estimates. Two strategies were compared: long-term medical management or immediate laparoscopic surgery for GORD. Health outcomes were expressed in terms of QALYs with a lifetime time horizon (30 years) for a patient aged 45 years at commencement of treatment. Costs (pound, 2004 values) of drugs and costs associated with surgery were obtained from five of the REFLUX study centres. Costs and outcomes were discounted by 3.5% per anum. Value of information analysis was used to quantify the cost of uncertainty associated with the decision about which therapy to adopt, indicating the maximum value of future research.

RESULTS

Treatment with laparoscopic fundoplication is the most costly strategy but is also associated with more QALYs. The incremental cost per additional QALY for surgery versus medical management was 180 pounds. However, the cost effectiveness of surgery was uncertain, and the probability that it is cost effective at the threshold of 30,000 pounds per QALY was 0.639. Value of information analysis suggests that further research in this area could be potentially worthwhile. Specifically, this research should focus on the health-related quality of life of patients on medical management or post-surgery.

CONCLUSIONS

The results of the model suggest that, on the basis of current evidence, laparoscopic fundoplication represents a cost effective means of treating GORD rather than lifelong medical management.

Reflux, dysphagia, and gas bloat after laparoscopic fundoplication in patients with incidentally discovered hiatal hernia and in a control group

BACKGROUND

Laparoscopic fundoplication effectively controls reflux symptoms in patients with gastroesophageal reflux disease (GERD). However, symptom relapse and side effects, including dysphagia and gas bloat, may develop after surgery. The aim of the study was to assess these symptoms in patients who underwent laparoscopic fundoplication, as well as in control subjects and patients with hiatal hernia.

METHODS

A standardized, validated questionnaire on reflux, dysphagia, and gas bloat was filled out by 115 patients with a follow-up of 1 to 7 years after laparoscopic fundoplication, as well as by 105 subjects with an incidentally discovered hiatal hernia and 238 control subjects.

RESULTS

Patients who underwent fundoplication had better reflux scores than patients with hiatal hernia ( P = .0001) and similar scores to control subjects ( P = .11). They also had significantly more dysphagia and gas bloat than patients with hiatal hernia and controls ( P < .005 for all comparisons). Gas bloat and dysphagia were more severe in hiatal hernia patients than in controls ( P < 0.005). After fundoplication, the 25% of the patients with the shortest follow-up (1.5 +/- 0.2 years) and the 25% patients with the longest follow-up (5.8 +/- 0.6 years) had similar reflux, dysphagia, and gas bloat scores ( P = .43, .82, and .85, respectively).

CONCLUSION

In patients with severe GERD, laparoscopic fundoplication decreases reflux symptoms to levels found in control subjects. These results appear to be stable over time. However, patients who underwent fundoplication experience more dysphagia and gas bloat than controls and patients with hiatal hernia-symptoms that should be seen as a side effect of the procedure and of GERD itself.

Robotic Laparoscopic Fundoplication

Gastroesophageal reflux disease is a very common disorder, and both medical and surgical treatments have shown outstanding results. Whereas proton pump inhibitors are the mainstay of treatment, laparoscopic fundoplication has become a very attractive alternative due to its efficacy and low morbidity. There are defined patient categories that may benefit more from laparoscopy than medical therapy, but a conclusive comparison between the two is lacking. Robotic laparoscopic fundoplication can be performed safely without increased morbidity. Potential advantages include enhanced precision, improved dexterity, and remote telesurgical applications. Disadvantages include increased cost and prolonged operative times. Further studies and more long-term outcome data are needed to fully evaluate the procedure. Robotic surgery is currently in its infancy and not cost effective but has a very promising future. With further development of automatization and miniaturization features, robotic surgery may prove more efficient than conventional laparoscopy.

Use of pharmacoeconomics in prescribing research. Part 5: modelling - beyond clinical trials

This paper provides an overview of modelling in the economic evaluation of pharmaceuticals, reflecting the increasing use of models in analyses prepared for reimbursement applications to national and local drug formularies. The paper seeks to demystify the most commonly encountered modelling techniques (extrapolation, decision analysis, Markov modelling and Monte Carlo simulation), and to provide guidance in assessing the quality of submitted or published modelled economic evaluations.

Medical or invasive therapy for GERD: an acidulous analysis

This review critically appraises the evidence on the benefits and costs of the available treatments for gastroesophageal reflux disease (GERD) and concludes that antireflux surgery has no clear advantages over medical therapy for efficacy of healing, prevention of complications, safety, side effects, and cost. Indeed, medical therapy is safer and, probably, more cost-effective. Compared with medically treated patients, those who have successful fundoplication may be less inconvenienced by GERD because they are less likely to need to take pills on a daily basis. The patient and physician must judge whether that benefit justifies the risks of surgery for a benign condition. There is not yet sufficient data available on the endoscopic antireflux procedures to make meaningful conclusions regarding their safety and efficacy.