Skip to main content

Advertisement

SpringerLink
Log in

What is heartburn worth?

A cost-utility analysis of management strategies

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

OBJECTIVE: To determine the best treatment strategy for the management of patients presenting with symptoms consistent with uncomplicated heartburn.

METHODS: We performed a cost-utility analysis of 4 alternatives: empirical proton pump inhibitor, empirical histamine2-receptor antagonist, and diagnostic strategies consisting of either esophagogastroduodenoscopy (EGD) or an upper gastrointestinal series before treatment. The time horizon of the model 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 projected to provide the greatest quality-adjusted survival for the cohort. Empirical treatment with a histamine2 receptor antagonist was projected to be the least costly of the alternatives. The marginal cost-effectiveness of using a proton pump inhibitor over a histamine2-receptor antagonist was approximately $10,400 per quality-adjusted life year (QALY) gained in the base case analysis and was less than $50,000 per QALY as long as the utility for heartburn was less than 0.95. Both diagnostic strategies were dominated by proton 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 histamine2-receptor antagonist depends on the impact of heartburn on quality of life.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Richter JE. Long term management of gastroesophageal reflux disease and its complications. Am J Gastroenterol. 1997;92(4):30S-35S.

    PubMed  CAS  Google Scholar 

  2. DeVault KR, Castell DO. Guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Arch Intern Med. 1995;155(13):2165–73.

    Article  PubMed  CAS  Google Scholar 

  3. Heading RC. Epidemiology of esophageal reflux disease. Scand J Gastroenterol. 1989;24(suppl 168):33–7.

    Google Scholar 

  4. Howden CW, Castell DO, Cohen S, et al. The rationale for continuous maintenance treatment of reflux esophagitis. Arch Intern Med. 1995;155:1465–71.

    Article  PubMed  CAS  Google Scholar 

  5. Vigneri S, Termini R, Leandro G, et al. A comparison of five maintenance therapies for reflux esophagitis. N Engl J Med. 1995;333(17):1106–10.

    Article  PubMed  CAS  Google Scholar 

  6. Klinkenberg-Knol EC, Festen HP, Jansen JB, et al. Long term treatment with omeprazole for refractory reflux esophagitis: efficacy and safety. Ann Intern Med. 1994;121(3):161–7.

    PubMed  CAS  Google Scholar 

  7. Robinson M, Lanza F, Avner D, et al. Effective maintenance treatment of reflux esophagitis with low-dose lansoprazole. Ann Intern Med. 1996;124(10):859–67.

    PubMed  CAS  Google Scholar 

  8. Johnsson F, Joelsson B, Gudmundsson K, et al. Symptoms and endoscopic findings in the diagnosis of gastroesophageal reflux disease. Scand J Gastroenterol. 1987;22:714–8.

    PubMed  CAS  Google Scholar 

  9. Johnston BT, McFarland RJ, Collins JSA, et al. Symptom index as a marker of gastro-oesophageal reflux disease. Br J Surg. 1992;79:1054–5.

    Article  PubMed  CAS  Google Scholar 

  10. Singh S, Richter JE, Bradley LA, et al. The symptom index: Differential usefulness in suspected acid-related complaints of heartburn and chest pain. Dig Dis Sci. 1993;38(8):1402–8.

    Article  PubMed  CAS  Google Scholar 

  11. Sox HC, Blatt MA, Higgins MC, et al. In: Medical Decision Making. Stoneham, Mass: Butterworths Publishing; 1988.

    Google Scholar 

  12. Gold MR, Siegel JE, Russell LB, et al. In: Cost-Effectiveness in Health and Medicine. New York, NY: Oxford University Publishing; 1996.

    Google Scholar 

  13. Spiro HM. Clinical Gastroenterology. 4th Ed. New York, NY: McGraw-Hill; 1993.

    Google Scholar 

  14. Thompson JK, Koehler RE, Richter JE. Detection of gastroesophageal reflux: value of barium studies compared with 24-hr pH monitoring. AJR. 1994;162:621–6.

    PubMed  CAS  Google Scholar 

  15. Ott DJ. Gastroesophageal reflux: what is the role of barium studies? AJR. 1994;162(3):627–9.

    PubMed  CAS  Google Scholar 

  16. Robinson M, Earnest D, Rodriguez-Stanley S, et al. Heartburn requiring frequent antacid use may indicate significant illness. Arch Intern Med. 1998;158:2373–6.

    Article  PubMed  CAS  Google Scholar 

  17. Joelsson B, Johnsson F. Heartburn—the acid test. Gut. 1989;30:1523–5.

    PubMed  CAS  Google Scholar 

  18. Dehn TC, Shepard HA, Colins-Jones D, et al. Double blind comparison of omeprazole (40mg qd) versus cimetidine (400 mg qd) in the treatment of symptomatic erosive reflux oesophagitis, assessed endoscopically, histologically and by 24 h pH monitoring. Gut. 1990;31:509–13.

    PubMed  CAS  Google Scholar 

  19. Klinkenberg EC, Jansen JM, Festen HP, et al. Double-blind multicentre comparison of omeprazole and ranitidine in the treatment of reflux oesophagitis. Lancet. 1987;349–51.

  20. Vantrappen G, Rutgeerts L, Schurmans P, et al. Omeprazole (40mg) is superior to ranitidine in short-term treatment of ulcerative reflux esophagitis. Dig Dis Sci. 1988;33(5):523–9.

    Article  PubMed  CAS  Google Scholar 

  21. Sandmark S, Carlsson R, Fausa O, et al. Omeprazole or ranitidine in the treatment of reflux esophagitis: results of a double-blind, randomized, Scandinavian multicenter study. Scand J Gastroenterol. 1988;23:625–32.

    PubMed  CAS  Google Scholar 

  22. Hatlebakk J, Berstad A, Carling L, et al. Lansoprazole versus omeprazole in short-term treatment of reflux oesophagitis: results of a Scandinavian multicentre trial. Scand J Gastroenterol. 1993;28:224–8.

    PubMed  CAS  Google Scholar 

  23. Hetzel D, Dent J, Reed W, et al. Healing and relapse of severe peptic esophagitis after treatment with omeprazole. Gastroenterology. 1988;95:903–12.

    PubMed  CAS  Google Scholar 

  24. Sontag SJ, Hirschowitz BI, Holt S, et al. Two doses of omeprazole versus placebo in symptomatic erosive esophagitis: The U.S. Multicenter Study. Gastroenterology. 1992;102:109–18.

    PubMed  CAS  Google Scholar 

  25. Dent J, Hetzel DJ, Hetzel MA, et al. Evaluation of omeprazole in reflux oesophagitis. Scand J Gastroenterol. 1989;24(suppl 166):76–82.

    Google Scholar 

  26. Robinson M, Campbell DR, Sontag S, et al. Treatment of erosive reflux esophagitis resistant to H2-receptor antagonist therapy: lansoprazole, a new proton pump inhibitor. Dig Dis Sci. 1995;40(3):590–7.

    Article  PubMed  CAS  Google Scholar 

  27. Feldman M, Harford W, Fisher R, et al. Treatment of reflux esophagitis resistant to H2-receptor antagonist with lansoprazole, a new H+/K+-ATPase inhibitor: a controlled, double-blind study. Am J Gastroenterol. 1993;88(8):1212–7.

    PubMed  CAS  Google Scholar 

  28. Gough AL, Long RG, Cooper BT, et al. Lansoprazole versus ranitidine in the maintenance treatment of reflux oesophagitis. Ailment Pharmacol Ther. 1996;10:529–39.

    Article  CAS  Google Scholar 

  29. Dent J, Yeomans N, Mackinnon M, et al. Omeprazole v ranitidine for prevention of relapse in reflux oesophagitis: a controlled double blind trial of their efficacy and safety. Gut. 1994;35:590–8.

    PubMed  CAS  Google Scholar 

  30. Lundell L, Backman L, Ekstrom P, et al. Prevention of relapse of reflux esophagitis after endoscopic healing: the efficacy and safety of omeprazole compared with ranitidine. Scand J Gastroenterol. 1991;26:248–56.

    PubMed  CAS  Google Scholar 

  31. Lundell L. Prevention of relapse of reflux oesophagitis after endoscopic healing: the efficacy and safety of omeprazole compared with ranitidine. Digestion. 1990;47(suppl 1):72–5.

    Article  PubMed  Google Scholar 

  32. Lind T, Havelund R, Carlsson R., et al. Effect of omeprazole (OME) 20 mg and 10 mg daily on heartburn in patients with endoscopy negative reflux disease (ENRD) treated on an on demand basis. Gastroenterology. 1996;110(suppl 6):A178.

    Google Scholar 

  33. Soll AH. Medical treatment of peptic ulcer disease. JAMA. 1996;275:622–9.

    Article  PubMed  CAS  Google Scholar 

  34. Walsh JH, Peterson WL. The treatment of Helicobacter pylori infection in the management of peptic ulcer disease. N Engl J Med. 1995;333:984–91.

    Article  PubMed  CAS  Google Scholar 

  35. Bell NJV, Hunt RH. Role of gastric acid suppression in the treatment of gastrooesophageal reflux disease. Gut. 1992;33:118–24.

    PubMed  CAS  Google Scholar 

  36. Feinstein AR. Clinimetrics. New Haven, Conn: Yale University Press; 1987.

    Google Scholar 

  37. Fryback DG, Dasbach EJ, Klein R, et al. The Beaver Dam Health Outcomes Study: initial catalog of health-state quality factors. Med Decis Making. 1993;13:89–102.

    Article  PubMed  CAS  Google Scholar 

  38. 1996 Drug Topics Red Book. Montvale, NJ: Medical Economics; 1996.

  39. Doubilet P, Begg CB, Weinstein MC, et al. Probabilistic sensitivity analyses using Monte Carlo simulation. Med Decis Making. 1985;5:157–77.

    Article  PubMed  CAS  Google Scholar 

  40. Harris RA, Kupperman M, Richter JE. Prevention of recurrences of erosive reflux esophagitis: a cost-effectiveness analysis of maintenance proton pump inhibition. Am J Med. 1997;102:78–88.

    Article  PubMed  CAS  Google Scholar 

  41. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: Manual and Interpretation Guide. Boston, Mass: The Health Institute, New England Medical Center; 1993.

    Google Scholar 

  42. Sonnenberg A, Delco F, El-Serag H. Empirical therapy versus diagnostic tests in gastroesophageal reflux disease: a medical decision analysis. Dig Dis Sci. 1998;43:1001–8.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. the Division of General Internal Medicine, University of Alabama at Birmingham, Birmingham, Ala

    Gustavo R. Heudebert MD, Robert M. Centor MD & Joshua C. Klapow PhD

  2. the Division of Gastroenterology, University of Alabama at Birmingham, Birmingham, Ala

    Robert Marks MD, Lawrence Johnson MD & C. Mel Wilcox MD

  3. Department of Medicine, and Birmingham VA Medical Center, University of Alabama at Birmingham, Birmingham, Ala

    Gustavo R. Heudebert MD

  4. Department of Psychology, University of Alabama at Birmingham, Birmingham, Ala

    Joshua C. Klapow PhD

  5. School of Public Health, University of Alabama at Birmingham, Birmingham, Ala

    Joshua C. Klapow PhD

Authors
  1. Gustavo R. Heudebert MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Robert M. Centor MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Joshua C. Klapow PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Robert Marks MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Lawrence Johnson MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. C. Mel Wilcox MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Gustavo R. Heudebert MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Heudebert, G.R., Centor, R.M., Klapow, J.C. et al. What is heartburn worth?. J GEN INTERN MED 15, 175–182 (2000). https://doi.org/10.1046/j.1525-1497.2000.02639.x

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1046/j.1525-1497.2000.02639.x

Key words

Search

Navigation