Cost Effectiveness of Competing Strategies to Prevent or Treat GORD-Related Dysphagia
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Pharmacoeconomics 2000 Apr; 17 (4): 391-401 1170-7690/00/0004-0391/$20.00/0 © Adis International Limited. All rights reserved.
Cost Effectiveness of Competing Strategies to Prevent or Treat GORD-Related Dysphagia Amnon Sonnenberg The Department of Veterans Affairs Medical Center and The University of New Mexico, Albuquerque, New Mexico, USA
Abstract
Objectives: The variety of influences that contribute to the occurrence of dysphagia in gastro-oesophageal reflux disease (GORD) provide the physician with many options to intervene in the pathophysiology of the disease process. The aims of the present analysis were to compare the relationships between the costs and effectiveness of competing therapeutic interventions in preventing dysphagia. Methods: Dysphagia was modelled as the focal point of multiple influences leading to its development. The costs associated with different forms of drug therapy were based on the average wholesale prices listed in the Red Book of 1998. Procedural costs were estimated from Medicare reimbursements. Different treatment options were assessed by their incremental cost-effectiveness ratio. Results: Lifestyle modifications, treatment with prokinetic agents or antacids reduce the occurrence of dysphagia by 22, 21 or 25%, respectively. Acid inhibition results in a 57 to 89% reduction of dysphagia, depending on treatment with histamine-2-receptor antagonists (H2RAs) or proton pump inhibitors (PPIs). Oesophageal dilation results in a reduction ranging between 54 and 81%. The incremental ratio of cost effectiveness associated with prokinetic agents or H2RAs is much higher than that of PPIs. Based on the concept of extended dominance, therefore, prokinetic drugs and H2RAs do not constitute cost-effective means to prevent dysphagia and should be excluded in favour of treatment with PPIs. Conclusions: An economic analysis of various treatment strategies to reduce the risk of GORD-related dysphagia indicates that PPIs are the most cost-effective means to prevent its occurrence.
Multiple factors contribute to the occurrence of dysphagia in gastro-oesophageal reflux disease (GORD).[1-3] Healing of oesophageal erosions and ulcers results in scars and narrowing of the oesophageal lumen. Erosive oesophagitis itself stems from the failure of various mechanisms to protect the oesophageal mucosa from the corrosive action of gastric acid regurgitated into the oesophagus. These mechanisms include, among others: the inter-
play of salivary secretion, aborad oesophageal peristalsis and gravity in maintaining oesophageal clearance; the barrier function of the lower oesophageal sphincter in keeping gastric contents from entering the oesophagus; and various protective mechanisms of the oesophageal mucosa, such as mucosal blood flow, bicarbonate secretion, and cell renewal.[4] Independently of mucosal injury, it appears that in a subgroup of patients exposure of
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the oesophagus to acid alone suffices to compromise oesophageal motility and result in dysphagia.[5] The multitude of influences that contribu
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