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 £2648 (€3110; 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 £20 000. 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.

T he overall aim of the NHS R&D Health Technology Assessment (HTA) programme is to ensure that high-quality research information on the costs, effectiveness and broader impact of health technologies is produced in the most efficient way for those who use, manage and work in the NHS. Research is undertaken in those areas where the evidence will lead to the greatest benefits to patients, either through improved patient outcomes or the most efficient use of NHS resources. The Standing Group on Health Technology advises on national priorities for health technology assessment. Six advisory panels assist the Standing Group in identifying and prioritising projects. These priorities are then considered by the HTA Commissioning Board supported by the National Coordinating Centre for HTA (NCCHTA). This report is one of a series covering acute care, diagnostics and imaging, methodology, pharmaceuticals, population screening, and primary and community care. It was identified as a priority by the Acute Sector Panel and funded as project number 93/01/02. The views expressed in this publication are those of the authors and not necessarily those of the Standing Group, the Commissioning Board, the Panel members or the Department of Health. The editors wish to emphasise that funding and publication of this research by the NHS should not be taken as implicit support for the recommendations for policy contained herein. In particular, policy options in the area of screening will, in England, be considered by the National Screening Committee. This Committee, chaired by the Chief Medical Officer, will take into account the views expressed here, further available evidence and other relevant considerations. Reviews in Health Technology Assessment are termed 'systematic' when the account of the search, appraisal and synthesis methods (to minimise biases and random errors) would, in theory, permit the replication of the review by others.

Abstracts Gregory L. Moneta, MD, Section Editor Atherosclerotic Plaque Composition and Occurrence of Restenosis After Carotid EndarterectomyHellings WE, Moll FL, De Vries JP, et al. JAMA 2008;299:547-54. Conclusion: Lipid-rich inflammatory plaques are associated with a reduced risk of restenosis after carotid endarterectomy.Summary: Both clinical and angiographic criteria have been used to try to determine the risk of restenosis after a vascular intervention. The authors of this study evaluated the composition of the atherosclerotic plaque at the intervention site in terms of plaque features that may be related to carotid restenosis after carotid endarterectomy. There were 500 patients prospectively followed up between April 1, 2002, and March 14, 2006. Patients were assessed for carotid artery restenosis as measured by duplex ultrasound imaging 1 year after intervention. A Ͼ50% stenosis was defined as a peak systolic velocity of Ͼ125 cm/s and a Ͼ70% stenosis was defined as a peak systolic velocity of Ͼ230 cm/s. Carotid restenosis after carotid endarterectomy was determined with predefined histologic plaque characteristics. These included macrophage and smooth muscle cell infiltration, collagen, calcification, interplaque hemorrhage, luminal thrombus, and lipid core size. Comparisons were determined using multivariate logistic regression analysis and were adjusted for clinical characteristics.At 1 year, 85 patients (17%) had developed Ն50% carotid restenosis, and 40 (8%) developed Ն70% restenosis. Histologic examination of the plaque revealed that increased macrophage infiltration (n ϭ 286) had a lower risk of Ն50% restenosis than plaques with no or minor macrophage infiltration (n ϭ 215; 11.5% vs 24.3%; adjusted odds ratio [OR], 0.43; 95% confidence interval [CI], 0.26-0.72). Patients with higher macrophage infiltration also had a lower risk of developing Ն70% restenosis (4.5% vs 12.6%; adjusted OR, 0.36; 95% CI, 0.17-0.74). The 177 patients whose plaque had a lipid core that was Ͼ40% of plaque volume also had a lower risk of Ն50% restenosis than the 94 patients with a lipid core size of Ͻ10% (11.3% vs 25.5%; adjusted OR, 0.40; 95% CI, 0.19-0.81). A large lipid core also had a lower risk of developing Ն70% restenosis (5.6% vs 14.9%; adjusted OR, 0.42; 95% CI, 0.17-1.04).Comment: Many of the findings of this study are unexpected. Plaque characteristics of inflammation and higher lipid content, commonly thought to be associated with more dangerous plaques were, in this study, associated with lower rates of restenosis after carotid endarterectomy. Their other findings also seem in opposition to previous studies or prevailing opinion. For example, an incidence of 21% of Ͼ50% restenosis with Dacron patch angioplasty at 1 year is higher than usually reported. Also, vein and Dacron patches are not generally regarded as having much difference in their ability to prevent restenosis after carotid endarterectomy, but this study found vein patches were more much effective in preventing restenosis than Dacron patches. The...

et al. A systematic review update of the clinical effectiveness and cost-effectiveness of glycoprotein IIb/IIIa antagonists. Health Technol Assess 2002;6(25). Health Technology Assessment is indexed in Index Medicus/MEDLINE and Excerpta Medica/ EMBASE. Copies of the Executive Summaries are available from the NCCHTA website (see opposite). NHS R&D HTA Programme T he NHS R&D Health Technology Assessment (HTA) Programme was set up in 1993 to ensure that high-quality research information on the costs, effectiveness and broader impact of health technologies is produced in the most efficient way for those who use, manage and provide care in the NHS. The research reported in this monograph was commissioned by the HTA Programme on behalf of the National Institute for Clinical Excellence (NICE). Technology assessment reports are completed in a limited time to inform the appraisal and guidance development processes managed by NICE. The review brings together evidence on key aspects of the use of the technology concerned. However, appraisals and guidance produced by NICE are informed by a wide range of sources. The research reported in this monograph was funded as project number 00/04/02. The views expressed in this publication are those of the authors and not necessarily those of the HTA Programme, NICE or the Department of Health. The editors wish to emphasise that funding and publication of this research by the NHS should not be taken as implicit support for any recommendations made by the authors. Criteria for inclusion in the HTA monograph series Reports are published in the HTA monograph series if (1) they have resulted from work commissioned for the HTA Programme, and (2) they are of a sufficiently high scientific quality as assessed by the referees and editors. Reviews in Health Technology Assessment are termed 'systematic' when the account of the search, appraisal and synthesis methods (to minimise biases and random errors) would, in theory, permit the replication of the review by others.

No abstract