Early Referral for Esophageal pH Monitoring Is More Cost-Effective Than Prolonged Empiric Trials of Proton-Pump Inhibitors for Suspected Gastroesophageal Reflux Disease

Abstract

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.

BRAVO esophageal pH monitoring: more cost-effective than empiric medical therapy for suspected gastroesophageal reflux

“…Patients were stratified into four groups based on GERD symptoms and BRAVO pH monitoring results as we previously described [8]. The four groups included patients with positive or negative BRAVO pH monitoring results and patients with typical or atypical symptoms.…”

“…A cost equivalence calculation was first performed to calculate the time period (in weeks) necessary for the cost of PPIs to reach equivalence with the cost of BRAVO pH monitoring, as previously described [8]. In the formula below, N represents the cost equivalence point (in weeks):…”

“…On the other hand, patients with extraesophageal symptoms are more difficult to diagnose and thus should undergo pH monitoring sooner in the diagnostic algorithm. Various pH monitoring devices have been used, including 24-h transnasal catheter placement and BRAVO wireless esophageal pH probe monitoring, which have both been proven as effective modalities to accurately diagnose GERD [8][9][10][11].…”

“…We previously reported our experience with early referral for 24-h pH monitoring and demonstrated a costeffective algorithm [8]. Avoidance of unnecessary empiric PPIs for an indefinite time period alleviates a spending burden on the healthcare system as well as avoids potential unwanted side effects associated with their widespread use.…”

“…Avoidance of unnecessary empiric PPIs for an indefinite time period alleviates a spending burden on the healthcare system as well as avoids potential unwanted side effects associated with their widespread use. While transnasal 24-h pH monitoring is an effective tool for diagnosis of GERD, it is limited by a broad range of sensitivities (30-96 %) as previously described [8]. Moreover, patient discomfort and behavior modification during those 24 h preclude most patients and physicians from choosing this testing modality.…”