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

To compare the cost and utility of healing and maintenance regimens of omeprazole and laparoscopic Nissen fundoplication (LNF) in the framework of the Canadian medical system.

Medical therapy with proton pump inhibitors for endoscopically proven reflux esophagitis is a safe and effective treatment option. Of late, the surgical treatment of choice for this disease has become LNF.

The authors' base case was a 45-year-old man with erosive reflux esophagitis refractory to H2-blockers. A cost-utility analysis was performed comparing the two strategies. A two-stage Markov model (healing and maintenance phases) was used to estimate costs and utilities with a time horizon of 5 years. Discounted direct costs were estimated from the perspective of a provincial health ministry, and discounted quality-of-life estimates were derived from the medical literature. Sensitivity analyses were performed to test the robustness of the model to the authors' assumptions and to determine thresholds. A Monte Carlo simulation of 10,000 patients was used to estimate variances and 95% interpercentile ranges.

For the 5-year period studied, LNF was less expensive than omeprazole (3519.89 dollars vs. 5464.87 dollars per patient) and became the more cost-effective option at 3.3 years of follow-up. The authors found that 20 mg/day omeprazole would have to cost less than 38.60 dollars per month before medical therapy became cost effective; conversely, the cost of LNF would have to be more than 5,273.70 dollars or the length of stay more than 4.2 days for medical therapy to be cost effective. Estimates of quality-adjusted life-years did not differ significantly between the two treatment options, and the incremental cost for medical therapy was 129,665 dollars per quality-adjusted life-years gained.

For patients with severe esophagitis, LNF is a cost-effective alternative to long-term maintenance therapy with proton pump inhibitors.