Decision making in gastroesophageal reflux disease. What are the critical issues?

This article has identified several crucial decision points in the management of GERD. Although there seems to be a strong epidemiologic association with esophageal adenocarcinoma, the clinical and economic benefits of screening endoscopy are not clear. Given the low incidence of this cancer, it is conceivable that screening programs in these patients, such as colon cancer screening and breast cancer screening, may provide a greater health benefit at a lower incremental cost. Surveillance endoscopy in BE is another contentious issue, with the surveillance interval and cost-effectiveness hinging on the cancer risk. As more precise estimates of cancer risk, accounting for publication bias, are derived, the economics of surveillance will require further evaluation. Finally, several, management strategies seem to improve outcomes for patients with uninvestigated GERD, but the incremental costs of the more effective step-down approach seem minimal. More important than the initial strategy may be the ability to implement a systematic approach to care that ensures that patients attempt step-down when symptoms are resolved and do not remain on potent therapy indefinitely when it is not necessary. The results of prospective effectiveness trials are anticipated to validate the findings of these economic analyses.