Cost-Effective pH Testing Can Rule Out GERD

Esophageal pH monitoring is more cost effective than the long-term use of proton-pump inhibitors (PPIs), since it can help rule out gastroesophageal reflux diseases (GERD) and avoid the unneeded costs associated with prolonged medication therapy, according to a study presented at Digestive Disease Week 2013, held May 18-21, 2013, in Orlando, Fla.

Although the testing requires placing a recording device in the esophagus, researchers from New York Presbyterian Hospital and Weill-Cornell Medical College, in New York, found it could substantially reduce the cost of treating GERD with PPIs.

Most guidelines recommend an eight-week trial of PPIs and monitoring for whether symptoms have completely subsided. David Kleiman, MD, a research fellow in the surgery department at New York Presbyterian Hospital, made a case for closely following the guidelines, as he indicated the current study found patients will often stay on the drugs for much longer periods of time despite the fact that they have not received confirmation of the diagnosis through an objective test.

“The burden that GERD places on our health care system is immense,” Kleiman said. “It is the most common gastrointestinal indication for all health care encounters and results in $12 billion of direct costs every year. The vast majority of these costs are related to proton-pump inhibitor use.”

Kleiman and colleagues compared the common early GERD management practice of taking PPIs empirically and for as long as they are believed to be effective with the results of 24-hour esophageal pH monitoring after completing only eight weeks of medical therapy to confirm or rule out the diagnosis of GERD.

Using data from 100 patients who underwent pH monitoring, the researchers found 6,764 weeks of PPI therapy — or 32 percent all PPI therapy — was prescribed to patients with no evidence of GERD, and thus unnecessary.

The research team estimates a cost savings of up to $7,300 per patient during a 10-year period with early pH monitoring. While that amount is based on patients taking the most expensive PPI and receiving the most accurate pH monitoring, Kleiman said a more generalized projection would be about $6,500 for patients taking the most likely PPI and receiving an assumed limitation of the pH monitoring.

In a separate evaluation, the researchers found that between six and 23 weeks of PPI therapy reaches cost equivalence, depending on the drug and the dose. Patients in the study were on PPI therapy for a median of 152 weeks before being referred, which far exceeded cost equivalency. Some patients were taking the drugs for no reason for as long as 20 years, Kleiman said. Three-quarters of the study population reported either no relief or partial relief with the drugs, and 15 percent had a complete resolution of symptoms. Kleiman advised clinicians not to delay pH testing as a cost-saving measure.

“We believe more patients should be referred for pH monitoring earlier in the course of their management, immediately after the eight-week empiric PPI trial,” Kleiman said. “We believe earlier identification of patients who do not have GERD would enable clinicians to continue to seek the true cause of the patient’s symptoms and may lead to earlier identification of potentially serious alternative diagnoses, such as heart disease or cancer, which may improve outcomes, as well as save money.”