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. 2010 Aug;24(8):489-98.
doi: 10.1155/2010/379583.

A one-year economic evaluation of six alternative strategies in the management of uninvestigated upper gastrointestinal symptoms in Canadian primary care

Alan N Barkun  1 , Ralph Crott, Carlo A Fallone, Wendy A Kennedy, Jean Lachaine, Carey Levinton, David Armstrong, Naoki Chiba, Alan Thomson, Sander Veldhuyzen van Zanten, Paul Sinclair, Sergio Escobedo, Bijan Chakraborty, Sandra Smyth, Robert White, Helen Kalra, Krista Nevin
Affiliations

A one-year economic evaluation of six alternative strategies in the management of uninvestigated upper gastrointestinal symptoms in Canadian primary care

Alan N Barkun et al. Can J Gastroenterol. 2010 Aug.

Abstract
in English, French

Background: The cost-effectiveness of initial strategies in managing Canadian patients with uninvestigated upper gastrointestinalsymptoms remains controversial.

Objective: To assess the cost-effectiveness of six management approaches to uninvestigated upper gastrointestinal symptoms in the Canadian setting.

Methods: The present study analyzed data from four randomized trials assessing homogeneous and complementary populations of Canadian patients with uninvestigated upper gastrointestinal symptoms with comparable outcomes. Symptom-free months, qualityadjusted life-years (QALYs) and direct costs in Canadian dollars of two management approaches based on the Canadian Dyspepsia Working Group (CanDys) Clinical Management Tool, and four additional strategies (two empirical antisecretory agents, and two prompt endoscopy) were examined and compared. Prevalence data, probabilities, utilities and costs were included in a Markov model, while sensitivity analysis used Monte Carlo simulations. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were determined.

Results: Empirical omeprazole cost $226 per QALY ($49 per symptom-free month) per patient. CanDys omeprazole and endoscopy approaches were more effective than empirical omeprazole, but more costly. Alternatives using H2-receptor antagonists were less effective than those using a proton pump inhibitor. No significant differences were found for most incremental cost-effectiveness ratios. As willingness to pay (WTP) thresholds rose from $226 to $24,000 per QALY, empirical antisecretory approaches were less likely to be the most costeffective choice, with CanDys omeprazole progressively becoming a more likely option. For WTP values ranging from $24,000 to $70,000 per QALY, the most clinically relevant range, CanDys omeprazole was the most cost-effective strategy (32% to 46% of the time), with prompt endoscopy-proton pump inhibitor favoured at higher WTP values.

Conclusions: Although no strategy was the indisputable cost effective option, CanDys omeprazole may be the strategy of choiceover a clinically relevant range of WTP assumptions in the initial management of Canadian patients with uninvestigated dyspepsia.<p>

HISTORIQUE :: On ne s’entend toujours pas sur le rapport coût:efficacité des stratégies initiales de prise en charge des patients canadiens présentant des symptômes digestifs hauts non investigués.

OBJECTIF :: Évaluer le rapport coût:efficacité de six approches thérapeutiques aux symptômes gastro-intestinaux hauts non investigués, dans le contexte canadien.

MÉTHODE :: La présente étude a analysé les données de quatre essais randomisés visant à évaluer des populations homogènes et complémentaires de patients canadiens présentant des symptômes gastro-intestinaux hauts non investigués et des pronostics comparables. Le nombre de mois sans symptômes, les années de vie ajustées par la qualité (AVAQ) et les coûts directs en dollars canadiens de deux approches thérapeutiques établies à partir de l’outil de prise en charge clinique CanDys (pour Canadian Dyspepsia Working Group) et de quatre autres stratégies (deux agents antisécréteurs empiriques et deux endoscopies promptes) ont été analysés et comparés. Les auteurs ont inclus dans un modèle de Markov les données de prévalence, les probabilités, l’utilisation des services et les coûts, tandis que l’analyse de sensibilité a reposé sur des simulations de Monte Carlo. Les rapports coût:efficacité incrémentiels et les courbes d’acceptabilité coût:efficacité ont ainsi été déterminés.

RÉSULTATS :: L’oméprazole en traitement empirique coûte 226 $ par AVAQ (49 $ par mois sans symptômes) par patient. L’oméprazole et les approches endoscopiques selon l’indice CanDys ont été plus efficaces mais plus coûteux que l’oméprazole en traitement empirique. Les options à base d’anti-H2 ont été moins efficaces que les approches par inhibiteurs de la pompe à protons (IPP). Aucune différence significative n’a été observée pour les rapports coût:efficacité incrémentiels. À mesure que les seuils de volonté de payer (VDP) croissaient de 226 $ à 24 000 $ par AVAQ, les approches antisécrétrices empiriques étaient moins susceptibles d’être le choix le plus économique, l’oméprazole selon l’indice CanDys devenant progressivement une option plus probable. Pour les valeurs de VDP allant de 24 000 $ à 70 000 $ par AVAQ, l’éventail le plus cliniquement pertinent, l’oméprazole selon l’indice CanDys a été la stratégie la plus rentable (dans 32 % à 46 % des cas), la stratégie endoscopie prompte-IPP étant préférée avec les valeurs de VDP plus élevées.

CONCLUSIONS :: Bien qu’aucune stratégie ne se soit démarquée comme la plus rentable, l’oméprazole selon l’indice CanDys pourrait être la stratégie de choix pour un éventail cliniquement pertinent d’hypothèses de VDP dans la prise en charge initiale des patients canadiens souffrant de dyspepsie non investiguée.

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Figures

Figure 1)
Figure 1)
Markov model of 12-month treatment strategies for the management of uninvestigated dyspepsia. Open square: decision node; Solid circle (M): Markov node; Open circle: probability node; Triangle: terminal node. Each alternative is represented by a Markov model, and the stated probabilities determine the weight of each arm. The patient enters the model in the symptomatic state, and proceeds through the initial cycle, either ending in a symptomatic remission state or remaining symptomatic. In the Canadian Dyspepsia Working Group (CanDys) and prompt endoscopy alternatives, the symptom and Helicobacter pylori (Hp, HP) status probabilities are determined according to extracted trial data. Tracker variables were used to ensure that the appropriate probabilities and costs were associated with discrete patient groups and carried from one cycle to the next. Asympt Asymptomatic; cont Continue; EA Empirical antisecretory; GERD Gastroesophageal reflux disease; H2RA H2-receptor antagonist; Hp neg Helicobacter pylori negative; NSAIDs Nonsteroidal anti-inflammatory drugs; ome omeprazole; pos Positive; PPI Proton pump inhibitor; pred Predominant; ran Ranitidine; remiss Remission; SFHTBN Free of heartburn symptoms; Sympt symptomatic; UBT Urea breath test
Figure 2)
Figure 2)
Incremental cost-effectiveness defined as incremental costs ($)/incremental quality-adjusted life-year (QALY) compared with the baseline (least costly) strategy: Empirical omeprazole (each mark represents a simulation). Note that the y axis was truncated at $10,000 to better illustrate the results and a sample of 500 simulations was charted. CanDys Canadian Dyspepsia Working Group; H2RA H2-receptor antagonist; PPI Proton pump inhibitor
Figure 3)
Figure 3)
Acceptability curve of all strategies. Plot representing the changing percentage of iterations for which each comparator is cost effective relative to all other strategies. The x axis displays varying levels of willingness to pay ($ per quality-adjusted life-year) and the y axis displays the proportion of simulations falling under this threshold. Note that the x axis has been truncated at $100,000 to better illustrate the changing curves. CanDys Canadian Dyspepsia Working Group; H2RA H2-receptor antagonist; PPI Proton pump inhibitor
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