On Doctoring MEDLINE searches, with reference librarian comments, March 2000

The question was

Gastroesophageal Reflux (GERD)- most people need lifelong Rx. The choices are medicine for life (proton pump inhibitors) or surgery (laproscopic nissen fundoplication). Which is safer? Which is cost effective? Which is more effective?

1     Gastroesophageal reflux/dt,su,th [Drug Therapy, Surgery,    results=1829   
Therapy]
2     exp Cost-benefit analysis/    results= 12231   
3     1 and 2    results= 27   
4     exp "outcome assessment (health care)"/ or Treatment    results= 90578   
outcome/
5     1 and 4    results= 375   
6     Fundoplication/    results= 727   
7     5 and 6    results= 190   
8     "PROTON PUMP INHIBITOR".mp.    results= 600   
9     7 and 8    results= 3   

Reference Librarian comments

Your MEDLINE searching is good. You used subject-headings appropriately; you selected subheadings, combined sets, etc. Thanks for participating in the assignment.

I thought I'd try the search myself, from a different perspective. Given that YOUR search seems reasonable to me, I intentionally took a different tack. I thought I'd simplify my thinking - like this:

"gastroesophageal reflux, the economics" (and that's all...)

(this is based on the assumption that the common available therapeutic measures are well-known; I don't need to search for them; they'll be discussed in any paper on the economic aspects of GERD...)

For the best possible search, I'd probably combine something like what YOU did, with something like what I did. See below.

Oh, one more thing: in addition to MEDLINE, I repeated the search in "HealthSTAR," which is a database which addresses those "non-clinical" aspects of medicine (costs, manpower, legislation, etc.).

The process is to "change databases" (in Ovid), select HealthStar, say "YES" to Ovid's offer to re-run the same search you just did in MEDLINE, and then check the "non-Medline" check-box when you get into HealthSTAR, so that you don't see any duplicates. This process resulted in one more reference, which looks VERY relevant to me. See below..

Medline 1991 to January 2000

#
Search History
Results
1
exp *Gastroesophageal reflux/ec [Economics]
18
2
limit 1 to (human and english language)
15

<1>
AN 99210095
AU Heikkinen TJ. Haukipuro K. Koivukangas P. Sorasto A. Autio R. Sodervik
H. Makela H. Hulkko A.
IN Department of Surgery and Health Economics, Oulu University Hospital,
Finland.
TI Comparison of costs between laparoscopic and open Nissen fundoplication: a
prospective randomized study with a 3-month followup.
SO Journal of the American College of Surgeons. 188(4):368-76, 1999 Apr.
LM MFHSL. Incomplete holdings, check catalog.
AB BACKGROUND: Laparoscopic antireflux surgery has replaced
conventional operation despite the fact that currently no randomized trials
have been published regarding its cost effectiveness. The objective of the
present study was to compare costs and some short-term outcomes of
laparoscopic and open Nissen fundoplication. STUDY DESIGN: Forty-two patients
with documented gastroesophageal reflux
disease were randomized between October 1995 and October 1996 to either
laparoscopic (LNF) or open (ONF) Nissen fundoplication. Some short-term
outcomes, Gastrointestinal Quality of Life Index (GIQLI) hospital costs, and
costs to society were assessed. Followup was 3 months. RESULTS: Medians of
operation times in the LNF and ONF groups were 98 min and 74 min,
respectively. Hospital stay was 2.5 days shorter after laparoscopic operation
(LNF 3 days versus ONF 5.5 days). Both operations were equally safe and
effective, but the LNF group experienced significantly less pain and fatigue
during the first 3 postoperative weeks. Improvement in the GIQLI and overall
patient satisfaction were comparable between the methods. Convalescence was
faster in the LNF group: return to normal life being 14 versus 31 days and
return to work being 21 versus 44 days in the LNF and ONF groups,
respectively. Hospital costs were similar, $2,981 and $3,140 in the LNF and
ONF groups, respectively, but total costs were lower ($7,506 versus $13,118)
in the LNF group as a result of an earlier return to work. CONCLUSIONS: LNF
is superior in cost effectiveness, assuming that the longterm results between
the methods are comparable.

<2>
AN 98166777
AU Eggleston A. Wigerinck A. Huijghebaert S. Dubois D. Haycox A.
IN Janssen Research Foundation, Beerse, Belgium.
TI Cost effectiveness of treatment for gastro-oesophageal
reflux disease in clinical practice: a clinical database
analysis [see comments].
CM Comment in: Gut 1998 Nov;43(5):728; discussion 729-30, Comment in: Gut 1998
Nov;43(5):728-9; discussion 729-30, Comment in: Gut 1998 Nov;43(5):729-30
SO Gut. 42(1):13-6, 1998 Jan.
LM Pre-1993 Dana; 1993-dateMFHSL;for Web access-check catalog
AB BACKGROUND: Previous evaluation of the cost effectiveness of
antireflux medication used in gastro-oesophageal
reflux disease (GORD) have been based on results obtained in
controlled clinical trials. Unfortunately such an approach does not
necessarily identify the therapeutic option which provides the greatest
benefit from available resources in real life situations. To make an informed
choice requires a recognition that the costs and benefits of therapy in
practice may differ from those identified in trials. AIMS: To evaluate, based
on a retrospective prescription database analysis, the cost effectiveness of
alternative treatment options for patients with uncomplicated GORD. The
analysis assesses health service resource use during the first six months of
treatment in three groups of patients initially prescribed cisapride (CIS),
ranitidine (RAN), or omeprazole (OME). METHODS: The MediPlus UK database was
used to identify all health care resources consumed by patients in the three
treatment groups during their first six months of treatment. Patients with
more complicated GORD, as indicated by initial referral to a specialist or
outpatient hospital visit (< 13%), were excluded from the analysis. RESULTS:
The average cost per patient for the initial six months of treatment for CIS,
RAN, and OME based therapies was 136 Pounds, 177 Pounds, 189 Pounds per
patient, respectively. A major element underlying this cost variation was the
acquisition cost and quantity of antireflux medication
required by patients. The average number of one month equivalent
prescriptions consumed during this six month period was 1.85 (CIS), 2.57
(RAN), and 2.96 (OME) with associated costs of 49 Pounds (CIS), 67 Pounds
(RAN), and 105 Pounds (OME). Antacid and alginate/antacid use was higher in
the CIS and RAN groups (about 1.0 antacid prescription per patient versus 0.4
for OME), but their contribution to the total cost per patient was less than
2%. The number of general practitioner consultations over the six month
period for each treatment group was 2.4 (CIS), 2.9 (RAN), and 2.6 (OME) with
associated costs of 60.31 Pounds (CIS), 73.06 Pounds (RAN), and 65.52 Pounds
(OME). The average number of non-drug interventions (referrals, outpatient
visits, endoscopies, barium meals, or x rays) was 0.34 in the RAN group
compared with less than 0.2 in the CIS and OME groups. The costs associated
with such interventions were 23.80 Pounds (RAN), 9.60 Pounds (CIS), and 11.10
Pounds (OME) per patient. CONCLUSION: The data indicate that the "step up"
approach, starting with a prokinetic or H2 receptor antagonist, represents
the most cost effective initial therapeutic strategy for a primary care
physician to adopt when faced with a patient with first diagnosis of
uncomplicated GORD.

<3>
AN 97426263
AU Viljakka M. Nevalainen J. Isolauri J.
IN Medical School, Dept. of Surgery, University of Tampere, Finland.
TI Lifetime costs of surgical versus medical treatment of severe
gastro-oesophageal reflux disease in Finland.
SO Scandinavian Journal of Gastroenterology. 32(8):766-72, 1997 Aug.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB BACKGROUND: Gastro-oesophageal reflux disease (GERD) can be
effectively treated pharmacologically or surgically. As GERD is often a
chronic condition, we compared the long-term costs of medical and surgical
management. METHODS: The medical regimens were ranitidine (150 or 300
mg/day), omeprazole (20 or 40 mg/day), and lansoprazole (30 mg/day), with
costs calculated for total life expectancy after diagnosis and for one-third
of that time. Costs for open or laparoscopic surgery (Nissen fundoplication)
included pre- and post-operative investigations, sick leave, and calculated
financial loss due to fatal outcome. RESULTS: Costs were lowest with
ranitidine, 150 mg/day, for one-third of the patient's lifetime and highest
with lifelong omeprazole, 40 mg/daily. The cost of open or laparoscopic
operation was less than that of lifelong daily treatment with proton pump
inhibitors or ranitidine, 300 mg daily. CONCLUSION: In Finland,
antireflux surgery for GERD is cheaper than lifetime
treatment with proton pump inhibitors.

<4>
AN 98006740
AU Sadowski D. Champion M. Goeree R. Leddin D. Otten N. Morris G. Beck I.
Faloon T. Fedorak RN.
IN Department of Medicine, University of Alberta, Edmonton.
TI Health economics of gastroesophageal
reflux disease.
SO Canadian Journal of Gastroenterology. 11 Suppl B:108B-112B, 1997 Sep.
LM Not at Dartmouth/DHMClibraries;request on interlibrary loan.
AB The present study provides an overview of the current state of health
economics studies of gastroesophageal
reflux disease (GERD). It indicates the strengths and
weaknesses of individual studies, and the state of health economics analysis
in general as they apply to GERD. Specifically, this study adopts a
pharmacoeconomic perspective, which is a subsection of health economics
analytical methods, to provide a comparative analysis of alternative courses
of action based on cost and consequence. The pharmacoeconomic outlook is most
effective when it considers a comprehensive societal perspective, with
special consideration given to other relevant viewpoints, such as the payer,
the primary provider and, most important, the patient. Pharmacoeconomics
provides several specific analytical techniques for GERD-related health
economics analysis. The Canadian Association of Gastroenterology consensus
conference on GERD in 1996 thought that a cost effective analysis was the
most appropriate technique to assess the pharmacoeconomics of GERD. Six
previous studies on GERD health economics have been performed comparing
omeprazole with H2 receptor antagonists. These studies vary in cost data
collected and in analytical techniques. In general, the existing outcome
measurements of these previous health economics studies are not ideal.
Namely, they combine various GERD grades, use randomized controls, are
endoscopically based, assess pharmaceutical therapy only and are short term.
More appropriate health economic trials in GERD, which focus on GERD
management strategies and therapeutic treatment of GERD, need to be designed
and conducted. These economic assessments, however, should not replace
detailed thinking, careful observation, good judgement and common sense.

<5>
AN 97126367
AU Sridhar S. Huang J. O'Brien BJ. Hunt RH.
IN Department of Medicine, McMaster University Medical Centre, Hamilton,
Ontario, Canada.
TI Clinical economics review: cost-effectiveness of treatment alternatives for
gastro-oesophageal reflux disease. [Review] [49 refs]
SO Alimentary Pharmacology & Therapeutics. 10(6):865-73, 1996 Dec.
LM Not at Dartmouth/DHMClibraries;request on interlibrary loan.
AB Gastro-oesophageal reflux disease is a chronic recurring
disorder, which is widespread, especially in Western societies. Faced with
increasing health costs and finite resources, an increasingly important part
of evaluating new treatments is economic appraisal. In this paper, we review
critically the published economic studies of the cost-effectiveness of
treatments for gastro-oesophageal reflux disease. Proton
pump inhibitors are considered the best choice for the management of grades
II-IV oesophagitis and are more cost-effective than H2-receptor antagonists
because of their fast healing of oesophagitis, early relief of symptoms, and
prevention of recurrent oesophagitis and development of complications.
[References: 49]

<6>
AN 97043147
AU Steele GH.
IN Department of Medicine, Allegheny University of the Health Sciences,
Philadelphia, Pennsylvania, USA.
TI Cost-effective management of dyspepsia and gastroesophageal
reflux disease. [Review] [52 refs]
SO Primary Care; Clinics in Office Practice. 23(3):561-76, 1996 Sep.
LM Dana Biomedical Library (Dana).
AB Dyspepsia and heartburn are common symptoms in primary care practice. This
article outlines the diagnosis and management of these problems with an
emphasis on cost-effectiveness as well as the prevention of complications. It
reviews what evaluations and treatments have been shown in the literature to
be helpful and which have been found to be ineffective or much more expensive
without clear benefit. It also clarifies the various diseases that can
present as dyspepsia and refers readers to the appropriate articles included
in this book. [References: 52]

<7>
AN 96402863
AU Van Den Boom G. Go PM. Hameeteman W. Dallemagne B. Ament AJ.
IN Dept. of Health Economics, University of Limburg, Maastricht, Netherlands.
TI Cost effectiveness of medical versus surgical treatment in patients with
severe or refractory gastroesophageal
reflux disease in the Netherlands.
SO Scandinavian Journal of Gastroenterology. 31(1):1-9, 1996 Jan.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB BACKGROUND: For a significant number of patients with severe or refractory
gastroesophageal reflux disease,
maintenance treatment with omeprazole and reflux surgery
(Nissen fundoplication) are alternative treatment options. In this study
maintenance treatment with omeprazole is compared with open and laparoscopic
Nissen fundoplication from a health-economic perspective. METHODS:
Meta-analysis of published articles to assess effectiveness and simple
decision-analytic techniques to combine costs and effects are used. Findings
and assumptions are submitted to sensitivity analysis. RESULTS: It is
estimated that it costs approximately 1880 Dutch guilders to initially heal a
patient with severe or refractory esophagitis with 40 mg omeprazole daily.
When medical maintenance therapy was compared with surgery, it appeared that
medical maintenance therapy with omeprazole (20-40 mg daily) for a prolonged
period of time (more than 4 years) is less cost effective than a Nissen
procedure. It is estimated that a laparoscopic Nissen will shift this
so-called break-even point towards 1.4 years, mainly due to a shorter
hospital stay. CONCLUSIONS: Although caution is required in drawing
conclusions, it appears that replacing treatment with (laparoscopic) Nissen
fundoplications in these patients might lead to substantial savings.

<8>
AN 96117881
AU Glise H.
IN Dept. of Surgery, NAL, Trollhattan, Sweden.
TI Quality of life and cost of therapy in reflux disease.
[Review] [33 refs]
SO Scandinavian Journal of Gastroenterology - Supplement. 210:38-42, 1995.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB BACKGROUND AND RESULTS IN THE LITERATURE: Reflux symptoms
are common, with an incidence of up to 40% monthly and 7% daily in the
general adult population. The duration of symptoms in patients seeking help
for reflux is often in excess of 5 years in an unselected
population. A majority, 70%, of those with daily symptoms do not have
esophagitis at endoscopy but still require regular medication for symptom
control. After treatment, relapse is seen in a majority of cases in whom
esophagitis is present at start of therapy. Symptoms of
reflux and upper abdominal dyspepsia affect several aspects
of daily living. Consequently quality of life (QoL) is low in patients with
reflux esophagitis and upper dyspepsia. Values normalize
during medical treatment or after surgery for reflux
esophagitis. Cost of treatment is complex. Evaluations in patients with
reflux esophagitis are based on the effectiveness and cost
of the drug, the cost of investigations and time lost from work. In
comparisons based on the results of clinical healing trials, omeprazole has
been found the most cost-effective drug for treatment of
reflux esophagitis. There are as yet no evaluations made for
patients with reflux symptoms only. CONCLUSIONS: The
consequences for the patient and society regarding QoL and costs for
reflux symptoms should be evaluated more closely to optimize
future therapy. [References: 33]

<9>
AN 92328616
AU Hillman AL. Bloom BS. Fendrick AM. Schwartz JS.
IN General Internal Medicine Division, University of Pennsylvania,
Philadelphia.
TI Cost and quality effects of alternative treatments for persistent
gastroesophageal reflux disease.
SO Archives of Internal Medicine. 152(7):1467-72, 1992 Jul.
LM Dana (complete) and MFHSL (incomplete, check catalog).
AB BACKGROUND--Gastroesophageal reflux
disease is commonly encountered by general internists and
gastroenterologists. METHODS--We used decision analysis to assess the
clinical and economic effects of three treatments--phase 1 therapy alone or
combined with omeprazole or ranitidine hydrochloride therapy--for patients
with persistent, symptomatic grade 2 or higher
gastroesophageal reflux disease. To the
maximum extent possible, data were obtained from the published literature. We
convened an expert consensus panel to estimate specific data points when they
were unavailable or contradictory in the literature, including estimates of
optimal and actual clinical practice patterns. A 7-month model was used to
correspond to the time frame of available clinical trial data. The
perspective of the analysis was that of the payer. The costs of medical care
for various clinical outcomes were based on actual mean payments made by
Independence Blue Cross of Philadelphia and Pennsylvania Blue Shield.
RESULTS--Although the retail payments for daily omeprazole therapy are the
highest among the three interventions tested, it produced both the lowest
expected overall payments for medical care and the most effective strategy
for treating symptoms during the 7-month model. Omeprazole therapy was
consistently approximately $1800 less costly than ranitidine therapy and
$2700 less costly than phase 1 therapy alone during the period examined,
regardless of whether empiric or nonempiric treatment strategies were used.
Even when payments for major complications (the most important cost variable)
were reduced by 80%, omeprazole therapy resulted in payments 17% and 22%
lower than those associated with ranitidine therapy and phase 1 therapy
alone, respectively. Omeprazole also produced the most symptom-free months
during the 7-month follow-up period. The clinical and economic outcomes of
performing an initial diagnostic workup, compared with treating patients
empirically, were equal. CONCLUSIONS--We conclude that omeprazole therapy is
the preferred initial therapeutic approach for patients with persistent,
symptomatic gastroesophageal reflux disease
in whom phase 1 therapy fails. Assessment of long-term approaches must await
the results of extended clinical studies.

=== and this one, from HealthSTAR

<1>
AN 99112069
AU Holzer SS. Juday TR. Joelsson B. Crawley JA.
IN MEDSTAT Group, Washington, DC 20008, USA.
TI Determining the cost of gastroesophageal
reflux disease: a decision analytic model.
SO American Journal of Managed Care. 4(10):1450-60, 1998 Oct.
LM Not at Dartmouth/DHMClibraries;request on interlibrary loan.
AB OBJECTIVE: To design a decision analytic model to help determine the costs
associated with various treatment regimens for
gastroesophageal reflux disease (GERD).
STUDY DESIGN: A decision analytic model incorporating Markov processes was
developed to calculate clinical and direct economic outcomes for patients
with GERD after 2 years of treatment. PATIENTS AND METHODS: We used
retrospective data in the Markov model to generate clinical and economic
outcomes. The primary data sources were the 1993 MarketScan claims database,
the 1992 National Hospital Discharge Survey, and the clinical literature.
RESULTS: Patients with mild GERD (17.6% of patients) contributed 37.8% of
costs, while those with moderate to severe disease (14.4% of patients)
contributed 49.9% of costs. The remaining 12.3% of costs was spent on the 68%
of patients with non-GERD diagnoses. The class of drugs with the highest
acquisition cost--proton pump inhibitors--had the lowest total cost per case.
The high level of efficacy of these drugs may explain this result.
Sensitivity testing showed no evidence that our model's results depended
heavily on any one probability or cost factor. CONCLUSIONS: This model showed
that patients with moderate to severe GERD were the most expensive cases to
treat and that proton pump inhibitors resulted in the lowest total cost per
case. Further testing and manipulation of the model are required to gain a
better understanding of the trade-offs involved in different options for GERD
management. (Abstract by: Author)