Assessing the value of symptom relief for patients with gastroesophageal reflux disease treatment: willingness to pay using a discrete choice experiment.

OBJECTIVES: To assess patients' preferences and estimate willingness to pay (WTP) for gastroesophageal reflux disease (GERD) treatments. METHOD: Patients were randomly selected from a multicenter clinical study to participate in the discrete choice experiment (DCE) survey. Relevant treatment attributes were identified through literature review, clinical expert consultation, and focus groups. The DCE included 14 choice tasks composed of six attributes, three treatment profiles, and a "none"option considering orthogonality, D-efficiency, and level balance, while keeping patient response burden reasonable. Individual-level preferences and WTP were estimated by aggregate-level conditional logit and hierarchical Bayes analyses. RESULTS: Our sample of 361, drawn from a clinical trial, had a mean age of 57 years, were primarily women (53%), and rated their GERD symptoms as mild/moderate (31%) and moderately severe/severe (7%). Most important attributes of GERD treatment were (in order) as follows: avoiding side effects, sleeping discomfort, daytime discomfort, dietary changes, medication cost, and treatment frequency. Simulations found that patients are willing to pay an additional US $36 to reduce susceptibility to side effects from moderate to mild or to decrease the frequency of sleeping discomfort. Patients 65 years or older were willing to pay less for daytime discomfort relief, while women would pay more to avoid sleeping discomfort. CONCLUSIONS: Key factors concerning patients with GERD and their preference for treatment features to control GERD symptoms were confirmed. A DCE estimated WTP by GERD sufferers for relief from symptoms and avoidance of side effects using relevant treatment costs. These findings may help guide clinical treatment decisions for individual patients to improve GERD symptom control.

The gain in quality-adjusted life months by switching to esomeprazole in those with continued reflux symptoms in primary care: EncomPASS--a cluster-randomized trial.

OBJECTIVES: Proton pump inhibitors (PPIs) are effective in gastroesophageal reflux disease (GERD), but their cost effectiveness is unknown. This is usually determined by cost/quality-adjusted life year (QALY) gained, but whether PPI therapy improves QALYs has not been assessed in a randomized trial. The PPI acid suppression symptom (PASS) test is a five-item questionnaire that identifies patients with persistent acid-related symptoms. We evaluated whether a PASS test-based management strategy of changing GERD therapy to esomeprazole in those with continued symptoms on another PPI or H(2) receptor antagonist therapy would be cost effective. We expressed the data in terms of cost per quality-adjusted life months (QALM), as this was a 4-week trial. METHODS: This is a multicenter, cluster-randomized, open-label study in primary care physician centers across Canada. Primary care physician centers were randomized to intervention or control arms. Patients on acid-suppressing medication were identified from primary care records and asked to complete the PASS test. PASS test failures at baseline assessment continued current therapy in control practices or switched to esomeprazole 20 or 40 mg daily (the dose was at the clinician's discretion) for 4 weeks in intervention practices. A planned secondary end point was QALM gain, measured using the validated Euroqol (EQ-5D) completed at baseline and 4 weeks. Medication use was also assessed by questionnaire. Canadian unit generic costs were applied to all GERD drugs, except to esomeprazole and lansoprazole, wherein proprietary costs were used (all costs in Canadian $). Data were analyzed using bootstrap sampling. RESULTS: A total of 1,564 patients were recruited from 134 intervention sites and 92 control sites. Data were evaluable for 808 intervention and 445 control patients. The mean (±standard deviation) QALM at 4 weeks in the intervention group was 0.885±0.164 compared with 0.814±0.179 in the control group, resulting in a mean 0.071 (95% CI=0.091-0.051) QALM gain (P<0.0001). Esomeprazole was cost effective for PASS test failures, with a mean cost of $763 (95% CI=456-1,414) per QALM gain. CONCLUSIONS: Esomeprazole was associated with a statistically significant gain in QALMs and was cost effective in primary care patients with persistent acid-related symptoms identified by the PASS test.