Marked increase in proton pump inhibitors use in Australia.

OBJECTIVES: To examine the trends in the prescribing of subsidized proton pump inhibitors (PPIs) and histamine receptor antagonists (H2RAs), in the Australian population from 1995 to 2006 to encourage discussion regarding appropriate clinical use. PPIs and H2RAs are the second highest drug cost to the publicly subsidized Pharmaceutical Benefits Scheme (PBS). DESIGN: Government data on numbers of subsidized scripts, quantity and doses for PPIs and H2RAs were analysed by gender and age, dose and indication. MAIN OUTCOME MEASURE: Drug utilisation as DDD [defined daily dose]/1000 population/day. RESULTS: The use of combined PPIs increased by 1318%. Utilisation increased substantially after the relaxation of the subsidized indications for PPIs in 2001. Omeprazole had the largest market share but was substituted by its S-enantiomer esomeprazole after its introduction in 2002. There was considerable use in the elderly with the peak use being in those aged 80 years and over. The utilisation of H2RAs declined 72% over 12 years. CONCLUSIONS: PPI use has increased substantially, not only due to substitution of H2RAs but to expansion in the overall market. Utilisation does not appear to be commensurate with prevalence of gastro-oesophageal reflux disease (GORD) nor with prescribing guidelines for PPIs, with significant financial costs to patients and PBS. This study encourages clinical discussion regarding quality use of these medicines.

Economic analysis of on-demand maintenance therapy with proton pump inhibitors in patients with non-erosive reflux disease.

AIM: To evaluate the costs and effectiveness of on-demand maintenance therapy with oral esomeprazole, lansoprazole, omeprazole, pantoprazole or rabeprazole in patients with endoscopy-confirmed non-erosive reflux disease (NERD) in the UK. METHODS: A probabilistic model was developed to compare the costs and effectiveness of five proton pump inhibitors (PPIs) in endoscopy-negative, symptomatic NERD patients who had complete resolution of heartburn symptoms following 4 weeks of open-label acute PPI treatment. The total annual expected costs (euro, 2003 values) and utilities gained per patient were measured over a 1-year horizon from the perspective of the UK NHS. Model uncertainty was addressed by sensitivity analyses. RESULTS: The base-case annual median costs and utilities gained with on-demand PPI therapy were: 123 euro and 0.89 for rabeprazole 10mg; 176 euro and 0.90 for pantoprazole 20mg; 190 euro and 0.89 for esomeprazole 20mg; 195 euro and 0.91 for lansoprazole 15mg; 201 euro and 0.90 for omeprazole 20mg; and 210 euro and 0.91 for omeprazole 10mg. Differences in costs, but not in outcomes, were statistically significant. The results were robust to sensitivity analyses. CONCLUSIONS: In this analysis, on-demand use of rabeprazole for the management of NERD incurred the least cost in comparison with the other PPIs evaluated. Utility gains were comparable for all on-demand PPIs. The place of on-demand PPIs in therapy, however, requires further evaluation.

Social and medical impact, sleep quality and the pharmaceutical costs of heartburn in Taiwan.

BACKGROUND: Little is known about the social and medical burdens of heartburn in Asia. AIM: To assess the impact of heartburn in Taiwan. METHODS: We applied a questionnaire to 2018 apparently healthy adult Chinese receiving a routine health maintenance programme. Costs of heartburn-related prescriptions were obtained from the Bureau of National Health Insurance of Taiwan. RESULTS: Heartburn prevalence (>1 episode/week) was 7%. Smoking and increased body mass index were associated with heartburn occurrence. Heartburn sufferers reported more atypical gastro-oesophageal reflux disease symptoms, e.g. chest pain, dysphagia and globus. They were more likely to consult physicians, and have an increased frequency and number of days of absenteeism, irrespective of upper gastrointestinal or nongastrointestinal-related illnesses. They experienced sleep disturbances more frequently. The 62 heartburn consulters (48%) were more likely to have co-existing globus, visited physicians more, had more absenteeism, suffered from more sleep disturbances and had higher costs for antacids, proton pump inhibitors, hypnotic/sedatives, tranquilizers and antidepressants than nonconsulters. CONCLUSIONS: Heartburn prevalence in Taiwan is lower than in Western countries. Nevertheless, heartburn in Taiwanese creates a significant burden in terms of social impact, health resource utilization, sleep quality and pharmaceutical costs. The increased costs of psychoactive drugs in consulters suggest that anxiety/depression affects their health-seeking behaviour.

Cost-effectiveness and cost-utility of long-term management strategies for heartburn.

OBJECTIVES: To compare the expected costs and outcomes of seven alternative long-term primary care strategies for the management of patients with moderate-to-severe heartburn over a 1-year period. METHODS: A decision-analytic model was developed to estimate costs and effects (weeks with heartburn symptoms and quality adjusted life years [QALYs]) for each strategy. Meta-analyses were used to synthesize acute treatment and maintenance studies and physician surveys to collect information on patient management. The impact of uncertainty on the base case results was assessed using probabilistic sensitivity analysis. Probability distributions were defined for key model parameters and techniques of Monte Carlo simulation were used to draw values from these distributions. Cost-effectiveness acceptability curves (CEACs) conditional on the monetary value decision makers are willing to pay for a symptom-free day or QALY were created for each strategy. RESULTS: In the base case, no strategy was strictly dominated by any other strategy. However, two strategies (maintenance H2-receptor antagonists H2RA] and step-down proton pump inhibitor PPI]) were dominated through principles of extended dominance. The least costly and least effective strategy was intermittent H2RA, while maintenance PPI was the most costly and most effective. CONCLUSIONS: This analysis showed that the best way of managing patients with heartburn depends on how much society is willing to pay to achieve health improvements. Based on the commonly quoted threshold of US 50,000 dollars per QALY, the optimal primary care strategy for managing patients with moderate-to-severe heartburn symptoms is to treat the symptoms with a PPI followed by maintenance therapy with an H2RA to prevent symptomatic recurrence.

What is heartburn worth? A cost-utility analysis of management strategies.

OBJECTIVE: To determine the best treatment strategy for the management of patients presenting with symptoms consistent with uncomplicated heartburn. METHODS: We performed a cost-utility analysis of 4 alternatives: empirical proton pump inhibitor, empirical histamine2-receptor antagonist, and diagnostic strategies consisting of either esophagogastroduodenoscopy (EGD) or an upper gastrointestinal series before treatment. The time horizon of the model was 1 year. The base case analysis assumed a cohort of otherwise healthy 45-year-old individuals in a primary care practice. MAIN RESULTS: Empirical treatment with a proton pump inhibitor was projected to provide the greatest quality-adjusted survival for the cohort. Empirical treatment with a histamine2 receptor antagonist was projected to be the least costly of the alternatives. The marginal cost-effectiveness of using a proton pump inhibitor over a histamine2-receptor antagonist was approximately $10,400 per quality-adjusted life year (QALY) gained in the base case analysis and was less than $50,000 per QALY as long as the utility for heartburn was less than 0.95. Both diagnostic strategies were dominated by proton pump inhibitor alternative. CONCLUSIONS: Empirical treatment seems to be the optimal initial management strategy for patients with heartburn, but the choice between a proton pump inhibitor or histamine2-receptor antagonist depends on the impact of heartburn on quality of life.

Prevalence of dyspepsia, heartburn, and peptic ulcer disease in veterans.

OBJECTIVE: Medications used to treat gastrointestinal symptoms account for a substantial share of pharmacy expenses for veterans affairs medical centers. Prior studies have shown that the prevalence of peptic ulcer disease is higher in veterans than in nonveterans. Our aim was to determine the prevalence of upper gastrointestinal symptoms among patients seeking health care in the Department of Veterans Affairs outpatient clinics. METHODS: A total of 1582 veterans completed a previously validated bowel symptom questionnaire in the following clinics: gastroenterology (n = 693), walk-in (n = 403), general medicine (n = 379), and women's health (n = 107). RESULTS: Overall response was 78%. Dyspepsia was reported in 30%, 37%, 44%, and 53% of patients in general medicine, walk-in, women's health, and gastroenterology clinics, respectively. Heartburn, at least weekly, was reported in 21%, 21%, 28%, and 40% of patients in general medicine, walk-in, women's health, and gastroenterology clinics, respectively. Prior peptic ulcer disease (PUD) was reported in 29%, 26%, 22%, and 44% of patients in general medicine, walk-in, women's health, and gastroenterology clinics, respectively. Dyspepsia, heartburn, and PUD were significantly associated with increased physician visits and lower general health. CONCLUSIONS: Dyspepsia and heartburn are common symptoms among veterans. Lifetime prevalence of PUD is high among veterans. Gastrointestinal symptoms have a significant impact on health care utilization and general health. These prevalence estimates provide a basis for studies of resource utilization and for cost-effectiveness analyses of the treatment of gastrointestinal disorders in the veteran population. Moreover, the high prevalence of symptoms helps to explain the high utilization of gastrointestinal medications.

Switching the histamine H2 receptor antagonist famotidine to nonprescription status in Canada. An economic evaluation.

The aim of this study was to compare the direct medical costs associated with the treatment of patients with heartburn/nonulcer dyspepsia under 2 scenarios: (i) no nonprescription histamine H2 receptor antagonist (H2RA) is available (the 'status quo scenario'); and (ii) the H2RA famotidine (at a daily dosage of 10mg) is available over-the-counter (OTC) at retail pharmacies (the 'OTC scenario'). We employed a decision analysis model over a 16-week period that considered direct medical costs from 2 alternative perspectives: (i) society, including the cost of self-medication borne by patients; and (ii) a provincial third-party payer for healthcare. Data concerning direct medical costs associated with consumer self-medication and physician prescription of medication (including pharmacist dispensing fees), tests and procedures, and consultations with general practitioners and specialists were drawn from a clinician panel, published unit costs, and special surveys of institutional databases. All costs are reported in 1993 Canadian dollars ($Can; $Can1 = $US0.72, October 1995). From a societal perspective, the expected cost per patient over a 16-week period is not substantially different between the status quo and the OTC scenarios ($Can98 and $Can96, respectively). From a provincial third-party payer perspective, the expected costs per patient for the same scenarios are $Can95 and $Can89, a saving of $Can6 per patient. These results are sensitive to the proportion of patients who initially choose to see their physician rather than self-medicate, and the percentage of patients achieving successful treatment of symptoms. Changes in the rate or the cost of nonprescription medication, tests/procedures and physician visits do not affect the relative cost rankings. The total number of physician visits remained constant in both scenarios. From the societal cost perspective, the availability of famotidine in nonprescription form yields total costs that are similar to the status quo. However, from the perspective of the provincial payer, the expected costs per patient are likely to be slightly lower than the status quo if famotidine is available in unrestricted OTC scenario use. To generate significant savings to provincial payers, the number of people choosing immediate physician contact would have to be reduced, although not substantially, in the OTC scenario.

Use of non-antacid antiulcer agents in the treatment of heartburn and dyspepsia.

This study examined secondary-claims data to measure the cost of using non-antacid antiulcer agents to treat patients with heartburn or dyspepsia. Health care utilization data were obtained from the Pennsylvania Medicaid program. The study population comprised all enrollees with dyspepsia or heartburn, excluding those with a history of ulcers. The rate and cost of gastrointestinal-related outpatient services were examined for patients receiving antiulcer drug monotherapy. The mean age of the study population (n = 1830) was 39.1 years. Ranitidine patients (n = 856) received monotherapy for an average of 71.1 days. Cimetidine (n = 395) and famotidine (n = 255) patients received monotherapy for an average of 65.0 and 71.7 days, respectively. (Mean duration of monotherapy for the other four groups ranged from 58.0 to 112.6 days). On average, there were 0.83 prescriptions issued, 0.21 physician visits, and 0.23 outpatient hospital visits per patient-month across all treatment groups. The average cost to the Pennsylvania Medicaid program was approximately $68 monthly per patient. Drugs accounted for the majority of these costs ($51.04), followed by surgical/diagnostic procedures ($5.13), outpatient hospital visits ($4.89), and physician visits ($4.15).

Use of H2-receptor antagonists in patients with dyspepsia and heartburn: a cost comparison.

OBJECTIVE: Under the Pharmaceutical Benefits Scheme, the use of H2-receptor antagonists (H2A) in the treatment of dyspepsia and heartburn is only subsidised when there is a proven diagnosis of ulcer. This study compared the costs of this Australian practice with a simulation of British practice, which allows unrestricted prescribing of subsidised H2A. DESIGN: Patients with heartburn and/or dyspepsia were prospectively randomised to either a "British" group treated freely at the discretion of their general practitioner without necessarily being investigated or an "Australian" group where use of H2A was allowed only after gastroscopy or a barium meal had demonstrated a peptic ulcer or ulcerative oesophagitis. The patients were followed up for six months and all direct and indirect costs were recorded. SETTING: Forty-nine Sydney general practitioners recruited primary care patients for the study. PATIENTS: Any patient with heartburn or dyspepsia was considered for recruitment; 139 patients entered the study and 137 completed it. MAIN OUTCOME MEASURES: The outcome measures were the costs of general practitioner consultations, specialist consultations, radiology and gastroscopy, other tests, H2A, other medications, personal costs, and total cost per patient. RESULTS: The cumulative total cost per patient at the end of the study was equivalent in the "Australian" ($392) and "British" ($406) groups. A higher initial cost per patient of H2A in the "British" group was offset by a rapid decrease in the proportion that continued to use H2A and by the cost of specialist consultations and investigations in the "Australian" group. CONCLUSION: Over a six-month period the cost of early investigation of heartburn and dyspepsia was equivalent to the cost of a therapeutic trial of H2A.