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Dr. Lamm's weekly review of relevant articles and research

There is an increasing amount of information available about the gut.  Here are a few informative articles you may find valuable.

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pH Testing for GERD

Early pH Test in GERD May Save Money
By Nancy Walsh, Staff Writer, MedPage Today, Published: May 20, 2013

Reviewed by F. Perry Wilson, MD, MSCE; Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner.

ORLANDO -- Early referral of patients with gastroesophageal reflux disease (GERD) for pH monitoring can help avoid extensive and costly use of proton pump inhibitors (PPIs), a researcher said here.

A cost analysis revealed that, over the course of 10 years, $6,600 could be saved per patient if they underwent pH monitoring, according to David Kleiman, MD, of Weill Cornell Medical College in New York City.

"The costs of PPIs are staggering, reaching almost $10 billion each year," Kleiman toldMedPage Today at the annual Digestive Disease Week.

Patients with GERD typically are given an empiric 2-month course of PPIs, as recommended by the American Gastroenterological Association guidelines, but many remain on the drugs for much longer, as clinicians may be hesitant to refer them for 24-hour pH monitoring. While the latter can definitively rule out the disease, clinicians may think that the test will be associated with unnecessary costs.

The pH monitoring test involves passage of a very thin tube through the nose into the lower esophagus where a probe can monitor acid levels continuously. The test cost $690 according to 2012 Medicare fees, and its sensitivity in the literature has ranged from 30% to 96%.

"But we hypothesized that performing the monitoring test after the initial 8-week PPI trial would be a more cost-effective strategy than having patients remain on the drugs indefinitely," he said.

To examine this, Kleiman's group reviewed the medical records of 100 patients who underwent the test in order to determine the pattern of symptoms and duration of PPI treatment before having the test.

They then estimated the weekly cost of PPIs, both low-dose (20 mg per day) generic omeprazole and high dose (40 mg twice per day) name-brand agents such as esomeprazole (Nexium) and pantoprazole (Protonix).

The weekly cost of PPIs ranged from $29.06 to $107.70, Kleiman found.

Patients who reported primarily esophageal GERD symptoms had used PPIs for a median of 208 weeks, while those with extra-esophageal symptoms used the drugs for a median of 52 weeks.

"Yet the cost of PPI therapy reached equivalence with the monitoring test at anywhere from 6.4 to 23.7 weeks, depending on the regimen used," he said.

Overall, the patients in the cohort had used PPIs for 21,411 weeks after the original 8-week regimen, and in one-third of them, the pH monitoring test had negative results so their PPI use had been unnecessary.

In the cost analysis, assuming 100% sensitivity for the monitoring test would have saved between $1,966 and $7,285 per patient each year over a decade.

But in a two-way sensitivity analysis, using a range of sensitivities and costs, the strategy of performing pH monitoring after 8 weeks of PPI treatment remained cost effective as long as the sensitivity of the test remained above 35%.

"Clinicians should not let the additional costs of pH monitoring deter them from referring patients for this test, which can help prevent the unnecessary use of PPIs," he said.

Limitations of the study included its retrospective design and the possibility of selection bias, because the study population may have represented particularly difficult cases.

In addition, the study didn't include "utility value estimates," meaning subjective factors such as patient inconvenience.

The cost analysis also reflected the perspective of a third-party payer, and didn't address other costs such as hospital and physician expenditures.

Kleiman reported no financial conflicts of interest. One co-author has consulted and received support from Abbott, Salix Pharmaceuticals, and Centocor.

Primary source: Digestive Disease Week
Source reference:
Kleiman D, et al "Early referral for 24-hour esophageal pH monitoring is more cost-effective than prolonged use of proton pump inhibitors in patients with suspected gastroesophageal reflux disease" DDW 2013; Abstract 201.

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Nancy Walsh, Staff Writer
Nancy Walsh has written for various medical publications in the United States and England, including Patient Care, The Practitioner, and the Journal of Respiratory Diseases. She also has contributed numerous essays to several books on history and culture, most recently to The Book of Firsts (Anchor Books, 2010).

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