Cost analysis of endoscopic antireflux procedures: endoluminal plication vs. radiofrequency coagulation vs. treatment with a proton pump inhibitor

Background: Both endoluminal gastroplication and radiofrequency coagulation of the lower esophageal sphincter and gastroesophageal junction (Stretta procedure) represent emerging endoscopic therapies for GERD. The economic impact of endotherapy for GERD has not been described. The aim of this study was to apply a decision analysis model to compare the costs of endoluminal gastroplication vs. the Stretta procedures vs. a proton pump inhibitor for treatment of GERD. A cost minimization approach was used. Methods: Model entry criteria were GERD responsive to daily or twice daily administration of a proton pump inhibitor. Performance characteristics of endotherapy were determined from published data. The baseline probabilities for annual endotherapy failure rates (20%), partial failure rates (10%), and complication rates (1%) were varied through a plausible range by using sensitivity analysis. Cost data for endotherapy were calculated from per case instrumentation costs plus professional fees plus facility fees for ambulatory patient classification codes; cost of treatment with a proton pump inhibitor was based on national average wholesale price. The endpoint was sustained resolution of GERD symptoms. Results: In patients requiring twice daily use of a proton pump inhibitor for symptom relief, endotherapy proves to be the most economical strategy after 17 months. If uniform endotherapy failure rates over time are assumed, medication regains superiority after 29 months. Sensitivity analysis revealed that a proton pump inhibitor remains the most economical option beyond 3 years, provided annual endotherapy failure rates remain greater than 20% (endoluminal gastroplication) or 19% (Stretta). Pharmacotherapy is the least costly approach, irrespective of time, if the daily cost of a proton pump inhibitor is less than $140 a month or endotherapy costs more than $3400. For patients in whom symptoms are relieved with once daily dosing with a proton pump inhibitor, medication remains the most economical option regardless of endotherapy failure rate. Conclusion: Endotherapy appears to offer an economical treatment option for patients requiring a proton pump inhibitor twice daily, with its cost superiority enduring for 2.5 years. More long-term follow-up data are required to determine the durability of the endotherapy benefit over time.