From the Journals

How to manage heartburn cost-effectively after PPI failure




A decision-support model for managing patients with heartburn in whom proton pump inhibitor (PPI) therapy fails suggests that endoscopy with ambulatory reflux monitoring is the optimal cost-effective approach, matching therapy to phenotype.


  • Researchers compared the cost-effectiveness over 1 year of four strategies for managing patients in whom empirical PPI treatment failed.
  • Strategies were PPI optimization without diagnostic testing; endoscopy with PPI optimization to identify erosive reflux disease; endoscopy with PPI discontinuation when no erosive reflux disease was found; and combined endoscopy/ambulatory reflux monitoring and PPI discontinuation as appropriate for the phenotype (i.e., erosive disease, nonerosive disease, or functional heartburn).
  • All index testing was assumed to be done while patients were off PPI treatment.


  • PPI optimization without testing cost insurers $3,784 a year and patients $3,128 a year owing to health care expenses and lower work productivity associated with suboptimal symptom relief, resulting in a loss of 40 healthy days over the course of the year.
  • Endoscopy with PPI optimization lowered insurer costs by $1,020 a year and patient costs by $1,621 a year, compared with optimization without testing, and added 11 healthy days a year by identifying erosive reflux disease.
  • Endoscopy with PPI discontinuation added 11 healthy days a year by identifying patients without erosive reflux disease who did not need PPI therapy.
  • Endoscopy with ambulatory reflux monitoring and a trial of PPI discontinuation was the most effective strategy, optimizing phenotype-guided treatment, saving insurers $2,183 and patients $2,396 a year, and adding 22 healthy days a year.
  • The findings support recent clinical practice guidelines from the American Gastroenterological Association and the


“[A]n algorithmic approach to comprehensively stratify erosive and non-erosive reflux disease from functional heartburn combined with a trial of PPI discontinuation for patients without erosive findings provides value to patients and insurers,” the authors wrote.


Eric D. Shah, MD, MBA, division of gastroenterology and hepatology, Michigan Medicine, Ann Arbor, led the study, which was published online in Clinical Gastroenterology and Hepatology.


Centers may have limited capacity for routine ambulatory reflux monitoring or may not perform it at all. Single-center and older studies were used for model inputs when no other data were available.


The study had no specific funding. Dr. Shah is supported by a National Institutes of Health grant and disclosed that he has consulted for Salix, Mahana, Neuraxis, Phathom, Takeda, Ardelyx, Sanofi, and GI Supply. Other coauthors have consulted for pharmaceutical and/or biotech companies.

A version of this article appeared on

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