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Should Noncardiac Chest Pain Be Treated Empirically?
A Cost-effectiveness Analysis
Ann M. Borzecki, MD, MPH;
Marcos C. Pedrosa, MD, MPH;
Mark J. Prashker, MD, MPH
Arch Intern Med. 2000;160:844-852.
Background Chest pain is a common clinical problem, but up to 30% of patients who present with chest pain lack coronary disease. Subsequent investigation often reveals an esophageal source for the pain, with gastroesophageal reflux disease identified most frequently. Controversy exists regarding whether to establish the cause or to empirically treat as reflux.
Objective To assess the cost-effectiveness of empirical treatment in patients with noncardiac chest pain.
Methods Decision analysis was used to compare a strategy of empirical treatment as reflux using an H-blocker or proton pump inhibitor with initial investigation for gastrointestinal causes over a period of up to 16 weeks and over a period of more than a year. The prototype patient was an outpatient with chest pain and a normal coronary angiogram. Gastrointestinal investigations included an upper gastrointestinal tract series, endoscopy, manometry, 24-hour pH monitoring, and provocation tests. The main outcome measure was direct medical costs per case treated from a third-party payer perspective.
Results Total medical costs were $2187 per case treated for the initial investigation arm and $849 for the empirical treatment arm in the 8- to 16-week model. One-way sensitivity analyses revealed that the model was robust; the treatment arm was less expensive in all cases. At just over a year empirical treatment remained dominant.
Conclusions An initial therapeutic trial with antisecretory agents for patients with noncardiac chest pain is cost-effective compared with investigation for gastrointestinal causes in the short term of weeks, with cost savings persisting beyond a year.
From Dalhousie University School of Medicine, Halifax, Nova Scotia (Dr Borzecki); Boston University School of Medicine (Drs Pedrosa and Prashker), Boston Veterans Affairs Medical Center (Dr Pedrosa), and Boston University School of Public Health (Dr Prashker), Boston, Mass; and Center for Health Quality, Outcomes and Economic Research, Bedford Veterans Affairs Medical Center, Bedford, Mass (Dr Prashker).
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