A hypothetical road map to reduce acid related diseases costs management

In the last few years the containment of healthcare costs has become a key point in many education and research programs. In relation to this issue, the management of acid related diseases is one of the most important problems, because of the high prevalence of underlying diseases. Indeed a current question is: are acid related diseases better managed by empiric treatment or by a diagnostic approach? To address this question we analysed the outcome of 182 patients with dyspepsia and/or gastro-oesophageal reflux disease (GERD) in primary care, over a period of 12 months, in the Campania region (southern Italy). Ninety-eight patients were treated since the beginning (therapeutic group; median age 49; males 50) and 84 underwent a diagnostic approach (diagnostic group; median age 50; males 44). After 12 months the direct management costs (consultations, diagnostic procedures, drugs) were calculated for both groups. Obviously, for patients in the diagnostic group there were higher management costs than for other patients (268€/year vs. 156€/year on average). An intriguing finding was the role of diagnostic procedures in providing additional information to determine therapy. In our study we analysed the diagnostic procedures defined as “not useful”, i.e., procedures that did not provide additional information to help us decide on therapy changes, whether the prescription had been prescribed only on the basis of the symptoms (therapeutic group) or it had only been hypothesized before the diagnostic approach (diagnostic group). This analysis was conducted on 84 of the patients in the diagnostic group and 20 of those in the therapeutic group in whom the practitioner had decided to perform a diagnostic procedure after starting treatment. The diagnostic procedure prevalently performed in all patients was endoscopy with urease test to search Helicobacter pylori infection; some patients had already undergone non-invasive H. pylori testing (fecal or breath test) before endoscopy. Eleven patients with dyspepsia were also investigated by abdominal sonography. The diagnostic criteria influencing therapy and disease management were presence of organic disease (severe esophagitis, duodenal or gastric ulcers, neoplasia, etc.) and H. pylori infection. The results showed that the diagnostic procedures did not modify the prescribed or hypothesized therapy and clinical management in 75% (21/28) of patients with GERD, 52% (26/50) with dyspepsia and 58% (15/26) with both GERD and dyspepsia. Based on these results, we tried to estimate a possible decrease in healthcare costs in the Campania region if diagnostic procedures, not leading to therapy changes, were eliminated from the outcome of acid related diseases. The analysis was performed considering that, in Campania, the estimated prevalence of clinically relevant (more than two symptomatic episodes/week) acid related diseases is 1.2% for GERD, 2.2% for dyspepsia and 5.5% for both GERD and dyspepsia [1] and [2]. Moreover using another analysis we found that the practitioner chooses the diagnostic approach for GERD, dyspepsia and dyspepsia-GERD in 27%, 38% and 39%, respectively [3]. Based on these estimates and on the increased cost management of diagnostic approaches calculated with our analysis, the cost/year of “not useful” diagnostic procedures in Campania could be of about 2.64, 4.16 and 10.73 million euros for GERD, dyspepsia and dyspepsia-GERD, respectively (see Table 1). Although the concept of “not useful” diagnostic procedure is debatable, the results of this analysis further suggest to address more attention to the improvement of education for disease management with the aim to contain healthcare costs.