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Gastroesophageal Motility Disorders Laboratory

For appointments and information, please call (212) 746-5130

At NewYork-Presbyterian Hospital/Weill Cornell Medical Center the esophageal motility unit is directed by Dr. Rasa Zarnegar. He is trained in the diagnosis and surgical management of esophageal motility disorders. He works closely with renowned gastroenterologists who provide endoscopic techniques for the management and treatment of esophageal disorders.

More about the Gastroesophageal Reflux and Motility Disorders Laboratory.

Research and Clinical Trials

Providing the very best treatment options for patients is a key priority at NewYork-Presbyterian/Weill Cornell. All patients are regularly followed to assess long-term results. We maintain data on patients' progress in a database. By tracking patients' results over the long term, we can perform studies on clinical outcomes to verify the efficacy and durability of interventions. Results are reported regularly in scientific journals so that the medical community and patients can be aware of the alternatives, benefits and risks of each procedure.

Reuters Health reported on an important new GERD study conducted at our hospital that shows early referral for testing is more cost-effective in treating GERD than prolonged proton pump inhibitors (PPIs) .

For GERD, early referral for testing more cost-effective than prolonged PPI use

Last Updated: 2013-05-22 18:15:19 -0400 (Reuters Health)

By Nancy Lapid

ORLANDO, Fl. (Reuters Health) - Patients with suspected gastroesophageal reflux disease (GERD) often stay on proton pump inhibitors (PPIs) for years when it would be more cost-effective to confirm the condition with the gold-standard test after just a couple of months, researchers said Sunday.

That test - 24-hour monitoring of acid levels in the distal esophagus - is from 30% to 96% sensitive for GERD, depending on the study. But even at the lower end of that range, using it after a short trial of proton pump inhibitors would still be more cost-effective than keeping patients on those drugs indefinitely, said Dr. David Kleiman, who was part of a Presidential Plenary session at the Digestive Disease Week 2103 meeting here.

Most guidelines recommend an empiric eight-week trial of PPIs, but patients often keep taking them for much longer periods. "PPIs account for the vast majority" of the health care dollars spent on GERD each year, according to Dr. Kleiman, a research fellow in the department of surgery at New York Presbyterian Hospital - Weill Cornell Medical College.

Unfortunately, he added, 24-hour pH monitoring tends to be underutilized.

"The perception is that it's costly and inconvenient," he told Reuters Health. "But the benefits show that it should be strongly considered."

"It's not fun," he admitted. "It's easier than an endoscopy but lasts longer."

As he described it, a 2 mm tube is advanced through the nose into the distal esophagus, where it remains for the next 24 hours. Patients are instructed to act and eat normally and keep a diary in which they record any GERD symptoms.

"We do it when patients are off therapy, after a two-week washout," Dr. Kleiman said. "Some centers do it with patients on therapy, which we do not encourage."

THOUSANDS IN SAVINGS

For the new study, his group identified 100 patients who'd undergone pH monitoring and built a model meant to reflect insurance companies' costs over a 10-year period.

For these 100 patients, the median duration of PPI use prior to referral ranged from 208 weeks for patients with esophageal GERD symptoms to 52 weeks for patients with extra-esophageal symptoms.

Drug costs ranged from roughly $29 a week for low-dose (20 mg/day) generic PPIs to roughly $107 a week for high-dose (40 mg twice daily) name-brand PPIs, based on average wholesale prices in the 2012 Micromedex Redbook. The cost of 24-hour pH monitoring and manometry (necessary to determine esophageal function and for appropriate positioning of the pH probe), was $690, based on 2012 Medicare reimbursement figures.

According to Dr. Kleiman, in his group's model the cost of PPI therapy equaled that of pH monitoring after 6.4 to 23.7 weeks, depending on the PPI regimen - and after that, it would have saved money to do the test.

"We added up the cost of doing pH monitoring for all 100 patients, which came to $69,000," he explained. "Then we subtracted the cost of unnecessary PPIs, i.e., PPIs in patients with a negative pH monitoring study. We divided that by the number of patients to calculate the average savings."

The cohort was prescribed more than 21,000 weeks of PPIs beyond the initial eight-week trial, about a third of which were for patients who had a negative 24-hour pH monitoring study and were therefore unnecessary, the study showed.

If the sensitivity of pH monitoring were 100%, the researchers say, then performing pH monitoring on all patients after an eight-week PPI trial would have saved between $1,276 and $6,595 per patient over 10 years.

But what about in the real world, where the sensitivity of pH monitoring isn't 100%? This strategy remains cost-effective as long as the sensitivity of pH monitoring is at least 35%, the researchers found.

INCONVENIENCE, OTHER OBSTACLES

Dr. Kleiman acknowledges some obstacles to widespread adoption of early pH monitoring studies. For example, 24-hour pH monitoring isn't available at every center, so there may be access issues. Even when access isn't a problem, "there's not a lot of awareness of the value," he said, although he hopes this new study might help in that regard.

Perceptions about cost can also stand in the way, and he admitted that the Medicare allowances used as a measure of cost in this study might be lower than actual average costs.

Finally, he noted, "This study didn't address the inconvenience factor. Patients need to take time off work, and they need to make two visits" to have the monitor inserted and removed.

Dr. Stanley Ashley, who moderated the session, pointed out later to Reuters Health that testing wouldn't just save money for insurance companies, because now, with proton pump inhibitors available over the counter, patients are often "paying a lot money themselves, out of pocket."

"Patients often come in with dyspeptic symptoms, vague abdominal pain, and we say to them, 'Why don't you try one of these medicines,'" added Dr. Ashley, the Chief Medical Officer at Brigham and Women's Hospital in Boston.

Often the patient feels better, whether from the medicine, or from a placebo effect, and they just never stop taking the drug, he pointed out.

The 24-hour pH monitoring study, he said, "would be a benefit to patients because they may be taking a medication that's not helping them."

To read the Wall Street Journal article about the NYP/Weill Cornell GERD study, click here

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