Intended for healthcare professionals


Laparoscopic fundoplication compared with medical management for gastro-oesophageal reflux disease: cost effectiveness study

BMJ 2009; 339 doi: (Published 14 July 2009) Cite this as: BMJ 2009;339:b2576
  1. David Epstein, honorary visiting fellow, doctoral student12,
  2. Laura Bojke, research fellow1,
  3. Mark J Sculpher, professor of health economics1,
  4. The REFLUX trial group
  1. 1Centre for Health Economics, University of York, Heslington, York YO1 5DD
  2. 2Faculty of Economics and Business Sciences, Campus Universitario de la Cartuja, 18071 Granada, Spain
  1. Correspondence to: L Bojke
  • Accepted 19 March 2009


Objective To describe the long term costs, health benefits, and cost effectiveness of laparoscopic surgery compared with those of continued medical management for patients with gastro-oesophageal reflux disease (GORD).

Design We estimated resource use and costs for the first year on the basis of data from the REFLUX trial. A Markov model was used to extrapolate cost and health benefit over a lifetime using data collected in the REFLUX trial and other sources.

Participants The model compared laparoscopic surgery and continued proton pump inhibitors in male patients aged 45 and stable on GORD medication.

Intervention Laparoscopic surgery versus continued medical management.

Main outcome measures We estimated quality adjusted life years and GORD related costs to the health service over a lifetime. Sensitivity analyses considered other plausible scenarios, in particular size and duration of treatment effect and the GORD symptoms of patients in whom surgery is unsuccessful.

Main results The base case model indicated that surgery is likely to be considered cost effective on average with an incremental cost effectiveness ratio of £2648 (€3110; US$4385) per quality adjusted life year and that the probability that surgery is cost effective is 0.94 at a threshold incremental cost effectiveness ratio of £20 000. The results were sensitive to some assumptions within the extrapolation modelling.

Conclusion Surgery seems to be more cost effective on average than medical management in many of the scenarios examined in this study. Surgery might not be cost effective if the treatment effect does not persist over the long term, if patients who return to medical management have poor health related quality of life, or if proton pump inhibitors were cheaper. Further follow-up of patients from the REFLUX trial may be valuable.

Trial registration ISRCTN15517081.


  • Trial team: Aberdeen—Marion Campbell, Adrian Grant, Craig Ramsay, Samantha Wileman; York—Garry Barton (1999-2002), Laura Bojke, David Epstein, Sue Macran, Mark Sculpher. Trial steering group: Wendy Atkin (independent chair), John Bancewicz, Ara Darzi, Robert Heading, Janusz Jankowski, Zygmunt Krukowski, Richard Lilford, Iain Martin (1997-2000), Ashley Mowat, Ian Russell, Mark Thursz. Data monitoring committee: Jon Nicholl, Chris Hawkey, Iain MacIntyre. Wendy Atkin, Janusz Jankowski, Richard Lilford, Jon Nicholl, Chris Hawkey, and Iain MacIntyre were independent of the trial. Members of the reflux trial group responsible for recruitment in the clinical centres were as follows. Aberdeen Royal Infirmary: A Mowat, Z Krukowski, E El-Omar, P Phull, T Sinclair, L Swan. Belfast Victoria Hospital: B Clements, J Collins, A Kennedy, H Lawther, B Mulvenna. Royal Bournemouth Hospital: D Bennett, N Davies, M McCullen, S Toop, P Winwood. Bristol Royal Infirmary: D Alderson, P Barham, K Green, R Mountford, S Tranter, R Mittal. Princess Royal University Hospital, Bromley: M Asante, L Barr, S El Hasani. Royal Infirmary of Edinburgh: A De Beaux, R Heading, L Meekison, S Paterson-Brown, H Barkell. Royal Surrey County Hospital, Guildford: G Ferns, M Bailey, N Karanjia, TA Rockall, L Skelly, M Smith. Hull Royal Infirmary: M Dakkak, J King, C Royston, P Sedman. Raigmore Hospital, Inverness: K Gordon, I McGauran, LF Potts, C Smith, PL Zentler-Munro, A Munro. General Infirmary at Leeds: A Axon, B Chanley, S Dexter, M McMahon, P Maoyeddi. Leicester Royal Infirmary: DM Lloyd, A Palmer-Jeffrey, B Rathbone. St Mary’s Hospital, London: V Loh, M Thursz, A Darzi. Whipps Cross Hospital, London: A Ahmed, R Greaves, A Sawyerr, J Wellwood, T Taylor. Poole Hospital: S Hosking, T Karlowski, S Lowrey, N Sharer, J Snook. Queen Alexandra Hospital, Portsmouth: H D Duncan, P Goggin, T Johns, A Quine, S Somers, S Toh. Hope Hospital, Salford: SEA Attwood, C Babbs, J Bancewicz, M Greenhalgh, W Rees, A Robinson. North Staffordshire Hospital, Stoke-on-Trent: T Bowling, Dr Brind, CVN Cheruvu, M Deakin, S Evans, R Glass, J Green, F Leslie, JB Elder. Morriston Hospital, Swansea: JN Baxter, P Duane, MM Rahman, M Thomas, J Williams. Princess Royal Hospital, Telford: J Bateman, D Maxton, N Moreton, A Sigurdsson, MSH Smith, G Townson. Yeovil District Hospital: N Beacham, C Buckley, S Gore, RH Kennedy, ZH Khan, J Knight, L Martin. York District Hospital: D Alexander, S Kelly, G Miller, D Parker, A Turnbull, J Turvill, W Wong, L Delaney.

  • Contributors: All authors took part in the REFLUX trial and have seen and approved the final version of the manuscript. MS was responsible for the economic evaluation section of the grant application and protocol, and LB and DE conducted the economic analysis for the paper.

  • Funding: This study was commissioned and funded by the National Coordinating Centre for Health Technology Assessment (NCCHTA). The funder of this study, other than the initial peer review process prior to funding and six-monthly progress reviews, did not have any involvement in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. The views expressed in this report are those of the authors and not necessarily those of the NCCHTA or the funders that provide institutional support for the authors of this report.

  • Competing interests: None declared.

  • Ethical approval: Approval for this study was obtained from the Scottish Multicentre Research Ethics Committee and the appropriate local research ethics committees.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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