Canadian Digestive Health Foundation Public Impact Series: Gastroesophageal Reflux Disease in Canada: Incidence, Prevalence, and Direct and Indirect Economic Impact

Abstract

The Canadian Digestive Health Foundation initiated a scientific program to assess the incidence, prevalence, mortality and economic impact of digestive disorders across Canada. The current article presents the updated findings from the study concerning gastroesophageal reflux disease - a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications (Montreal definition).

Full text

Can J Gastroenterol Vol 24 No 7 July 2010 431
Canadian Digestive Health Foundation Public Impact
Series: Gastroesophageal reflux disease in Canada:
Incidence, prevalence, and direct and indirect
economic impact
Richard N Fedorak MD FRCPC1, Sander Veldhuyzen van Zanten MD FRCPC1, Ron Bridges MD FRCPC2
1Division of Gastroenterology, University of Alberta, Edmonton; 2Division of Gastroenterology, University of Calgary, Calgary, Alberta
Correspondence: Dr Richard N Fedorak, Division of Gastroenterology, University of Alberta, 2-14A Zeidler Building,
Edmonton, Alberta T6G 2X8. Telephone 780-492-6941, fax 780-492-8121, e-mail richard.fedorak@ualberta.ca
Received for publication May 21, 2010. Accepted May 24, 2010
The Canadian Digestive Health Foundation (CDHF)
launched a scientific project to define the incidence, preva-
lence, mortality and economic impact of digestive disorders
across Canada. Detailed information regarding 19 digestive
disorders was compiled through systematic reviews, government
documents and websites. This information was published as
“Establishing Digestive Health as a Priority for Canadians, The
Canadian Digestive Health Foundation National Digestive
Disorders Prevalence and Impact Study Report”, and released to
the press and the government in late 2009 (www.CDHF.ca).
The CDHF Public Impact Series presents a full compilation of
the available statistics regarding the impact of digestive disor-
ders in Canada.
Gastroesophageal reflux disease (GERD) is a condition that
develops when the reflux of stomach contents causes trouble-
some symptoms and/or complications (Montreal definition).
The most frequent complication is inflammation leading to
esophagitis, stricture, Barrett’s esophagus and adenocarcinoma
(Table 1). Most people consider symptoms troublesome if they
are mild and occur more than once a week, or at least once a
week for moderate to severe symptoms. Many individuals self-
medicate with over-the-counter medications such as antacids
(1). Although the cause or origin of this chronic disease is not
well understood, there are certain risk factors associated with
GERD development (Table 2). It has been well documented
that individuals with untreated GERD experience a significant
decrease in their quality of life and have a higher risk for
developing serious complications.
The Canadian Association of Gastroenterology has created
an evidence-based practice guideline for the diagnosis and
treatment of GERD (2). Initial diagnosis of GERD is made if
the symptomatic patient responds to antacid therapies such
as H2-receptor antagonists or the more effective – but more
costly – proton pump inhibitors. Patients who experience
ORIGINAL ARTICLE
©2010 Pulsus Group Inc. All rights reserved
RN Fedorak, S Veldhuyzen van Zanten, R Bridges. Canadian
Digestive Health Foundation Public Impact Series:
Gastroesophageal reflux disease in Canada: Incidence,
prevalence, and direct and indirect economic impact. Can J
Gastroenterol 2010;24(7):431-434.
The Canadian Digestive Health Foundation initiated a scientific pro-
gram to assess the incidence, prevalence, mortality and economic
impact of digestive disorders across Canada. The current article pres-
ents the updated findings from the study concerning gastroesophageal
reflux disease – a condition that develops when the reflux of stomach
contents causes troublesome symptoms and/or complications (Montreal
definition).
Key Words: Acid reflux; Chronic disease; Gastroesophageal reflux
disease; GERD; Heartburn; Pyrosis
Le reflux gastro-œsphagien au Canada : Incidence, prévalence et
impact économique direct et indirect selon la série Impact public
de la Fondation canadienne pour la promotion de la santé
digestive
La Fondation canadienne pour la promotion de la santé digestive a mis sur
pied un programme scientifique dans le but de mesurer l’incidence, la
prévalence, la mortalité et l’impact économique associés aux maladies
digestives au Canada. Cet article présente les conclusions mises à jour de
l’étude sur le reflux gastro-œsophagien, une maladie caractérisée par le
reflux du contenu gastrique et qui occasionne des symptômes et/ou des
complications ennuyeux (d’après la définition de Montréal).
TABLE 1
Overview of gastroesophageal reflux disease
Common symptoms Uncommon symptoms Complications
Heartburn Hoarseness and
sore throat
Erosive esophagitis
Regurgitation Esophageal stricture
Localized or diffuse or
retrosternal pain or
epigastric pain
Difficulties swallowing Ulceration and bleeding
Asthma Barrett’s epithelium
Sinusitis Esophageal
adenocarcinoma
Sleep disturbance Nausea
Postprandial fullness Vomiting Upper respiratory
complaints
(eg, wheezing, chronic
coughing
or throat clearing)
Upper abdominal
distension
Early satiety

Fedorak et al
Can J Gastroenterol Vol 24 No 7 July 2010432
no symptom improvements are commonly referred to gastro-
enterologists for testing to eliminate other possible causes. A
diagnosis of refractory GERD is made if no other causes are
identified and a patient’s symptoms persist in spite of proton
pump inhibitor dose escalation to twice daily; typically, this
represents 19% to 32% of GERD patients (3,4). Surgical inter-
ventions (eg, Nissen fundoplication) can be associated with
significant symptom improvements for adults with refractory or
moderate to severe GERD.
Increased awareness of GERD is necessary to improve the
health of Canadians who may be suffering in silence. Much
information has already been obtained in other western cul-
tures, which can be placed into a Canadian context; to date,
however, this has yet to be completed. By understanding the
epidemiological and economic impact of GERD on Canadians
and our society, health care professionals, policy makers and
the public at large can take the next steps in developing a dis-
ease management priority list.
METHODS
A systematic literature review was conducted to retrieve
peer-reviewed, English language scholarly articles using the
PubMed, Medline, EMBASE and Scopus databases. The
search terms “reflux disease”, “GERD” and “GORD” were
used, with specific focus on epidemiological and economic
studies from developed countries. Additional information was
retrieved from government sources, the WHO and not-for-
profit organizations.
RESULTS
Incidence (Table 3)
Only two longitudinal studies (5,6) examining the incidence
of GERD in adults have been conducted. The first (5) was
conducted in the United Kingdom (UK) and relied on first-
time physician diagnoses of GERD, esophagitis, esophageal
inflammation or heartburn as recorded in the General Practice
Research Database in 1996. The authors found that the annual
incidence of GERD was 4.5 per 1000 person-years (95% CI
4.4 to 4.7). The second study (6) used the Medicaid database
for the state of Georgia (USA) to identify new cases of GERD
based on filled prescriptions. The incidence of 5.4 cases per
1000 person-years was very similar to the incidence reported in
the UK study. It should be noted that both studies only captured
the portion of GERD sufferers who sought medical assistance
for their symptoms, implying that this figure is much larger, but
it is unclear by how much. There are no prospective published
incidence studies of GERD in the Canadian population.
Extrapolating the UK and USA incidence rates, and using
an estimate population of 34 million within Canada, every
year, a minimum of 170,000 individuals will be newly diag-
nosed with GERD. Importantly, the peak age distribution of
GERD is 60 to 70 years, indicating that the incidence rate is
tightly linked with age in Western populations (7). Between
2010 and 2040, the proportion of Canadian seniors is projected
to nearly double, suggesting that the GERD incidence rate will
likely increase sharply rather than stabilize or decrease (8).
Using an American administrative claims database (9),
the diagnosis rate of pediatric GERD or acid-related disease
was 0.6% to 1.0% per year. Between 1999 and 2005, the inci-
dence rate of newly diagnosed GERD in children younger
than one year of age increased sharply from 3.4% to 12.3%. This
increase was largely attributed to increased awareness in addi-
tion to cases of either overdiagnosis or misdiagnosis of eosino-
philic esophagitis. Because this study’s findings corroborate
those from another (10) investigating prescription acid sup-
pression therapy in pediatrics and corresponds to the period in
which childhood obesity has leapt dramatically, it is likely that
these findings are not artefacts of either poor study design or
interpretation.
Sixteen per cent of the Canadian population of 34 million
are zero to 14 years of age and, at an incidence rate of 1%,
56,000 Canadian children are projected to be newly diagnosed
with GERD each year (11). The majority of these patients will
be younger than one year of age. Both prescription medicines
and over-the-counter antacids – many of which are in a solid
form unsuitable for the very young and for which there is neg-
ligible evidence supporting their efficacy in placebo-controlled
trials (9) – are not approved for use in children.
Prevalence (Table 3)
GERD is a chronic disease that can last for up to 18 years (12).
Between 34% and 41% of GERD patients recall experiencing
GERD-like symptoms for more than 10 years before diagnosis
(12). This long-term cumulative effect results in an increasing
patient population year after year. In Western countries, the
prevalence range for GERD is 10% to 20% of the population
(3.4 million to 6.8 million Canadians). A uniquely Canadian
consideration is the long life expectancy relative to other coun-
tries. The combination of long life expectancy and an aging
population will increase the overall number of GERD patients
in the years to come (8,13). There are no data that support sex
predominance with regard to GERD.
Pediatric GERD patients have been documented, with most
cases spontaneously resolving within a few months or years
TABLE 2
Risk factors for developing gastroesophageal reflux
disease
Obesity (24)
Smoking (25)
Age (24)
Parental or family history of gastrointestinal diseases (24)
Esophageal stricture (24)
High-cholesterol diet (25)
Lung transplantation (26)
Cystic fibrosis (27)
TABLE 3
Canadian incidence, prevalence and economic impact of
gastroesophageal reflux disease
Published data (reference) Canadian exposures*
Incidence
Adult 4.5 – 5.4/1000 person-years (5,6) 170,000 per year (19)
Pediatric 9 – 10/1000 person-years (9) 56,000 per year (19)
Prevalence 10% – 20% (11) 3.4 – 6.8 million
persons (19)
Direct costs $52,235,910 per year (16)
Indirect costs ~6.7 h per week lost work (20)
*Extrapolated to a population of 34 million

CDHF Impact Series: GERD in Canada
Can J Gastroenterol Vol 24 No 7 July 2010 433
after birth. Surgery is not recommended, especially because
proton pump inhibitors are well tolerated in pediatric patients.
The treatment goal is to eliminate GERD symptoms, then to
step down therapy to an ‘as-required’ basis (9).
Mortality
Because GERD is often not the primary cause of death but a
secondary or underlying condition, its role is often not
recorded, although it may be a significant contributor. Between
2000 and 2005, there was an annual mean of 65 mortalities
caused primarily by GERD (Figure 1) (14). As with incidence
and prevalence, there is no apparent sex discrimination.
Economics
Direct costs: In 2004/2005, the Canadian health care system
spent a mean of $6,915 per patient for the 7554 patients who had
a primary diagnosis of diseases of the esophagus and associated
complications, for a total of $52,235,910 (15).
In Canada, the first H2-receptor antagonist was licensed for
sale over the counter in June 1996 (16). Although not as
effective as proton-pump inhibitors (17), GERD patients can
self-medicate with H2-receptor antagonists; however, they
incur considerable personal expense and risk the development
of GERD-related health complications (16). Proton pump
inhibitor therapy has grossed in excess of $10 billion in global
sales since its introduction in 1988 (18). Worldwide, there
have been more than 720 million prescriptions written for pro-
ton pump inhibitor therapy (18). In 2004, there were 12.4 mil-
lion prescriptions for proton pump inhibitors – as prescribed by
MDs (19) (Figure 2). Canadian cost estimates for a 28-day sup-
ply of proton pump inhibitor therapy range from $40 to $70
(19).
Indirect costs
In 2005, a Canadian study (20) of medically diagnosed GERD
patients (n=217) with moderate-to-severe symptoms was con-
ducted to ascertain the impact of the disease. Of the 173 patients
who were employed, 6.7 h of work time was lost each week due
to GERD symptoms (16% lost work time, 95% CI 12.9% to
18.8%). Activity impairment also affected as much as 21% of
nonwork-related activities (95% CI 18.0% to 24.0%). This is
explained by the significantly lower scores for the physical and
mental component summaries of the Medical Outcomes Study
Short Form-36 Health Survey of the cohort compared with the
Canadian population (P<0.001). Relative to other diseases,
the GERD cohort had physical scores similar to individuals
with clinical depression or hypertension, while mental scores
were significantly worse (P<0.001) than hypertensive or dia-
betic patients.
The frequency of GERD patients who develop cancer from
associated dysplastic Barrett’s epithelium is low, suggesting that
routine endoscopic screening of this population group is not war-
ranted (21). In turn, this represents a considerable cost savings
to a health care insurer because a single endoscopy procedure
costs $575 (Ambulatory care classification system 28.1) (22).
For pediatric patients, GERD can be successfully treated
with proton pump inhibitors and, in severe cases, surgical
intervention may be required (17,23); however, surgery of this
nature on young patients is associated with comorbidity and
failure.
At any age, GERD diagnosis represents a considerable long-
term expense for the health insurer and the patient; however,
prompt diagnosis in the very young is essential to reduce health
care burdens and reduce the need for surgical interventions (17).
Figure 1) Gastroesophageal reflux disease-related mortalities per
year categorized according to age group
Figure 2) Retail market ($) for over-the-counter indigestion and
heartburn remedies in Canada according to year
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