Proton pump inhibitors (PPIs) have become an indispensable part of the armoury of treating gastro-oesophageal reflux disease (GORD). They are more effective than H₂ receptor antagonists and prokinetic agents in oesophagitis and endoscopy negative reflux disease.1 This efficacy comes at a price however and PPIs are the most expensive class of drug in the UK, costing nearly £300 million in 1998.2 There have been attempts to curb PPI expenditure and the UK National Institute for Clinical Excellence has issued guidelines on appropriate prescription.2

The problem is that there is a dearth of health economic data to inform those making health care decisions. Economic models have suggested that PPIs are cost effective therapy for GORD but there have been criticisms of this approach3 and they do not address the root of the problem. Economic decisions are simple when a drug that is more expensive and less effective is compared with a cheaper more effective agent. The latter is said to “dominate” the former and it requires little health economic expertise to realise that the cheaper drug should be used. Problems arise when a …