BACKGROUND AND AIMS: Many patients with laryngopharyngeal symptoms (LPS), chronic cough, or belching are referred to gastroenterologists for evaluation and management of GERD. We aimed to optimize a cost-effective approach to evaluating atypical GERD symptoms.

METHODS: We developed a decision analytic model comparing common strategies: (1) usual care defined by empiric PPI and endoscopy, or (2) comprehensive one-time diagnostics including endoscopy and ambulatory reflux testing to guide therapy. The model was applied to patients with LPS, belching, and chronic cough from patient and insurer perspectives. The time horizon was one year, and the willingness-to-pay threshold was set to $100,000/quality-adjusted life-year (QALY) gained.

RESULTS: For patients with LPS, up-front testing, including pH-impedance monitoring and wireless pH monitoring, optimized cost-effectiveness by identifying patients who can convincingly stop PPI therapy ($220-301 saved to patients, ∼$3,300 saved to insurers, +0.01 QALY-gained/year). For patients with belching, up-front testing, including pH-impedance monitoring, optimized cost-effectiveness by identifying patients with supragastric belching who would benefit from diaphragmatic breathing ($3,424 saved to patients, $5,847 saved to insurers, +0.10 QALY-gained/year). For patients with cough-predominant LPS, demonstration that GERD is absent with comprehensive testing appears cost-effective from an insurers' perspective, but not necessarily from patients' perspective, and the decision can be left to the patients and providers.

CONCLUSION: Phenotyping the approach to the dominant symptom may optimize evaluating patients with atypical GERD symptoms. These conclusions are consistent with the Lyon 2.0 and San Diego consensus recommendations of treatment avenues distinct from GERD management.