Reappraisal of non-invasive management strategies for uninvestigated dyspepsia: a cost-minimization analysis.
BACKGROUND
The benefits of the Helicobacter pylori test-and-treat strategy are attributable largely to the cure of peptic ulcer disease while limiting the use of endoscopy.


OBJECTIVE
To reappraise the test-and-treat strategy and empirical proton pump inhibitor therapy for the management of uninvestigated dyspepsia in the light of the decreasing prevalence of H. pylori infection, peptic ulcer disease and peptic ulcer disease attributable to H. pylori.


METHODS
Using a decision analytical model, we estimated the cost per patient with uninvestigated dyspepsia managed with the test-and-treat strategy ($25/test; H.pylori treatment, $200) or proton pump inhibitor ($90/month). Endoscopy ($550) guided therapy for persistent or recurrent symptoms.


RESULTS
In the base case (25%H. pylori prevalence, 20% likelihood of peptic ulcer disease, 75% of ulcers due to H.pylori), the cost per patient is $545 with the test-and-treat strategy and $529 with proton pump inhibitor, and both strategies yield similar clinical outcomes at 1 year. H. pylori prevalence, the likelihood of peptic ulcer disease and the proportion of ulcers due to H.pylori are important determinants of the least costly strategy. At an H. pylori prevalence below 20%, proton pump inhibitor is consistently less costly than the test-and-treat strategy.


CONCLUSIONS
As the H. pylori prevalence, the likelihood of peptic ulcer disease and the proportion of ulcers due to H. pylori decrease, empirical proton pump inhibitor becomes less costly than the test-and-treat strategy for the management of uninvestigated dyspepsia. Given the modest cost differential between the strategies, the test-and-treat strategy may be favoured if patients without peptic ulcer disease derive long-term benefit from H.pylori eradication.
Ladabaum
U
U
Division of Gastroenterology, Department of Medicine, University of California, San Francisco, Ca 94143-0538, USA. ladabau@itsa.ucsf.edu
Chey
W D
WD
Scheiman
J M
JM
Fendrick
A M
AM
D000900:Anti-Bacterial Agents / Q000191:economics / Q000627:therapeutic use; D000897:Anti-Ulcer Agents / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis / Q000379:methods; D003661:Decision Support Techniques; D004359:Drug Therapy, Combination; D004415:Dyspepsia / Q000188:drug therapy / Q000191:economics* / Q000382:microbiology; D017048:Health Care Costs; D016481:Helicobacter Infections / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D016480:Helicobacter pylori; D006801:Humans; D017059:Models, Econometric; D010437:Peptic Ulcer / Q000188:drug therapy / Q000191:economics / Q000382:microbiology; D011320:Primary Health Care / Q000191:economics / Q000379:methods; D054328:Proton Pump Inhibitors; D014481:United States
D000900:Anti-Bacterial Agents; D000897:Anti-Ulcer Agents; D054328:Proton Pump Inhibitors