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Management Strategies for Helicobacter pylori-Seropositive Patients with Dyspepsia: Clinical and Economic Consequences

Joshua J. Ofman, MD, MSHS; Jeff Etchason, MD; Steven Fullerton, MPH; Katherine L. Kahn, MD; and Andrew H. Soll, MD
[+] Article and Author Information

From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, School of Medicine, Los Angeles, California; Atlanta Veterans Affairs Medical Center and the Emory University Center for Clinical Evaluation Sciences, Atlanta, Georgia; and RAND, Santa Monica, California. Acknowledgments: The authors thank Emmett Keeler, PhD, for technical assistance and review of the decision model; Chris Conteas, MD, for assistance in data collection; and Kristi Wells for editorial assistance. Grant Support: In part by a grant from Astra-Merck. Requests for Reprints: Joshua J. Ofman, MD, MSHS, CURE/UCLA Gastroenteric Biology Center, West Los Angeles Veterans Affairs Medical Center, 11301 Wilshire Boulevard, Building 115, Room 215, Los Angeles, CA 90073. Current Author Addresses: Drs. Ofman and Soll and Mr. Fullerton: CURE/UCLA Gastroenteric Biology Center, West Los Angeles Veterans Affairs Medical Center, 11301 Wilshire Boulevard, Building 115, Room 215, Los Angeles, CA 90073.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1997;126(4):280-291. doi:10.7326/0003-4819-126-4-199702150-00004
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Background: Noninvasive testing for Helicobacter pylori is widely available and has been considered as an initial management strategy for uninvestigated dyspepsia. However, data to guide clinicians in the management of patients with dyspepsia who are seropositive for H. pylori are lacking.

Objective: To examine the economic, clinical, and policy implications of alternative initial management strategies for patients with uninvestigated dyspepsia who are seropositive for H. pylori.

Design: Decision analysis comparing the costs and outcomes of initial anti-H. pylori therapy and initial endoscopy.

Patients: Helicobacter pylori-seropositive patients with dyspepsia.

Measurements: Cost estimates were obtained from the Medicare reimbursement schedule and a health maintenance organization pharmacy. Probability estimates were derived from the medical literature.

Results: Initial endoscopy costs an average of $1276 per patient, whereas initial anti-H. pylori therapy costs $820 per patient; the average saving is $456 per patient treated. The financial effect of a 252% increase in the use of antibiotics for initial H. pylori therapy is more than offset by reducing the endoscopy workload by 53%. Endoscopy-related costs must be reduced by 96% before the two strategies become equally cost-effective. In patients with nonulcer dyspepsia, the financial benefits of initial anti-H. pylori therapy are not substantially affected by varying the rates of H. pylori eradication, the complications of antibiotics, or the response of symptoms to cure of H. pylori infection.

Conclusions: In H. pylori-seropositive patients with dyspepsia, initial anti-H. pylori therapy is the most cost-effective management strategy. Randomized studies of these strategies that evaluate outcomes and patient preferences are needed to optimize management decisions. In the meantime, unless physicians are concerned about resistance to antimicrobial agents or the lack of proven benefit of anti-H. pylori therapy in nonulcer dyspepsia, the strategy outlined in this analysis can be used as a basis for management and policy decisions about H. pylori-seropositive patients with dyspepsia.

Figures

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Figure 1.
Alternative strategies for the initial management of dyspepsia.H. pyloriHelicobacter pylori

The bold-faced limbs of the tree are the subject of this analysis. = .

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Figure 2.
The decision tree.H. pyloriHelicobacter pylori

Each terminal branch with complications is only shown once in each limb. DU = duodenal ulcer; GU = gastric ulcer; = ; NUD = nonulcer dyspepsia. A plus sign indicates the presence of a hidden branch similar to the adjacent branch.

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Grahic Jump Location
Figure 3.
Two-way sensitivity analysis: the cost of anti-Helicobacter pylori therapy and the fraction of base-case endoscopy costs.H. pylori

The values in the area marked by grid lines are the values of the variables under which initial anti- therapy is preferred. The values in the area marked by horizontal lines are the values of the variables under which initial endoscopy is preferred.

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Grahic Jump Location
Figure 4.
Two-way sensitivity analysis: the probability of having peptic ulcer disease and the probability that patients with nonulcer dyspepsia will respond to initial anti-Helicobacter pylori therapy.H. pylori

The values in the area marked by grid lines are the values of the variables under which initial anti- therapy is preferred. The values in the area marked by horizontal lines are the values of the variables under which initial endoscopy is preferred.

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