ALTERNATIVE MANAGEMENT STRATEGIES FOR PATIENTS WITH SUSPECTED PEPTIC-ULCER DISEASE

Objective: To estimate the clinical and economic effects of available invasive and noninvasive management strategies for peptic ulcer and He licobacter pylori in persons with symptoms suggesting peptic ulcer dis ease. Design: Cost-effectiveness analysis using a decision analytic mo del. Intervention: 2 immediate endoscopy and 3 noninvasive diagnostic and treatment strategies were evaluated: 1) immediate endoscopy for pe ptic ulcer and biopsy for H. pylori; 2) immediate endoscopy without bi opsy; 3) serologic test for H. pylori; 4) empiric treatment with antis ecretory therapy; and 5) empiric treatment with antisecretory therapy and antibiotic agents to eradicate H. pylori.Measurements: Cost per ul cer cured and cost per patient treated. Results: The estimated costs p er ulcer cured by strategy were as follows: 1) endoscopy and biopsy fo r H. pylori, $8045; 2) endoscopy without biopsy, $6984; 3) serologic t est for H. pylori, $4541; 4) empiric antisecretory therapy, $4835; and 5) empiric antisecretory and antibiotic therapy, $4155. The predicted costs per patient treated were as follows: 1) endoscopy and biopsy fo r H. pylori, $1584; 2) endoscopy without biopsy, $1375; 3) serologic t est for H. pylori, $894; 4) empiric antisecretory therapy, $952; and 5 ) empiric antisecretory and antibiotic therapy, $818. The cost-effecti veness advantage of the noninvasive strategies diminished as the cost of endoscopy decreased or as the probability of recurrent symptoms inc reased in patients initially managed without endoscopy. Conclusion: En doscopy, although costly, precisely guided diagnosis and treatment and thus potentially reduced the number of patients inappropriately treat ed. However, the safety and effectiveness of less expensive, less inva sive diagnostic and treatment strategies strongly support initial noni nvasive care of symptomatic persons thought to have peptic ulcer disea se.