MANAGEMENT STRATEGIES FOR HELICOBACTER PYLORI-SEROPOSITIVE PATIENTS WITH DYSPEPSIA - CLINICAL AND ECONOMIC CONSEQUENCES

Background: Noninvasive testing for Helicobacter pylori is widely avai lable and has been considered as an initial management strategy for un investigated dyspepsia. However, data to guide clinicians in the manag ement of patients with dyspepsia who are seropositive for H. pylori ar e lacking. Objective: To examine the economic, clinical, and policy im plications of alternative initial management strategies for patients w ith uninvestigated dyspepsia who are seropositive for H. pylori. Desig n: 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 we re obtained from the Medicare reimbursement schedule and a health main tenance organization pharmacy. Probability estimates were derived from the medical literature. Results: Initial endoscopy costs an average o f $1276 per patient, whereas initial anti-H. pylori therapy costs 8820 per patient; the average saving is $456 per patient treated. The fina ncial effect of a 252% increase in the use of antibiotics for initial H. pylori therapy is more than offset by reducing the endoscopy worklo ad by 53%. Endoscopy-related costs must be reduced by 96% before the t wo strategies become equally cost-effective. In patients with nonulcer dyspepsia, the financial benefits of initial anti-H. pylori therapy a re not substantially affected by varying the rates of H. pylori eradic ation, the complications of antibiotics, or the response of symptoms t o cure of H. pylori infection. Conclusions: In H. pylori-seropositive patients with dyspepsia, initial anti-H. pylori therapy is the most co st-effective management strategy. Randomized studies of these strategi es that evaluate outcomes and patient preferences are needed to optimi ze management decisions. In the meantime, unless physicians are concer ned about resistance to antimicrobial agents or the lack of proven ben efit of anti-H. pylori therapy in nonulcer dyspepsia, the strategy out lined in this analysis can be used as a basis for management and polic y decisions about H. pylori-seropositive patients with dyspepsia.