IMMEDIATE ENDOSCOPY OR INITIAL HELICOBACTER-PYLORI SEROLOGICAL TESTING FOR SUSPECTED PEPTIC-ULCER DISEASE - ESTIMATING COST-EFFECTIVENESS USING DECISION-ANALYSIS

Objective: To compare the clinical and economic effects of a strategy using immediate endoscopy to a non-invasive strategy utilizing a serol ogic test for Helicobacter pylori infection for individuals with sympt oms suggestive of peptic ulcer disease. Design: Cost-effectiveness ana lysis evaluating the clinical and economic effects of alternative mana gement strategies of hypothetical patients with suspected peptic ulcer disease in a computer simulation model. Intervention: Two strategies for hypothetical patients with suspected ulcer disease were evaluated: 1) Immediate endoscopy and biopsy for H. pylori, using antisecretory treatment in all patients with documented ulcers and adding antibiotic eradication therapy for those patients with ulcers whose biopsies wer e positive for H. pylori. 2) Empiric treatment with antisecretory ther apy and serologic testing for H. pylori for all patients, using antibi otic eradication therapy only in patients testing positive for H pylor i. Measurements: Cost per ulcer cured over a one-year study period. Re sults: The more cost-effective strategy was the test-and-treat strateg y (Strategy 2) with $4481 cost per ulcer cured. The immediate endoscop y strategy resulted in $8045 cost per ulcer cured. The cost-effectiven ess advantage of the non-invasive strategy diminished as the cost of e ndoscopy fell or as the probability of recurrent symptoms rose in pati ents initially managed without endoscopy. Conclusion: Endoscopy, thoug h costly, precisely guided diagnosis and treatment and, thus, potentia lly reduced the number of patients inappropriately treated. However, c ost-effectiveness analysis supports the continued practice of initial non-invasive management of patients with symptoms suggestive of peptic ulcer disease, achieving the benefits of H. pylori eradication throug h the use of serologic testing to guide antibiotic use.