Practice patterns for managing Helicobacter pylori infection and upper gastrointestinal symptoms.

OBJECTIVE To assess adherence with guidelines for testing and treatment of Helicobacter pylori infection and upper gastrointestinal symptoms. STUDY DESIGN Retrospective longitudinal cohort analysis of patient-level medical and pharmacy claims from 75 US managed care plans. METHODS Persons with new claims for antisecretory medication, H pylori tests, or endoscopies were selected from among 2 million plan members continuously enrolled from 2001 to 2004 and were grouped by initial clinical diagnosis (3456 with peptic ulcer disease [PUD], 14,593 with nonulcer dyspepsia [NUD], and 36,233 with gastroesophageal reflux disease [GERD]). Diagnostic procedures, medications received, and sequencing of specific procedures and medications were examined relative to published guidelines by initial diagnosis, age, and physician specialty. RESULTS While guidelines recommend testing before treatment, one third of persons receiving antibiotics for H pylori infection had not first been tested for the infection. In one third of all posttreatment testing, primary care practitioners incorrectly used serologic tests, despite their inability to distinguish cured from active infection. Eighteen percent of patients with GERD were tested for H pylori, although there is no causal link between them. Only two thirds of patients aged 50 to 64 years with presumed PUD underwent endoscopy, which guidelines recommend for older adults; yet one third of patients with PUD aged 18 to 49 years, for whom prompt endoscopy is generally not recommended, had an endoscopy within 30 days of their index date. CONCLUSIONS Substantial noncompliance with widely disseminated guidelines calls for better understanding of appropriate indications for H pylori testing and endoscopy to improve patient care and conserve healthcare resources.