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 serologic test for Helicobacter pylori infection for individuals with symptoms suggestive of peptic ulcer disease. DESIGN Cost-effectiveness analysis evaluating the clinical and economic effects of alternative management 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 were positive for H. pylori. 2) Empiric treatment with antisecretory therapy and serologic testing for H. pylori for all patients, using antibiotic eradication therapy only in patients testing positive for H. pylori. MEASUREMENTS Cost per ulcer cured over a one-year study period. RESULTS The more cost-effective strategy was the test-and-treat strategy (Strategy 2) with $4481 cost per ulcer cured. The immediate endoscopy strategy resulted in $8045 cost per ulcer cured. The cost-effectiveness advantage of the non-invasive strategy diminished as the cost of endoscopy fell or as the probability of recurrent symptoms rose in patients initially managed without endoscopy. CONCLUSION Endoscopy, though costly, precisely guided diagnosis and treatment and, thus, potentially reduced the number of patients inappropriately treated. However, cost-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 through the use of serologic testing to guide antibiotic use.