Review: prompt endoscopy is not a cost-effective strategy for initial management of dyspepsia.

et al. Helicobacter pylori ''test and treat'' or endoscopy for managing dyspepsia: an individual patient data meta-analysis. Q In patients with dyspepsia, how cost effective is initial management with prompt endoscopy compared with a test and treat approach for inducing resolution of symptoms? METHODS Data sources: a randomised controlled trial (RCT) register established by the Dyspepsia Trials Collaborators' Group supplemented by searches of the Cochrane database of RCTs and Medline (all up to December 2003). Study selection and assessment: RCTs that compared a prompt endoscopy strategy with a test and treat approach for the initial management of dyspepsia in adults in primary care or on first referral to secondary care, and reported relevant outcomes. Outcomes: total dyspepsia symptom score, presence of dyspepsia, cost (in 2003 US dollars), and incremental net benefit at 12 months. 5 RCTs (n = 1924) (mean age 41 years, 50% men) met the selection criteria. Effects of the intervention on dyspepsia symptoms were pooled using meta-analysis of individual patient data. The groups did not differ for total dyspepsia symptom scores (table). However, fewer persons in the endoscopy group than in the test and treat group still had symptoms of dyspepsia at 12 months (table). Mean total cost per patient was greater in the endoscopy group than in the test and treat group (table). At a willingness to pay of $1000 per patient who is free of dyspepsia symptoms, the incremental net benefit was lower in the endoscopy group than in the test and treat group. Prompt endoscopy became cost effective only when the willingness to pay per patient who is symptom free was increased to $180 000. CONCLUSION In patients with dyspepsia, initial management with prompt endoscopy is slightly more effective but not cost effective compared with a test and treat approach for inducing resolution of symptoms. Abstract and commentary also appear in ACP Journal Club.