What is the best strategy for diagnosis and treatment of Helicobacter pylori in the prevention of recurrent peptic ulcer bleeding? A cost-effectiveness analysis.

BACKGROUND Clinical trials provide evidence of the high effectiveness of Helicobacter pylori eradication for preventing recurrent ulcer-related gastrointestinal hemorrhage. The best strategy for curing the infection in this setting is, however, still under debate. OBJECTIVE To evaluate four different strategies for prevention of rebleeding in patients with peptic ulcer hemorrhage: 1) test for H. pylori and treatment, if positive; 2) proton pump inhibitor maintenance; 3) no preventive treatment; 4) empirical H. pylori eradication immediately after bleeding. METHODS A decision analysis model was used, with a time horizon of 2 years and a third-party payer perspective. Costs were estimated for two different settings: a low-cost-for-care area (Spain) and a high-cost area (USA). Main outcome measure was incremental cost-effectiveness ratio for each upper gastrointestinal hemorrhage avoided. RESULTS Empirical H. pylori eradication was the dominant strategy: its estimated rate of recurrent bleeding was lower (6.1%) than those of strategies 1 (7.4%), 2 (11.1%), and 3 (18.4%) and it was the least expensive strategy. The results remained stable when variables were changed inside a wide range of plausible values. Sensitivity analysis also showed that the prevalence of H. pylori in bleeding ulcer was the variable that most influenced the results: when it was below 45% in Spain or below 51% in the United States, empirical eradication was not a dominant strategy although it remained cost-effective. CONCLUSION In patients with bleeding peptic ulcer, empirical treatment of H. pylori infection immediately after feeding is restarted is the most cost-effective strategy for preventing recurrent hemorrhage.