[Assessment of ten-year dynamics of cases of hospitalizations of patients with peptic ulcer disease, chronic gastritis and chronic duodenitis].

AIM: To assess of the ten-year dynamics of cases of hospitalizations of patients with peptic ulcer disease (PUD), chronic gastritis and chronic duodenitis relative to the total number of people treated in the gastroenterological departments of the hospital in 20102019. MATERIALS AND METHODS: Data of the annual reports of the work of the hospital departments were studied retrospectively. RESULTS: The relative number of persons hospitalized for chronic duodenitis decreased 2.8 times (p0.001), but the proportion of patients with chronic gastritis did not tend to decrease. This is most likely due to diagnostic errors. The cases of hospitalization of persons with uncomplicated PUD decreased by 3.1 times (p0.001), the proportion of men with duodenal ulcer decreased by 6.3 times (p0.001), with gastric ulcer decreased 1.9 times (p0.01). The proportion of women hospitalized with duodenal ulcer decreased 2.3 times (p0.01). The number of hospitalized men with duodenal ulcer is 3.8 times more than females (p0.001). It can be explained by a decrease in social stressful influences and active anti-Helicobacter pylori therapy. CONCLUSION: Over the period of follow-up, the cases of hospitalization of patients with uncomplicated PUD decreased, primarily due to a decrease in the proportion of persons with ulcer of the duodenum and duodenitis, while the number of patients with chronic gastritis not undergoing modern examination did not have significant dynamics.

Cost-effectiveness modelling of use of urea breath test for the management of Helicobacter pylori-related dyspepsia and peptic ulcer in the UK.

OBJECTIVE: Clinical data comparing diagnostic strategies in the management of Helicobacter pylori-associated diseases are limited. Invasive and noninvasive diagnostic tests for detecting H. pylori infection are used in the clinical care of patients with dyspeptic symptoms. Modelling studies might help to identify the most cost-effective strategies. The objective of the study is to assess the cost-effectiveness of a 'test-and-treat' strategy with the urea breath test (UBT) compared with other strategies, in managing patients with H. pylori-associated dyspepsia and preventing peptic ulcer in the UK. DESIGN: Cost-effectiveness models compared four strategies: 'test-and-treat' with either UBT or faecal antigen test (FAT), 'endoscopy-based strategy' and 'symptomatic treatment'. A probabilistic cost-effectiveness analysis was performed using a simulation model in order to identify probabilities and costs associated with relief of dyspepsia symptoms (over a 4-week time horizon) and with prevention of peptic ulcers (over a 10-year time horizon). Clinical and cost inputs to the model were derived from routine medical practice in the UK. RESULTS: For relief of dyspepsia symptoms, 'test-and-treat' strategies with either UBT (€526/success) and FAT (€518/success) were the most cost-effective strategies compared with 'endoscopy-based strategy' (€1317/success) and 'symptomatic treatment' (€1 029/success). For the prevention of peptic ulcers, 'test-and-treat' strategies with either UBT (€208/ulcer avoided/year) or FAT (€191/ulcer avoided/year) were the most cost-effective strategies compared with 'endoscopy-based strategy' (€717/ulcer avoided/year) and 'symptomatic treatment' (€651/ulcer avoided/year) (1 EUR=0,871487 GBP at the time of the study). CONCLUSION: 'Test-and-treat' strategies with either UBT or FAT are the most cost-effective medical approaches for the management of H. pylori-associated dyspepsia and the prevention of peptic ulcer in the UK. A 'test-and-treat' strategy with UBT has comparable cost-effectiveness outcomes to the current standard of care using FAT in the UK.

[The paradigm shift for peptic ulcer disease]. / Magsårssjukdomens paradigmskiften ­ från högspecialiserad vårdorganisation till egenvård.

Knowledge development and paradigm shift for peptic ulcer disease is described over a fifty-year period using four levels of knowledge that place demands on the healthcare organization. When medical knowledge reached a healing level, continuity became subordinate. However, accessibility to treatment became more important. An important task for future healthcare will be to define and create broader knowledge structures. Efficiency losses can occur when control instruments apply to medical problems at low levels of knowledge which are not mature for this.

Does digestive symptoms require esophago gastroscopy prior to bariatric procedure? Assessment of 6 years' experience.

AIM: Performance of routine preoperative esophagogastroduodenal endoscopy (EGE) in patients undergoing bariatric surgery is still a controversial subject. The purpose of our study was to evaluate the benefits of performing preoperative EGE in a cohort of bariatric patients. MATERIAL AND METHODS: The present retrospective study was performed between March 2010 and June 2016. We divided the study participants into two groups: group A comprised subjects without disturbing upper digestive signs, while group B comprised patients with disturbing upper digestive signs. Logistic regression analysis was used to identify the predictors that might be associated with abnormal outcomes. RESULTS: Our study included 232 patients (who had undergone sleeve gastrectomy, gastric bypass, ileal interposition, or transit bipartition). The average age was 41.4 ± 10.3 years, and the average body mass index (BMI) was 43.6 ± 5.1 kg/m2. Of all the observed gastroscopic abnormalities, the prevalence for gastritis (17.3%), followed by esophagitis (10.2%), hiatus hernia (9.4%), and bulbitis (8.7%). In multivariate regression analysis, the Gastrointestinal Symptom Rating Scale (GSRS) score and upper gastric symptoms were found to be the only independent predictive markers (OR = 2.822, 95% CI: 1.674-3.456 and OR =2.735, 95% CI: 1.827-3.946, respectively). We identified a positive correlation between abnormal EGE findings and postoperative complications. CONCLUSION: Preoperative EGE had a high rate of detection for the possible abnormalities prior to bariatric surgery. Upper gastric symptoms are significant predictive factors of postoperative complications. Performing preoperative EGE for symptomatic patients could help reduce the morbidity and mortality rates in these patients. KEY WORDS: Bariatric surgery, Preoperative endoscopy, Upper digestive symptoms.

Symptomatic marginal ulcer disease after Roux-en-Y gastric bypass: incidence, risk factors and management.

BACKGROUND: One of the long-term complications of laparoscopic Roux-and-Y gastric bypass (LRYGB) is the development of marginal ulcers (MU). The aim of the present study is to assess the incidence, risk factors, symptomatology and management of patients with symptomatic MU after LRYGB surgery. METHODS: A consecutive series of patients who underwent a LRYGB from 2006 until 2011 were evaluated in this study. Signs of abdominal pain, pyrosis, nausea or other symptoms of ulcer disease were analysed. Acute symptoms of (perforated) MU such as severe abdominal pain, vomiting, melena and haematemesis were also collected. Patient baseline characteristics, medication and intoxications were recorded. Statistical analysis was performed to identify risk factors associated with MU. RESULTS: A total of 350 patients underwent a LRYGB. Minimal follow-up was 24 months. Twenty-three patients (6.6%) developed a symptomatic MU of which four (1.1%) presented with perforation. Smoking, the use of corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs) was significantly associated with the development of MU. Five out of 23 patients (22%) underwent surgery. All other patients could be treated conservatively. CONCLUSIONS: Marginal ulcers occurred in 6.6% of the patients after a LRYGB. Smoking, the use of corticosteroids and the use of NSAIDs were associated with an increased risk of MU. Most patients were managed conservatively.

The clinical diagnostic reasoning process determining the use of endoscopy in diagnosing peptic ulcer disease.

OBJECTIVE: To evaluate the clinical diagnostic reasoning process as a tool to decrease the number of unnecessary endoscopies for diagnosing peptic ulcer disease. tudy DESIGN: Cross-sectional KAP study. PLACE AND DURATION OF STUDY: Shifa College of Medicine, Islamabad, from April to August 2010. METHODOLOGY: Two hundred doctors were assessed with three common clinical scenarios of low, intermediate and high pre-test probability for peptic ulcer disease using a questionnaire. The differences between the reference estimates and the respondents' estimates of pre-test and post test probability were used for assessing the ability of estimating the pretest probability and the post test probability of the disease. Doctors were also enquired about the cost-effectiveness and safety of endoscopy. Consecutive sampling technique was used and the data was analyzed using SPSS version 16. RESULTS: In the low pre-test probability settings, overestimation of the disease probability suggested the doctors' inability to rule out the disease. The post test probabilities were similarly overestimated. In intermediate pre-test probability settings, both over and under estimation of probabilities were noticed. In high pre-test probability setting, there was no significant difference in the reference and the responders' intuitive estimates of post test probability. Doctors were more likely to consider ordering the test as the disease probability increased. Most respondents were of the opinion that endoscopy is not a cost-effective procedure and may be associated with a potential harm. CONCLUSION: Improvement is needed in doctors' diagnostic ability by more emphasis on clinical decision-making and application of bayesian probabilistic thinking to real clinical situations.

Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery.

OBJECTIVES: Roux-en-Y gastric bypass (RYGB) is a common intervention for morbid obesity. Upper gastrointestinal (UGI) symptoms are frequent and difficult to interpret following RYGB. The aim of our study was to examine the role of endoscopy in evaluating UGI symptoms after RYGB and to assess the safety and efficacy of endoscopic therapy. METHODS: Between 1998 and 2005, a total of 1,079 patients underwent RYGB for clinically severe obesity and were followed prospectively. Patients with UGI symptoms after RYGB who were referred for endoscopy were studied. RESULTS: Of 1,079 patients, 76 (7%) who underwent RYGB were referred for endoscopy to evaluate UGI symptoms. Endoscopic findings included normal surgical anatomy (n=24, 31.6%), anastomotic stricture (n=40, 52.6%), marginal ulcer (n=12, 15.8%), unraveled nonabsorbable sutures causing functional obstruction (n=3, 4%) and gastrogastric fistula (n=2, 2.6%). Patients with abnormal findings on endoscopy presented with UGI symptoms at a mean of 110.7 days from their RYGB, which was significantly shorter than the time of 347.5 days for patients with normal endoscopy (P<0.001). A total of 40 patients with anastomotic strictures underwent 86 endoscopic balloon dilations before complete symptomatic relief. In one patient, a needle knife was used to open a completely obstructed anastomotic stricture. Unraveled, nonabsorbable suture material was successfully removed using endoscopic scissors in three patients. CONCLUSIONS: Patients presenting with UGI symptoms less than 3 months after surgery are more likely to have an abnormal finding on endoscopy. Endoscopic balloon dilation is safe and effective in managing anastomotic strictures. Endoscopic scissors are safe and effective in removing unraveled, nonabsorbable sutures contributing to obstruction.

Effect of a community screening for Helicobacter pylori: a 5-Yr follow-up study.

BACKGROUND: Helicobacter pylori (H. pylori) screening and eradication may reduce the incidence of gastric cancer, AND AIMS: peptic ulcer, and ulcer complications, and it may reduce symptoms in a small proportion of individuals with functional dyspepsia. This study aimed to assess the effect of community H. pylori screening and treatment on the prevalence of dyspepsia, and as secondary outcomes, the effect on dyspepsia-related health-care consumption and quality of life over 5 yr. METHODS: In 1998-1999, individuals aged 40-65 yr were randomized to H. pylori screening and treatment or to the control group. Five years later, the participants were sent a questionnaire to assess the prevalence of dyspepsia and quality of life. In addition, we obtained information from registers on the use of endoscopies and prescription medication. An economic evaluation was done alongside the randomized trial. RESULTS: Of 12,530 participants attending the study at baseline, 11,065 (88%) were traced and contacted at the 5-yr follow-up. The response rate was 94%. At baseline, 17.5% in the screened group were H. pylori-positive. The absolute reduction in dyspepsia during the first year was 4% in the screened group, whereas no change was observed in the unscreened group; this rate remained constant during the next 4 yr. Quality of life did not change. A small effect was found for dyspepsia-related consultations and sick leave days, but not on the prescription rate of ulcer drugs. A 33% lower ulcer incidence (107 ulcers vs 148 ulcers) was seen in the screened group compared to the unscreened group. CONCLUSION: A population H. pylori screening and treatment program in an H. pylori low-prevalence area had only a modest, but insignificant, effect on the rate of dyspepsia, and a modest, significant effect on the consultation rate and sick leave days for dyspepsia, but resulted in a decreased ulcer incidence. The intervention resulted in an increased cost due to H. pylori screening and treatment.

A randomized controlled trial of test-and-treat strategy for Helicobacter pylori: clinical outcomes and health care costs in a managed care population receiving long-term acid suppression therapy for physician-diagnosed peptic ulcer disease.

BACKGROUND: Guidelines recommend Helicobacter pylori (HP) testing and treatment for patients with a history of peptic ulcer disease (PUD), assuming that PUD has been documented and that successful HP eradication would eliminate the need for further therapy and medical utilization. METHODS: An open-label, randomized controlled trial in a managed care setting evaluated the clinical outcome and costs of an HP test-and-treat (T & T) strategy in 650 patients receiving long-term acid suppression therapy for physician-diagnosed PUD. Patients were randomized to T & T for HP (n = 321) or to usual care (n = 329). Outcome measures included presence and severity of PUD symptoms, use of acid-reducing medication, and acid-peptic-related health care costs during 12-month follow-up. RESULTS: Only 17% of study participants had PUD confirmed by radiography or endoscopy; only 38% of the T & T group tested positive for HP. At 12 months, patients in the T & T group were less likely to report ulcerlike dyspepsia or use of acid-reducing medication; however, 75% of the T & T group used acid-reducing medication during the second half of the 12-month follow-up. In the 12 months after randomization, the T & T group had higher total acid-peptic-related costs than the usual care group. CONCLUSIONS: Most patients receiving long-term acid suppression therapy for physician-diagnosed PUD in community practice settings are likely to have HP-negative, uninvestigated dyspepsia. Routine testing and treating for HP will not reduce acid-peptic-related costs and have only a modest (though statistically significant) effect in reducing clinical symptoms and use of acid-reducing medications.

The cost-effectiveness of population Helicobacter pylori screening and treatment: a Markov model using economic data from a randomized controlled trial.

BACKGROUND: Economic models have suggested that population Helicobacter pylori screening and treatment may be a cost-effective method of reducing mortality from gastric cancer. These models are conservative as they do not consider that the programme may reduce health service peptic ulcer and other dyspepsia costs. We have evaluated the economic impact of population H. pylori screening and treatment over 2 years in a randomized controlled trial and have incorporated the results into an economic model exploring the impact of H. pylori eradication on peptic ulcer disease and gastric cancer. METHODS: Subjects between the ages of 40 and 49 years were randomly invited to attend their local primary care centre. H. pylori status was evaluated by (13)C-urea breath test and infected individuals were randomized to receive omeprazole, 20 mg b.d., clarithromycin, 250 mg b.d., and tinidazole, 500 mg b.d., for 7 days or identical placebos. Economic data on health service costs for dyspepsia were obtained from a primary care note review for the 2 years following randomization. These data were incorporated into a Markov model comparing population H. pylori screening and treatment with no intervention. RESULTS: A total of 2329 of 8407 subjects were H. pylori positive: 1161 were randomized to receive eradication therapy and 1163 to receive placebo. The cost difference favoured the intervention group 2 years after randomization, but this did not reach statistical significance (11.42 ponds sterling per subject cost saving; 95% confidence interval, 30.04 ponds sterling to -7.19 pounds sterling; P=0.23). Analysis by gender suggested a statistically significant dyspepsia cost saving in men (27.17 ponds sterling per subject; 95% confidence interval, 50.01 pounds sterling to 4.32 pounds sterling; P=0.02), with no benefit in women (-4.46 per subject; 95% confidence interval, -33.85 pounds sterling to 24.93 pounds sterling). Modelling of these data suggested that population H. pylori screening and treatment for 1,000,000 45-year-olds would save over 6,000,000 pounds sterling and 1300 years of life. The programme would cost 14, 200 pounds sterling per life year saved if the health service dyspepsia cost savings were the lower limit of the 95% confidence intervals and H. pylori eradication had only a 10% efficacy in reducing mortality from distal gastric cancer and peptic ulcer disease. CONCLUSIONS: Modelling suggests that population H. pylori screening and treatment are likely to be cost-effective and could be the first cost-neutral screening programme. This provides a further mandate for clinical trials to evaluate the efficacy of population H. pylori screening and treatment in preventing mortality from gastric cancer and peptic ulcer disease.

Validation of diagnoses of peptic ulcers and bleeding from administrative databases: a multi-health maintenance organization study.

The automated health plan data and data from medical chart abstractions from eight large health maintenance organizations were used to evaluate the positive predictive values (PPVs) of the International Classification of Diseases, 9th revision (ICD-9) codes for cases of peptic ulcers and upper gastrointestinal bleeding. Overall, 207 of 884 cases of peptic ulcers and upper gastrointestinal bleeding (23%) were confirmed by surgery, endoscopy, X-ray, or autopsy. The PPVs were 66% for hospitalizations with codes for duodenal ulcer (ICD-9-CM 532), 61% for gastric/gastrojejunal ulcer (ICD-9-CM 531, 534), 1% for peptic ulcer (ICD-9-CM 533), and 9% for gastrointestinal hemorrhage (ICD-9-CM578). The overall and diagnostic category-specific PPVs were generally similar for the various HMOs. This study, using data from a large number of health plans located in different geographical regions, underscores the importance of evaluating the accuracy of the diagnoses from automated health plan databases.

14C-urea breath test for assessment of gastric Helicobacter pylori colonization and eradication.

BACKGROUND AND OBJECTIVE: Urea breath test (UBT) is a reliable noninvasive technique for detecting gastric Helicobacter pylori colonization. 14C isotope-based test requires simple equipment and is inexpensive. We studied the utility of 14C-UBT in diagnosis of gastric H. pylori infection. METHODS: Presence of H. pylori was studied using antral histology and culture in patients with rapid urease test (RUT)-positive peptic ulcer. 14C-UBT was performed using a 185-kBq dose. Radioactivity in 15-min breath samples was measured using a beta-scintillation counter and result expressed as % dose recovered/mmol CO2. H. pylori was considered positive when any two tests were positive. All tests were repeated one month after completion of H. pylori eradication therapy. RESULTS: Among 41 patients (duodenal ulcer 36, gastric ulcer 5), H. pylori was detected by histology in 23 (56%) and by culture in 27 (66%). Overall, H. pylori was detected in 28 (68%) patients. Follow-up assessment was possible in 28 patients: 26 cleared the infection (all three tests negative). Mean 14C recovery values at 15 minutes associated with H. pylori-positive status were significantly higher (12.3 [SD 6.8] x 10(-3); n=30; p<0.001) than those associated with H. pylori-negative status (2.1 [0.9] x 10(-3); n=26). Using receiver-operating-characteristic analysis of 15-minute 14C recovery values, a cut-off of 6.5x10(-3) gave the best separation of H. pylori-positive and -negative cases. 14C-UBT had 93% sensitivity, 96% specificity and 95% accuracy. CONCLUSION: 14C-UBT appears to be a reliable noninvasive test for diagnosis of H. pylori infection.

Costs of managing Helicobacter pylori-infected ulcer patients after initial therapy.

BACKGROUND: The objective of this research was to evaluate the outcomes and costs of alternative approaches to managing patients previously treated for peptic ulcer disease and Helicobacter pylori infection. MATERIALS AND METHODS: A decision-analytic model was used to compare (1a) urease breath testing (UBT) for assessment of H. pylori status versus (1b) observation without further testing or treatment, among patients who were symptom-free following initial antimicrobial and antisecretory therapy for endoscopically demonstrated ulcer and H. pylori infection; and (2a) UBT versus (2b) repeat endoscopy with H. pylori testing, and versus (2c) repeat antimicrobial and antisecretory therapy without further testing, among patients who remained symptomatic following initial therapy. RESULTS: Among patients who were symptom free after initial therapy, 6.1% receiving UBT had symptomatic ulcer at one year, compared to 18.2% of those simply observed. The expected first-year cost per symptom-free patient following initial therapy was $591 for UBT compared to $480 for observation. Among patients with persistent symptoms after initial therapy, 21% receiving repeat therapy had symptomatic ulcer at one year, compared to 23.8% receiving repeat endoscopy, and 23.3% receiving UBT. Corresponding medical costs per patient were, respectively, $766, $1787 and $1122. CONCLUSIONS: The optimal approach to managing patients following initial treatment for ulcer and H. pylori infection depends on symptom status following initial therapy. For symptomatic patients, the preferred approach is to prescribe a repeat course of antimicrobial and antisecretory therapy. For patients without symptoms following initial therapy, UBT is the preferred approach because it is associated with a threefold lower risk of symptomatic ulcer at one year, although it costs an additional $110 per patient, compared with observation.

Cost effectiveness of initial endoscopy for dyspepsia in patients over age 50 years: a randomised controlled trial in primary care.

BACKGROUND: Dyspepsia can be managed by initial endoscopy and treatment based on endoscopic findings, or by empirical prescribing. We aimed to determine the cost effectiveness of initial endoscopy compared with usual management in patients with dyspepsia over age 50 years presenting to their primary care physician. METHODS: 422 patients were recruited and randomly assigned to initial endoscopy or usual management. Primary outcomes were effect of treatment on dyspepsia symptoms and cost effectiveness. Secondary outcomes were quality of life and patient satisfaction. Total costs were calculated from individual patient's use of resources with unit costs applied from national data. Statistical analysis of uncertainty on incremental cost-effectiveness ratio (ICER) was done along with a sensitivity analysis on unit costs with cost-effectiveness acceptability curves. FINDINGS: In the 12 months following recruitment, 213 (84%) patients had an endoscopy compared with 75 (41%) controls. Initial endoscopy resulted in a significant improvement in symptom score (p=0.03), and quality of life pain dimension (p=0.03), and a 48% reduction in the use of proton pump inhibitors (p=0.005). The ICER was Pound Sterling1728 (UK Pound Sterling) per patient symptom-free at 12 months. The ICER was very sensitive to the cost of endoscopy, and could be reduced to Pound Sterling165 if the unit cost of this procedure fell from Pound Sterling246 to Pound Sterling100. INTERPRETATION: Initial endoscopy in dyspeptic patients over age 50 might be a cost-effective intervention.

Patient, physician, and payer perceptions and misperceptions of willingness to pay for diagnostic certainty.

Little is known about the value patients, physicians, and payers place on intangible attributes of care. Differences in valuations among these groups and misperceptions of value of intangible attributes to other groups can contribute to conflicts about treatment recommendations or coverage decisions. We surveyed patients, physicians, and managed care executives to assess their willingness to pay (WTP) for diagnostic certainty for peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD). To determine if patients, physicians, and payers accurately perceive each other's valuations of diagnostic certainty, participants were also asked to estimate the WTP of each of the other types of respondents. Patients were most likely, and executives least likely, to value diagnostic certainty. For PUD, 84% of patients, 61% of physicians, and 43% of executives expressed a positive WTP. Median WTP was low for all three groups ($1-9 for patients and physicians; $0 for payers). Physicians and executives both correctly predicted patient WTP. For GERD, 87% of patients, 52% of physicians, and 29% of executives expressed a positive WTP. Executives underestimated patient WTP. For both diseases, physicians' WTP was overestimated by patients and underestimated by executives. The inconsistency in the value that patients, physicians, and managed care executives place on diagnostic certainty indicates the potential for conflict over practice guidelines or access to services. WTP surveys can provide information to aid in anticipating and addressing areas of disagreement.

The description of outcomes in Medicare patients hospitalized with peptic ulcer disease.

OBJECTIVE: The objective of this study was to describe outcomes of care for Medicare patients hospitalized with peptic ulcer disease from 1992 through 1997 and to identify factors related to cost, length of stay, and readmission rates. METHODS: General descriptive statistics were obtained from Medicare inpatient claims data by year, endoscopy grouping, diagnosis related group code, and principal diagnosis code. From abstracted clinical data, associations were derived for length of stay, readmission rates, and the following processes of care: screening or treatment for Helicobacter pylori; screening for nonsteroidal antiinflammatory drug (NSAID) use; and the performance of endoscopy. The Acute Physiology and Chronic Health Evaluation method was used to estimate patient health status for the study. RESULTS: During the 6-yr study, there were 878,212 claims, which constituted 1.3% of the total Medicare claims. The total Medicare payment for peptic ulcer claims was estimated at $4.8 billion. The inpatient mortality rate was 4.5%. Readmission rates remained relatively constant during the study period but decreased significantly when NSAID screening was documented during the hospitalization. Admission rates, length of stay, and mortality declined progressively during the study period. A reduction in length of stay of approximately 1 day was observed when screening or treatment for H. pylori, screening for NSAID use, or the performance of endoscopy was documented. CONCLUSIONS: Peptic ulcer disease has an important impact on the Medicare population with respect to cost, recurrence, and mortality. Adherence to selected processes of care is associated with shorter length of stay and lower readmission rates.

[A cost-effectiveness analysis of strategies for the diagnosis-treatment of Helicobacter pylori-associated peptic ulcer in primary care]. / Análisis coste-efectividad de estrategias de diagnóstico-tratamiento del ulcus péptico asociados a Helicobacter pylori en atención primaria.

OBJECTIVES: To undertake an economic evaluation of three strategies for diagnosing and treating Helicobacter pylori (HP)-related peptic ulcers (PU), and to find the most efficacious and efficient combination of medication for the most cost-effective strategy. DESIGN: Cost-effectiveness analysis based on retrospective information (systematic review of the literature) and Markov models for the simulation of a hypothetical cohort of patients with PU. PATIENTS: Patients seeking medical care at the primary level for an acute PU attack. The costs and health effects of the management of an attack were evaluated in a hypothetical cohort of adults (> 18 years old) with symptomatic peptic ulcer confirmed endoscopically and not associated with consumption of non-steroidal anti-inflammatory drugs (NSAIDs). INTERVENTIONS: Three strategies for handling PU patients were compared: pre- and post-treatment diagnosis of HP, pre-treatment diagnosis and empirical treatment. Then the most efficient strategy for comparing 6 combinations of antibiotics was used. RESULTS: The empirical treatment strategy was markedly less costly (saving of between 15000 and 39000 pesetas per patient treated) than the diagnosis strategies, and obtained equivalent effectiveness under all analytical hypotheses. In comparing drug combinations, the classic triple therapies based on bismuth subcitrate were more effective and less costly than other therapies. CONCLUSIONS: Empirical treatment with combinations of irradicatory drugs was the most efficient strategy for tackling the diagnosis/therapy of patients with HP-related PU. In terms of efficiency, the choice between the various combinations of irradicatory drugs with over 80% success depends basically on the cost of the drugs.