Cost-benefit analysis of testing for Helicobacter pylori in dyspeptic subjects.

OBJECTIVES It has remained controversial how to manage patients who present with symptoms of dyspepsia. Should all dyspeptic patients undergo a radiological or endoscopic procedure to diagnose peptic ulcer, or would a serological test for Helicobacter pylori provide sufficient evidence to start all H. pylori-positive patients on empirical antibiotic therapy? METHODS The outcome of serological testing for H. pylori in dyspepsia is analyzed using a decision tree. Successful eradication is associated with the potential benefits of healing dyspepsia and preventing peptic ulcer or gastric cancer. In a sensitivity analysis, all of the transition rates and benefits are varied over a wide range to test the robustness of the calculated decision outcomes. RESULTS The cost-benefit relationship of serological screening for H. pylori in dyspeptic patients is influenced primarily by the response rate of nonulcer dyspepsia to H. pylori eradication and secondly by the monetary benefit of ulcer prevention and the prevalence rate of peptic ulcer in H. pylori-positive patients. A response to H. pylori eradication in 5-10% of all patients with nonulcer dyspepsia would make screening and treatment for H. pylori a beneficial option, irrespective of any other potential benefits. If ulcer prevention were associated with long term benefit of $4000 or more and if the ulcer prevalence rate exceeded 10% of all dyspeptic patients, serological screening for H. pylori would also pay off. CONCLUSIONS As long as no unequivocal evidence exists that nonulcer dyspepsia responds to eradication of H. pylori, treating all dyspeptic patients who test positive for H. pylori cannot be recommended. At the present time, antibiotic therapy should be reserved to patients with proven ulcer or to patients with nonulcer dyspepsia for whom other measures have failed.