Noninvasive management strategies were more cost-effective in suspected peptic ulcer disease
ACP J Club. 1996 Jan-Feb;124:24. doi:10.7326/ACPJC-1996-124-1-024
Fendrick AM, Chernew ME, Hirth RA, Bloom BS. Alternative management strategies for patients with suspected peptic ulcer disease. Ann Intern Med. 1995 Aug 15;123:260-8.
To estimate the economic effects of 2 immediate endoscopy and 3 initially noninvasive diagnostic and treatment strategies for peptic ulcer and Helicobacter pylori in patients with symptoms suggestive of peptic ulcer disease.
Cost-effectiveness analysis using a decision analytic model.
A cohort of 1000 hypothetical patients presenting to a physician with symptoms suggestive of peptic ulcer disease who were not concurrently taking nonsteroidal anti-inflammatory drugs. All patients had symptoms severe enough to justify an empiric course of antisecretory agents and had no previously documented peptic ulcer disease. The hypothetical cohort was presumed to have a mix of clinical conditions as drawn from the literature (MEDLINE search for English-language articles and unpublished data presented at the NIH Consensus Development Meeting, February 1994).
2 immediate endoscopy and 3 noninvasive diagnostic and treatment strategies were evaluated: immediate endoscopy for peptic ulcer and biopsy for H. pylori; immediate endoscopy without biopsy; serologic testing for H. pylori; empiric treatment with antisecretory therapy; and empiric treatment with antisecretory and antibiotic therapy.
Main Cost and Outcome Measures
Cost per ulcer cured and cost per patient treated. Only third-party expenditures were included in the cost calculations of medical resource use.
The estimated treatment costs per ulcer cured by strategy were U.S. $8045 for endoscopy and biopsy for H. pylori; $6984 for endoscopy only; $4541 for serologic test for H. pylori; $4835 for empirical antisecretory therapy; and $4155 for empirical antisecretory and antibiotic therapy. The estimated treatment costs per patient by strategy were $1584 for endoscopy and biopsy for H. pylori; $1375 for endoscopy only; $894 for serologic tests for H. pylori; $952 for empirical antisecretory therapy; and $818 for empirical antisecretory and antibiotic therapy. The cost-effectiveness advantage of noninvasive strategies relative to immediate endoscopy strategies were sensitive to 2 variables: the cost of the endoscopy and the probability of recurrent symptoms in patients without an ulcer. The cost-effectiveness advantage of the noninvasive strategies diminished as the cost of the endoscopy decreased or as the probability of recurrent symptoms increased in patients initially managed without endoscopy.
In patients with symptoms suggesting peptic ulcer disease, the estimated costs per ulcer cured and per patient treated were lower when noninvasive management strategies were used.
Source of funding: Not stated.
For article reprint: Dr. A.M. Fendrick, Division of General Medicine, University of Michigan Medical Center, 3116 Taubam Center, Ann Arbor, MI 48109, USA. FAX 313-936-8944.
The study by Fendrick and colleagues shows the strengths and limitations of economic analysis. The authors developed clear recommendations about the advantages of a noninvasive approach to managing patients suspected of having a peptic ulcer. Clinicians may have difficulty, however, translating their recommendations into clinical practice, particularly if they work outside the United States.
First, the conclusions are very sensitive to the cost of endoscopy, which was assumed to be around $1200 U.S. In comparison, the schedule fee for upper gastrointestinal endoscopy in Australia is only $110 (Medicare Benefits Schedule Book, November 1994). Thus, an early endoscopy is a much more economically attractive strategy in Australia.
Second, the economic model did not consider all of the outcomes that are relevant to patients. Factors such as anxiety caused by diagnostic uncertainty, satisfaction with care, and capacity to work were not included. These factors were examined in a randomized trial done in general practice in Denmark (1) that compared empirical treatment with antisecretory drugs and early endoscopy in patients with dyspepsia. Patients who received early endoscopy were less likely to report dissatisfaction with care and time off from work than those who received treatment of symptoms.
Third, the practical problems of persuading patients to take a combination of antisecretory and antibiotic therapy for dyspeptic symptoms are considerable. Although both physicians and patients may be motivated to use a complex regimen despite the attendant side effects when the diagnosis and the potential benefits are clear, they may feel quite differently when there is only a 1 in 5 chance of a benefit.
Although the economic model developed by Fendrick and colleagues challenges us to think carefully about the optimal management of patients with ulcer symptoms, the strategies they propose need to be tested in a pragmatic randomized clinical trial.
David A. Henry, MB
The University of NewcastleCallaghan, New South Wales, Australia