Table 3. Cost-effectiveness studies evaluating the test-and-treat strategy.
| Author | Design | Strategies compared | Measured outcome | Conclusions |
|---|---|---|---|---|
| Barton et al.43 | Decision analysis model | Test-and-treat vs. empirical acid suppression vs. initial endoscopy | Cost effectiveness, QALYs, and costs | Endoscopy was dominated at all ages by other strategies. PPI therapy was the most cost-effective strategy in 30-year olds with a low prevalence of H. pylori. In 60-year olds, H. pylori test-and-treat was the most cost-effective option |
| Chey et al.44 | Decision analysis model | Antibody testing or testing to detect active H. pylori infection (active testing) | Appropriate and inappropriate treatment, cost per patient, incremental cost per unnecessary treatment avoided | Active testing led to a substantial reduction in unnecessary treatment for patients without active infection (antibody 23.7% active, 1.4% patients) at an incremental cost of $37 per patient |
| Chiba et al.45 | Corrected alpha percentile bootstrap method | Test-and-treat vs. PPI | Cost per patient (direct and indirect costs) | The annual saving per patient, calculated for each increment of change in global overall symptoms, was CDN$54 |
| Fendrick et al.46 | Decision analysis model | Two immediate endoscopy and three non-invasive diagnostic and treatment strategies | Cost per ulcer cured and cost per patient treated | The predicted costs per patient treated were as follows: (1) endoscopy and biopsy for H. pylori, $1,584; (2) endoscopy without biopsy, $1,375; (3) serology test for H. pylori, $894; (4) empirical antisecretory therapy, $952; and (5) empirical antisecretory and antibiotic therapy, $818 |
| Fendrick et al.47 | Decision analysis model | Immediate endoscopy vs. empirical treatment with antisecretory therapy and serology testing for H. pylori | Cost per ulcer cured over a 1-year study period | The most cost-effective strategy was the test-and-treat strategy with $4,481 cost per ulcer cured. The immediate endoscopy strategy resulted in a cost of $8,045 per ulcer cured |
| García-Altés et al.48 | Decision analysis model | Prompt endoscopy, score and scope, test and scope, test-and-treat, and empirical antisecretory treatment | Direct cost of each management strategy | Endoscopy was the most effective strategy for the management of dyspepsia. Incremental cost-effectiveness ratios showed that score and scope was the most cost-effective alternative (€483 per asymptomatic patient), followed by prompt endoscopy (€1,396) |
| Gee et al.49 | Cost analysis in a breath test service | Test-and-treat vs. endoscopy | Cost of each management strategy | Referral to the breath test service costs £84.67 per dyspeptic patient; referral for endoscopy costs £98.35 per patient |
| Klok et al.50 | Economical evaluation of a randomized clinical trial | Test-and-treat vs. prompt endoscopy | Health-care costs and quality of life | The total costs per patient were €511, with 0.037 QALY gained per patient in the test-and-treat group, and €748, with 0.032 QALY gained per patient in the endoscopy group. The test-and-treat strategy yielded cost savings and QALYs gained |
| Labadaum et al.51 | Decision analysis model | Test-and-treat strategy vs. 1-month PPI | Health-care utilization (cost per patients treated) | The cost per patient treated differs little between the two non-invasive strategies analyzed ($545 for the test-and-treat strategy vs. $529 with PPI), while both achieve similar clinical outcomes. |
| Makris et al.52 | Decision analysis model | Test-and-treat vs. endoscopy vs. empirical antisecretory treatment vs. empirical eradication treatment | Costs, effectiveness, and cost-effectiveness ratios | Endoscopy was not a cost-effective approach. Of the non-invasive test-and-treat strategies, using the breath test was the most effective and most costly strategy ($8,238 per additional patient cured) compared with laboratory serology. |
| Marshall et al.53 | Decision analysis model | Test-and-treat vs. empirical ranitidine | Direct medical costs and effectiveness in curing H. pylori-related ulcers | Breath test was more costly than either serology or ranitidine, but was the most effective strategy and required the fewest endoscopies. No strategy demonstrated dominance over another in the base case. The incremental cost-effectiveness ratio of serology vs. ranitidine was $118/cure |
| Mason et al.54 | Markov model from large randomized controlled trial data | Test-and-treat vs. placebo | Life years saved/population screening and intervention | Population test-and-treat would save more than £8,450,000 and 1,300 life-years per million people screened |
| Moayyedi et al.55 | Markov model from systematic review of randomized controlled trials | Test-and-treat vs. 1 month of antacids | No. of months of symptom remission | Test-and-treat favored vs. antacids |
| Moayyedi et al.32 | Decision analysis model | Test-and-treat vs. initial endoscopy | Costs effectiveness | H. pylori test-and-treat strategy is the most cost-effective method for managing dyspepsia, costing US $134 per patient per year compared with US $240 per patient per year for prompt endoscopy. The prompt endoscopy strategy only becomes cost effective in the unlikely scenario of endoscopy costing US$160, the non-invasive test costing US$80, and an H. pylori prevalence of <20% |
| Ofman et al.56 | Decision analysis model | Test-and-treat vs. initial endoscopy in patients who are seropositive for H. pylori | Costs per patient | Initial endoscopy costs an average of $1,276 per patient, whereas initial anti-H. pylori therapy costs $820 per patient; the average saving is $456 per patient treated. The financial effect of a 252% increase in the use of antibiotics for initial H. pylori therapy is more than offset by reducing the endoscopy workload by 53% |
| Silverstein et al.57 | Decision analysis model | Test-and-treat vs. endoscopy vs. empirical antisecretory treatment | Direct medical charges in the first year after the onset of dyspepsia | Medical care charges were $2,162.50 for initial endoscopy and $2,122.60 for empirical therapy, a difference of 1.8%. Empirical therapy has lower costs than initial endoscopy when H2-receptor antagonists are used to prevent recurrence of dyspepsia. Initial non-invasive testing for H. pylori has lower costs than initial endoscopy if patients with dyspepsia and H. pylori infection receive antimicrobial therapy without endoscopy |
| Sonnenberg et al.58, 59 | Decision analysis model | Serology testing vs. initial endoscopy | Cost–benefit relationship of serology testing for H. pylori | A response to eradication of H. pylori in 5–10% of all patients with non-ulcer dyspepsia would make screening and treatment for H. pylori a beneficial option, irrespective of any other potential benefits. If ulcer prevention were associated with a long-term benefit of $4,000 or more and if the ulcer prevalence rate exceeded 10% of all dyspeptic patients, serology testing for H. pylori would also pay off |
| Spiegel et al.60 | Decision analysis on a hypothetical cohort | Less invasive strategies (with either test-and-treat or PPI as first choice) vs. more invasive approaches | Proportion of symptom-free patients and QALY | Less invasive strategies (with either test-and-treat or PPI initial approach) preferred over more invasive strategies. Starting with test-and-treat had cost-effectiveness of $1,714/QALY and $2,007/symptom-free patient at 1 year |
| Vakil et al.61 | Decision analysis model | Test-and-treat vs. endoscopy vs. empirical H. pylori treatment | Costs | Costs were very similar for both endoscopy ($643) and serology ($646) in the USA. In Finland, endoscopy ($173) was less expensive than serology ($192). Empirical treatment of children with dyspepsia was not cost effective in either country. Sensitivity analysis showed that when prevalence of infection was >53%, empirical therapy was the optimal approach |
Abbreviations: PPI, proton pump inhibitor; QALY, quality adjusted life year.