Randomised controlled trial of Helicobacter pylori testing and endoscopy for dyspepsia in primary

doi:10.1136/bmj.322.7291.898

BMJ 2001;322:898 ( 14 April )

Primary care

Randomised controlled trial of Helicobacter pylori testing and endoscopy for dyspepsia in primary care

B C Delaney, senior lecturer, S Wilson, senior research fellow, A Roalfe, medical statistician, L Roberts, research associate, V Redman, research associate, A Wearn, lecturer, F D R Hobbs, professor of primary care and general practice.

Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, University of Birmingham Medical School, Birmingham B15 2TT

Correspondence to: B C Delaney b.c.delaney{at}bham.ac.uk

Objective: To determine the cost effectiveness of a strategyof near patient Helicobacter pylori testing and endoscopy formanagingdyspepsia.
Design: Randomised controlledtrial.
Setting: 31 UK primary carecentres.
Participants: 478 patients under 50 years old presentingwith dyspepsia of longer than four weeksduration.
Interventions: Near patient testing for H pylori and openaccess endoscopy for patients with positive results. Control patientsreceived acid suppressing drugs or specialist referral at generalpractitioner'sdiscretion.
Main outcome measures: Cost effectiveness based on improvement insymptoms and use of resources at 12 months; quality oflife.
Results: 40% of the study group tested positive forH pylori. 45% of study patients had endoscopy compared with 25%of controls. More peptic ulcers were diagnosed in the study group(7.4% v 2.1%, P=0.011). Paired comparison of symptom scores andquality of life showed that all patients improved over time withno difference between study and control groups. No significantdifferences were observed in rates of prescribing, consultation,or referral. Costs were higher in the study group (£367.85 v £253.16perpatient).
Conclusions: The test and endoscopy strategy increasesendoscopy rates over usual practice in primary care. The additionalcost is not offset by benefits in symptom relief or quality oflife.

What is already known on this topic
Patients younger than 50 without H pylori infection are unlikely to have treatable disease detected at endoscopy

Such patients can be managed by acid suppression and reassurance alone

Test and endoscopy (referral of patients testing positive for H pylori in primary care) has been recommended as a way to reduce endoscopic workload

What this paper adds
Applying a test and endoscopy strategy increased the endoscopy referral rate from 25% to 40%

The strategy produced no significant differences in symptoms or quality of life compared with usual management

The increased costs of this strategy cannot be justified

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Rapid Responses:

Read all Rapid Responses

H.pylori-induced disorders can be evaluated at bed-side by means of Biophysical Semeiotics: Sergio Stagnaro
bmj.com, 18 Apr 2001 [Full text]
Endoscopy in dyspeptic patients under the age of fitty-five: Luis Bujanda, et al.
bmj.com, 20 Apr 2001 [Full text]
Diagnosis is the key in dyspepsia: Val Heatley
bmj.com, 27 Apr 2001 [Full text]
Author's reply: Brendan C Delaney
bmj.com, 2 May 2001 [Full text]
Test and treat not test and scope: M J Lancaster Smith
bmj.com, 2 May 2001 [Full text]
There is no scope for H.pylori testing!: Abhinav Kant
bmj.com, 11 May 2001 [Full text]
New strategies of the management of dyspepsia should be based on local data: Helgi Kolk, et al.
bmj.com, 27 May 2001 [Full text]
Threats to validity: Johannes C van der Wouden
bmj.com, 2 Jun 2001 [Full text]