Comparison groups were not clear in study

BMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7057.623 (Published 07 September 1996) Cite this as: BMJ 1996;313:623
  1. Tony C K Tham, Visiting gastroenterology fellow,
  2. David R Lichtenstein, Instructor in medicine
  1. Endoscopy Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA

    EDITOR,—A H Briggs et al compared the cost effectiveness of screening for and eradication of Helicobacter pylori in the management of dyspeptic patients under 45 in the community using decision analysis and concluded that cost savings in the strategy of screening for H pylori compared with treatment with cimetidine could take almost eight years to accrue.1 We think, however, that there are flaws and limitations in this study and that their conclusions should be interpreted with caution.

    In their analysis of screening for H pylori in dyspeptic patients in the community, it is not clear what strategies they were comparing. They state that all patients who were serologically positive for H pylori underwent endoscopy to determine whether they had peptic ulcer disease followed presumably by eradication treatment if an ulcer was identified. What was the comparative strategy? Was it patients who were serologically positive for H pylori and then empirically treated with eradication treatment without previous endoscopy? Or was it patients who were empirically treated with cimetidine without previous serological testing for H pylori? Regardless of the comparative group, the outcome of patients who are negative for H pylori in serological tests or those who are positive for H pylori in such tests but do not have an ulcer on endoscopy should have been considered, although it is unclear if this was done. These subgroups of patients are important because they represent the majority of patients and could account for a significant number of follow up office visits, repeat endoscopies, and loss of days from work.

    The three strategies for managing dyspepsia in the community are (a) serological testing for H pylori followed either by endoscopy if H pylori positive or by antimicrobial treatment without endoscopy, (b) empirical treatment with antisecretory drugs, and (c) empirical treatment with antisecretory drugs and antibiotic agents to eradicate H pylori. Decision analysis studies from the United States have suggested that there is little difference in the cost effectiveness between these strategies.2 3 Compared with an invasive strategy of immediate endoscopy, a prospective randomised study comparing immediate endoscopy with empirical H2 receptor antagonists in dyspepsia has shown that in the long term endoscopy is more cost effective.4 However, decision analyses of immediate endoscopy compared with non-invasive strategies give conflicting findings.2 3

    Prospective studies to compare the different management strategies of dyspepsia in the community are clearly warranted. At present, any of the above strategies can be justified based on decision analyses.


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