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Am Fam Physician. 2001;64(9):1630-1632

The most appropriate diagnostic strategy for dyspepsia remains controversial. Some studies indicate that a positive test for Helicobacter pylori is so highly predictive of peptic ulcer that endoscopy is not necessary. Delaney and colleagues studied the cost effectiveness of a strategy of blood testing for H. pylori followed by endoscopy only in patients with a positive test result to diagnose the etiology of dyspepsia.

British patients younger than 50 years presenting to general practitioners because of dyspepsia of more than four weeks' duration were included in the study. The 478 patients were randomized to investigation by the test-and-scope strategy, or to usual care. Patients in the usual-care group received acid-suppressing drugs or were referred to a specialist at the discretion of the general practitioner. Any patient who failed initial treatment could be referred for endoscopy after six weeks. The main outcomes were symptom control and the cost of managing dyspepsia. Symptoms were assessed using a standardized and validated scoring system, and questionnaires were used to measure quality of life in terms of pain, and emotional and social functioning. Costs were figured from a health service perspective by abstracting data from primary care case records.

Blood tests for H. pylori were positive in 112 (40 percent) of the study group. Overall, 127 (45 percent) of the study group underwent endoscopy compared with 48 (25 percent) of control patients. Significantly more peptic ulcers were found by the test-and-scope strategy than by endoscopy alone (7.4 compared with 2.1 percent). Patients in both groups improved over time, and quality of life, symptom scores and health services used during the follow-up period were not significantly different in the two groups. Costs for the test-and-scope strategy were approximately two times higher per patient than those for conventional diagnosis.

The authors conclude that the test-and-scope strategy doubled rates of endoscopy but did not lead to improved outcomes in terms of symptom relief or quality of life for patients. Therefore, the increased costs of this strategy cannot be justified.

editor's note: Dyspepsia is one of the most common symptoms presented to (and even experienced by) family physicians, yet the “expert” advice on how best to investigate and treat the condition is frustrating. A recent American Academy of Family Physicians Home Study Monograph reviewed the topic and stressed the importance of screening for “red flags” of potential pathology and of integrating the patient's perspective into decisions between the various investigative strategies.—a.d.w.

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