Upper GI bleeds: cost effectiveness of H. pylori eradication regimens varied.

Clinical bottom line (level 1b)

  1. In patients with duodenal ulcer disease, treating with omeprazole, clarithromycin and metronidazole (OCM) plus C-urea breath test plus OCM if required was more expensive than OCM alone or omeprazole, amoxycillin and metronidazole plus breath test plus OCM if required, but was better at eradicating H. pylori.
  2. Strategies involving multiple breath tests were more expensive and no more effective at eradication.
  3. Using OCM alone was half the cost of using OCM plus breath test plus OCM and only 6% less effective.
Duggan et al: British Medical Journal 1998; 316: 1648-1654
Expires January 2003

The study

Decision analysis model
Setting: UK

Two decision analysis models comparing the cost effectiveness of two H. pylori eradication regimens with or without a subsequent confirmatory C-urea breath test, and a second course for patients in whom eradication was unsuccessful.

  • Viewpoint: prescriber
  • Benefit assessment: cumulative direct treatment costs
  • Resources and costs: Cost assessment involved the cost of omeprazole, clarithromycin and metronidazole (29.20GBP) and the omeprazole, amoxycillin and metronidazole (20.20GBP) regimens, cost of the C-urea breath test (30.80GBP) and the annual cost of maintenanace and relapse treatment of duodenal ulcer disease with ranitidine (55.60GBP). Unit costs were based on the cost of NHS drug treatments from the 1996 British National Formulary, and the cost of the C-urea breath test from the Bureau of Stable Isotope Analysis.
  • Sensitivity analysis: Varying efficacy and cost estimates.

    • The evidence

    intervention cost
    omeprazole, amoxycillin and metronidazole (OAM) 23.76GP for successsful eradication
    ( 85% eradication )
    omeprazole, clarithromycin and metronidazole (OCM) 32.08GBP for successful eradication
    ( 91% eradication )
    OAM+C-urea breath test+OCM 58.63GBP for successful eradication
    ( 94% eradication )
    OCM + breath test + OCM 64.78GBP for successful eradication
    ( 97% eradication )
    OAM + breath test 59.62GBP for successful eradication
    ( 85% eradication )
    OCM + breath test 66.34GBP for successful eradication
    ( 91% eradication )
    OAM + breath test + OCM + breath test 63.25GBP for successful eradication
    ( 94% eradication )
    OCM + breath test + OCM + breath test 68.06GBP for successful eradication
    ( 97% eradication )

    Effect of sensitivity analysis: The sensitivity analysis had little effect on the outcome.

    Comments

    1. Empiric treatment may be warranted in standard risk patients.
    2. Those with complicated disease (esp. bleeding ulcers) will probaly benefit from retesting as the risks of H.Pylori are increased.

    Citation

    1. Duggan AE, Tolley K, Hawkey CJ, et al: Varying efficacy of Helicobacter pylori eradication regimens: cost effectiveness study using a decision analysis model. British Medical Journal 1998; 316: 1648-1654
    Contributor: Clare Wotton and Musab Hayatli, January 2000
    Reviewer: Santiago Alvarez Montero

    Clinical Question.
    Patient duodenal ulcer disease
    Intervention or Exposure H. pylori eradication strategies
    Outcome cost-effectiveness