Economic constraints in the diagnosis of peptic ulcer disease

The discovery of Helicobacter pylori and its role in upper gastrointestinal disease has changed the outlook on diagnosis of peptic ulcer disease.

To address the questions of what types of diagnostic tests and how many of each type are needed to diagnose among patients with dyspepsia as many ulcers as possible at least cost.

Bayes' formula and a decision tree were used to follow the outcomes of alternative test combinations for ulcer diagnosis.

Assuming unlimited resources, only endoscopy of all subjects results in the correct diagnoses of all ulcers, but costs $5600 per diagnosis. Barium swallow followed by endoscopy is less expensive ($2980), but misses 5% of all ulcers. Serology for H. pylori followed by endoscopy or barium meal provides relatively high diagnostic yields (85 or 81% of all ulcers detected) at lower costs ($2900 or $1050 per ulcer diagnosis, respectively). In general, a higher number of ulcers is found at a lower cost if the cheap tests are used to screen patients before subjecting them to the more expensive tests.

The ideal work-up depends on the urgency of a correct diagnosis, the willingness to miss some ulcer diagnoses and the availability of resources. H. pylori serology followed by endoscopy or barium meal represents two cost-effective strategies.