Evaluation of initial noninvasive therapy in pediatric patients presenting with suspected ulcer disease

Objective: To compare the clinical and economic effects of five likely treatment strategies in children with dyspepsia: initial diagnostic endoscopy (EGD) with biopsy for Helicobacter pylori infection; initial EGD without biopsy; ii. pylori serology screening and treatment for if. pylori if positive; empiric treatment with antisecretory therapy; and empiric treatment for H. pylori with antibiotics and antisecretory therapy. Methods: Our decision analysis model incorporated data from published literature on the incidence of duodenal ulcer disease and effect of H. pylori infection. Cost inputs were derived from payments made by third-party payers. For the three noninvasive strategies that did not include immediate endoscopy, endoscopy was performed on the first episode of symptom recurrence. Results: The estimated costs per child evaluated far each strategy were: EGD with biopsy, $1458; EGD alone, $1248; H. pylori serology, $1224; antisecretory, $1160; and antisecretory-antibiotic, $1164. Results were sensitive to the casts of EGD and the likelihood of recurrent symptoms in children. When the cost of endoscopy fell below $950 or if over 65% of patients without ulcers eventually underwent endoscopy, there was no longer a cost advantage for initial noninvasive treatment when compared with EGD alone strategy. Conclusion: In a decision analysis model, empiric antisecretory treatment in children with dyspepsia was most cost-effective, eliminating 40% of endoscopies and leading to antibiotic use in only those patients with H. pylori (4%). Further studies to determine the actual recurrence rate of symptoms after empiric antisecretory treatment of children with dyspepsia are required.