Efficacy and Cost-Effectiveness of Vonoprazan–Amoxicillin Dual Therapy Versus Esomeprazole–Bismuth Quadruple Therapy for Helicobacter pylori: A Propensity Score-Matched Study

Vonoprazan–amoxicillin (VA) dual therapy offers a simplified alternative; however, its efficacy and cost-effectiveness relative to bismuth-containing quadruple therapy (BQT) in treatment-naïve patients remain unclear. This study aimed to compare the eradication rate and cost-effectiveness between the two groups using a propensity score-matched analysis. This retrospective, single-center study used outpatient electronic medical records from January 2024 to November 2025. After propensity score matching (1:1), 212 patients received vonoprazan–amoxicillin dual therapy (VA), and 212 matched patients received esomeprazole–bismuth quadruple therapy (EBAC) for two weeks. Eradication rates and cost-effectiveness were compared. According to the intention-to-treat (ITT) analysis, eradication rates were 90.56% (95% CI 85.88–93.81%) in the VA group and 90.09% (95% CI 85.33–93.43%) in the EBAC group (p = 0.869). The per-protocol (PP) analysis showed eradication rates of 93.03% (95% CI 88.64–95.80%) and 91.58% (95% CI 86.93–94.68%), respectively (p = 0.585). Multivariate logistic regression identified non-compliance as a significant risk factor for eradication failure (OR = 5.346, 95% CI 1.847–15.473, p = 0.002). Probabilistic sensitivity analysis showed that EBAC was more cost-effective than VA in stage 1. However, the eradication rate of EBAC dramatically declined, and VA became the more cost-effective option at higher WTP thresholds in stage 2. In conclusion, the 14-day VA dual therapy is as effective as BQT therapy but is safer and easier to use, offering a more streamlined eradication option. Nonetheless, EBAC remains a cost-effective option.