Varying efficacy of Helicobacter pylori eradication regimens: cost effectiveness study using a decision analysis modelCommentary: Helicobacter pylori eradication in primary care

Objective: To determine how small differences in the efficacy and cost of two antibiotic regimens to eradicate Helicobacter pylori can affect the overall cost effectiveness of H pylori eradication in duodenal ulcer disease. Design: A decision analysis to examine the cost effectiveness of eight H pylori eradication strategies for duodenal ulcer disease with and without 13 C-urea breath testing to confirm eradication. Main outcome measures: Cumulative direct treatment costs per 100 patients with duodenal ulcer disease who were positive for H pylori. Results: In model 1 the strategy of omeprazole, clarithromycin, and metronidazole alone was the most cost effective of the four strategies assessed. The addition of the 13 C-urea breath test and a second course of omeprazole, clarithromycin, and metronidazole achieved the highest eradication rate (97%) but was the most expensive (£62.63 per patient). The cost of each additional effective eradication was £589.00 (incremental cost per case) when compared with the cost of treating once only with omeprazole, clarithromycin, and metronidazole; equivalent to the cost of a patient receiving ranitidine for duodenal ulcer relapse for more than 15 years. Eradication strategies of omeprazole, amoxycillin, and metronidazole were less cost effective than omeprazole, clarithromycin, and metronidazole alone. In model 2 the addition of the 13 C-urea breath test after treatment, and maintenance treatment, increased the cost of all the strategies and reduced the cost advantage of omeprazole, clarithromycin, and metronidazole alone. Conclusion: Small differences in efficacy can influence the comparative cost effectiveness of strategies for eradicating H pylori . Of the strategies tested the most cost effective (omeprazole, clarithromycin, and metronidazole alone) was neither the least expensive (omeprazole, amoxycillin, and metronidazole alone) nor the most effective (omeprazole, clarithromycin, and metronidazole with further treatment for patients found positive for H pylori on 13 C-urea breath testing). Cost effectiveness should be an important part of choosing an eradication strategy for H pylori . Key messages It is unlikely that randomised controlled trials to examine the effect of small differences in efficacy and cost between eradication regimens will ever be performed because of the large numbers of patients required Decision analysis models show that relatively small differences in efficacy and cost between several strategies for eradication of H pylori in patients with duodenal ulcer disease lead to large differences in their relative cost effectiveness The most cost effective strategy was neither the least expensive nor the most effective for eradication of H pylori For uncomplicated duodenal ulcer disease performing a 13 C-urea breath test to identify patients failing eradication treatment is not cost effective if patients only receive acid suppression treatment for relapses that produce symptoms Performing a 13 C-urea breath test to identify patients failing eradication treatment may only be cost effective in high risk patients