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Clinical Scenario



You are a gastroenterologist on the staff of a large community hospital in which there is considerable pressure on the endoscopy service to provide more colonoscopy screening to reduce colorectal cancer mortality, but no funds are available to increase endoscopy facilities. Approximately 50% of the workload is devoted to upper gastrointestinal tract endoscopy for patients with dyspepsia. One possibility is to reduce upper gastrointestinal tract endoscopy demand by providing a Helicobacter pylori test-and-treat service as the preferential management strategy for patients younger than 55 years with dyspepsia without alarm symptoms. This strategy involves giving patients a noninvasive test for H pylori (eg, a serologic test or urea breath test), treating patients with positive results with antibiotic therapy, and reassuring patients with negative results that they are unlikely to have peptic ulcer disease.

You are hesitant to recommend the new approach. Some physicians believe that prompt endoscopy for all helps select the most effective treatment. Moreover, the H pylori test-and-treat strategy will save no resources if patients all undergo endoscopy anyway. Before providing your advice, you decide to seek a formal economic analysis of the H pylori test-and-treat approach compared with prompt endoscopy.


Finding the Evidence


Having recently attended a short workshop on economic evaluation, you are aware that a good source of information is the UK National Health Service Economic Evaluation Database (NHS EED). This database contains structured abstracts of full economic evaluations, plus references to methodology articles and cost studies, and is available through the advanced search Cochrane Library by selecting “Economic Evaluations” as a search limit ( Your hospital does not subscribe to the database, but you have free access through the website of the Centre for Reviews and Dissemination of the University of York (

You first select the box next to “NHS EED,” then select the drop-down option “Any field” and enter the following 3 search terms: “dyspepsia AND endoscopy AND helicobacter.” Note that the interface allows you to enter each term separately and link them with different operators, such as “AND,” “OR,” or “NOT,” to form more complex searches (see Chapter 5, Finding Current Best Evidence). This search generates 56 results in the NHS EED database. You scan the results and find that the structured abstract of the 16th citation on the list is an article by Ford et al,1 which reports that the economic analysis is based on a meta-analysis of 5 randomized clinical trials (RCTs), including 1924 patients, comparing the test-and-treat approach with prompt endoscopy. This strikes you as the highest quality evidence you are likely to find, and you retrieve the article.


Why Economic Analysis?


Clinicians not only make decisions about the care of individual patients but also help establish clinical policy. Some clinicians also help to set health policy at a broader level (addressing questions such as whether more ...

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