Economic Analysis of the HELPUP Trial
Economic Analysis of the HELPUP Trial
Background. Proton pump inhibitor (PPI) use is costly and about two-thirds of prescribing is long-term. Although 20-50% of patients may be infected with Helicobacter pylori, eradication is not normal clinical practice.
Aim. To establish if H. pylori eradication in long-term PPI users is cost-effective.
Methods. Long-term PPI-using patients (n = 183) testing positive for H. pylori were randomly assigned to true or placebo eradication therapy. Patients provided 2-year resource data, and 1-year symptom severity scores. A within-trial cost effectiveness analysis was conducted from a British health service perspective.
Results. Significant reductions in resource use occurred comparing eradication with placebo. After 2 years, PPI prescriptions (full-dose equivalents) fell by 3.9 (P < 0.0001); clinician (GP) consultations by 2.4 (P = 0.0001); upper gastrointestinal (GI) endoscopies by 14.8% (P = 0.008); clinician GI-related home visits by 19.9% (P = 0.005) and abdominal ultrasound scans fell by 20.3% (P = 0.005). Average net savings/patient were £93 (95% CI: 33-153) after costs of detection and eradication had been deducted. At 1 year, Leeds Dyspepsia Questionnaire symptoms fell by 3.1 (P = 0.005) and quality-of-life measures improved (EuroQol-5D: 0.089, P = 0.08; visual analogue scale: 5.6, P = 0.002) favouring eradication.
Conclusion.Helicobacter pylori eradication in infected, long-term PPI users is an economically dominant strategy, significantly reducing overall healthcare costs and symptom severity.
Although testing and treating for Helicobacter pylori in uninvestigated dyspepsia is likely to be beneficial in a significant number of patients, limitations in the generalizability of research from selected patient groups and concerns about provoking or aggravating reflux symptoms have meant that clinicians have not widely adopted this approach. In terms of cost-effectiveness, a recent multi-center RCT has shown that both test and treat and acid suppression are equally cost-effective as an initial management strategy for dyspepsia presentation in primary care.
In response to these concerns, the H. pylori eradication in long-term proton pump inhibitor (PPI) users in primary care (HELPUP) trial was conducted. After 1 year follow-up, eradication demonstrated significantly reduced symptom scores, PPI use and GP consultations. The trial provided evidence that reflux symptoms did not become more common, but might be more prevalent in those (fewer patients) with remaining symptomology after eradication.
Managing dyspepsia is expensive: it has been estimated to cost over £1.0 billion in the UK per year. Although the cost per prescription for PPI use has fallen dramatically in recent years, overall costs of PPI therapy in England have only recently begun to fall as drugs lose patent protection (Figure 1). PPI use in primary care cost the NHS in England about £240 million in 2007, the lowest cost in a decade, although still a considerable demand on scarce resources. More than two-thirds of usage is because of long-term prescribing. Although PPIs have a range of indications, dyspepsia, gastro-oesophageal reflux disease and gastro-protection constitute more than two-thirds usage. Concerns about the appropriateness of PPI usage have provoked initiatives to rationalize their use, but the volume of prescribing is still increasing (Figure 1). There are likely to be complex reasons for this trend and clinicians need evidence-based strategies to inform appropriate prescribing.
(Enlarge Image)
Trends in primary care proton pump inhibitor prescribing: England. (Data: National prescribing cost analyses 1998-2006).
This study draws on 2 years follow-up data from the HELPUP trial to estimate the costs and consequences of detecting and eradicating H. pylori in long-term PPI users in primary care. It is a within trial analysis, i.e. measured resources and outcomes provided the findings without the need to resort to longer term modelling of expected costs and benefits.
Abstract and Introduction
Abstract
Background. Proton pump inhibitor (PPI) use is costly and about two-thirds of prescribing is long-term. Although 20-50% of patients may be infected with Helicobacter pylori, eradication is not normal clinical practice.
Aim. To establish if H. pylori eradication in long-term PPI users is cost-effective.
Methods. Long-term PPI-using patients (n = 183) testing positive for H. pylori were randomly assigned to true or placebo eradication therapy. Patients provided 2-year resource data, and 1-year symptom severity scores. A within-trial cost effectiveness analysis was conducted from a British health service perspective.
Results. Significant reductions in resource use occurred comparing eradication with placebo. After 2 years, PPI prescriptions (full-dose equivalents) fell by 3.9 (P < 0.0001); clinician (GP) consultations by 2.4 (P = 0.0001); upper gastrointestinal (GI) endoscopies by 14.8% (P = 0.008); clinician GI-related home visits by 19.9% (P = 0.005) and abdominal ultrasound scans fell by 20.3% (P = 0.005). Average net savings/patient were £93 (95% CI: 33-153) after costs of detection and eradication had been deducted. At 1 year, Leeds Dyspepsia Questionnaire symptoms fell by 3.1 (P = 0.005) and quality-of-life measures improved (EuroQol-5D: 0.089, P = 0.08; visual analogue scale: 5.6, P = 0.002) favouring eradication.
Conclusion.Helicobacter pylori eradication in infected, long-term PPI users is an economically dominant strategy, significantly reducing overall healthcare costs and symptom severity.
Introduction
Although testing and treating for Helicobacter pylori in uninvestigated dyspepsia is likely to be beneficial in a significant number of patients, limitations in the generalizability of research from selected patient groups and concerns about provoking or aggravating reflux symptoms have meant that clinicians have not widely adopted this approach. In terms of cost-effectiveness, a recent multi-center RCT has shown that both test and treat and acid suppression are equally cost-effective as an initial management strategy for dyspepsia presentation in primary care.
In response to these concerns, the H. pylori eradication in long-term proton pump inhibitor (PPI) users in primary care (HELPUP) trial was conducted. After 1 year follow-up, eradication demonstrated significantly reduced symptom scores, PPI use and GP consultations. The trial provided evidence that reflux symptoms did not become more common, but might be more prevalent in those (fewer patients) with remaining symptomology after eradication.
Managing dyspepsia is expensive: it has been estimated to cost over £1.0 billion in the UK per year. Although the cost per prescription for PPI use has fallen dramatically in recent years, overall costs of PPI therapy in England have only recently begun to fall as drugs lose patent protection (Figure 1). PPI use in primary care cost the NHS in England about £240 million in 2007, the lowest cost in a decade, although still a considerable demand on scarce resources. More than two-thirds of usage is because of long-term prescribing. Although PPIs have a range of indications, dyspepsia, gastro-oesophageal reflux disease and gastro-protection constitute more than two-thirds usage. Concerns about the appropriateness of PPI usage have provoked initiatives to rationalize their use, but the volume of prescribing is still increasing (Figure 1). There are likely to be complex reasons for this trend and clinicians need evidence-based strategies to inform appropriate prescribing.
(Enlarge Image)
Trends in primary care proton pump inhibitor prescribing: England. (Data: National prescribing cost analyses 1998-2006).
This study draws on 2 years follow-up data from the HELPUP trial to estimate the costs and consequences of detecting and eradicating H. pylori in long-term PPI users in primary care. It is a within trial analysis, i.e. measured resources and outcomes provided the findings without the need to resort to longer term modelling of expected costs and benefits.
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