Diagnosis and Treatment of Dyspepsia

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Abstract
Dyspepsia is a common problem in ambulatory care. While many authorities recommend ordering upper gastrointestinal x-ray series (UGI) before therapy, there is evidence that clinicians frequently treat dyspepsia without diagnostic procedures. Decision analysis was performed to select optimal management based on probabilities and outcome values from the published literature. The choices evaluated were Symptomatic Therapy (low dose antacids or anticholinergics), Ulcer Therapy (high dose antacids or cimetidine), or UGI followed by further tests or therapy. Our model indicates that mortality is minimized if UGI is performed prior to selection of therapy, and if endoscopy is performed when the x ray shows gastric ulcer. Weeks of pain are minimized if Ulcer Therapy is begun immediately, but direct health care costs are minimized by beginning with Symptomatic Therapy. The marginal cost per additional life saved by performing a UGI rather than beginning with Ulcer Therapy was +1.6 million to +2.3 million, depending on whether endoscopy followed the finding of gastric ulcer. Mortality advantages of the strategies beginning with UGI were sensitive to assumptions regarding the incidence of gastric cancer and the benefits of early diagnosis. With slight reductions in these base case values, the Ulcer Therapy strategy appeared to minimize all outcomes except dollar cost.