Vakil N, Rhew D, Soll A, Ofman J J
Department of Medicine, University of Wisconsin Medical School, Milwaukee 53233, USA.
Am J Gastroenterol. 2000 Jul;95(7):1691-8. doi: 10.1111/j.1572-0241.2000.02193.x.
Several noninvasive methods are now available for diagnosing Helicobacter pylori infection. Because the prevalence of H. pylori infection is variable in patients requiring testing, the optimal testing strategies may vary under different conditions. The aim of this study was to evaluate the cost-effectiveness of competing diagnostic strategies for H. pylori in patients with varying H. pylori prevalence.
A decision analysis was performed comparing the costs per number of correct diagnoses achieved by alternative sequential testing strategies. Estimates of H. pylori prevalence and test characteristics were derived from a systematic review of the MEDLINE bibliographic database. Cost estimates were derived from the 2000 Medicare Fee Schedule.
The enzyme-linked immunosorbent assay (ELISA) test had the lowest cost per correct diagnosis at low (30%), intermediate (60%), and high (90%) prevalence ($90-$95/correct diagnosis), but its diagnostic accuracy was low (80-84%). At low and intermediate prevalence the stool test was more accurate (93%), with an average cost of $126-$127 per correct diagnosis. Additional confirmatory testing of positive or negative tests increased the diagnostic accuracy of the stool test, but had high incremental costs. ELISA testing was preferable when prevalence rates were very high (90%), and using a confirmatory urea breath test for negative ELISA tests increased the diagnostic accuracy to 96%, with modest incremental costs. If the cost of the breath test was <$50 or if the cost of the stool test is >$82, breath testing became preferable to stool testing. If the cost of the stool test fell to <$20, it became preferable to ELISA. Similarly, if the cost of the ELISA serology was >$39 then stool testing became preferable at all prevalence rates. Fingerstick whole blood tests were not cost-effective.
The choice of an initial test for H. pylori detection depends on the prevalence of H. pylori infection and the value placed on increased diagnostic accuracy. Although ELISA results in the lowest cost-effectiveness ratios, in patients at low-intermediate pretest probability of infection, the stool test provides increased accuracy, with modest incremental costs.
目前有几种非侵入性方法可用于诊断幽门螺杆菌感染。由于需要检测的患者中幽门螺杆菌感染率各不相同，因此在不同情况下最佳检测策略可能会有所不同。本研究的目的是评估在幽门螺杆菌感染率不同的患者中，相互竞争的幽门螺杆菌诊断策略的成本效益。
进行了一项决策分析，比较了替代序贯检测策略每正确诊断一例的成本。幽门螺杆菌感染率和检测特征的估计值来自对MEDLINE书目数据库的系统评价。成本估计来自2000年医疗保险费用表。
酶联免疫吸附测定（ELISA）试验在低（30%）、中（60%）和高（90%）感染率时每正确诊断一例的成本最低（90 - 95美元/正确诊断），但其诊断准确性较低（80 - 84%）。在低和中等感染率时，粪便检测更准确（93%），每正确诊断一例的平均成本为126 - 127美元。对阳性或阴性检测结果进行额外的确认性检测可提高粪便检测的诊断准确性，但增量成本较高。当感染率非常高（90%）时，ELISA检测更可取，对ELISA检测阴性的结果使用确认性尿素呼气试验可将诊断准确性提高到96%，增量成本适中。如果呼气试验成本低于50美元或粪便检测成本高于82美元，呼气检测就比粪便检测更可取。如果粪便检测成本降至20美元以下，就比ELISA检测更可取。同样，如果ELISA血清学检测成本高于39美元，那么在所有感染率下粪便检测都更可取。指尖全血检测不具有成本效益。
幽门螺杆菌检测初始试验的选择取决于幽门螺杆菌感染率以及对提高诊断准确性的重视程度。虽然ELISA导致最低的成本效益比，但在感染前概率为低 - 中等的患者中，粪便检测可提高准确性，且增量成本适中。
