Costs of Managing Helicobacter pylori ‐Infected Ulcer Patients After Initial Therapy

We read with interest the recent paper of Griffiths et al. recently published in Helicobacter [1] on the cost-effectiveness of different strategies of management after eradication therapy in peptic ulcer. The paper states that the most cost-effective strategy for these patients is the Urea breath test rather than observation. It also states that the topic has not been previously reviewed, failing to cite our recent paper [2] which in fact reached the opposite conclusion. The design of the decision tree in the paper of Griffiths et al. shows, in our opinion, a number of deficiencies that account for the differences between their conclusions and ours. Specifically, the authors did not include a branch analysing the strategy of giving eradication therapy to peptic ulcer patients and asking them to come back for the urea breath test if symptoms persist or relapse: As absence of symptoms has shown to be a good predictor of cure of Helicobacter pylori infection [3], this strategy is probably the most logical approach. Indeed it is extensively applied in primary care in our environment [4] CITA and is precisely the strategy that obtains the most favourable cost-effectiveness in our analysis [2]. Decision analyses are full of potential for bias. Even the most honest investigators may unknowingly be influenced by their personal opinions in a study in which they themselves create the hypothesis, the design, and – depending on the design – the results of the paper. As patients are not present to contradict the authors’ hypothesis and results, studies of this kind run the risk of merely validating the authors’ opinions, instead of generating scientific evidence. To avoid this risk, the decision tree must be carefully designed, and all possible situations accounted for. In conclusion, we believe that the paper of Griffiths et al. should have included a branch specifically examining the strategy of observation after eradication treatment, the performance of breath test if dyspeptic symptoms relapse, and treatment according to the results of the urea breath test. This branch is a logical and frequently used approach and it is possible that its inclusion would have entirely changed the final conclusion of the cost-effectiveness analysis.