Table A.11 Summary of articles examined for dyspepsia and endoscopy

Authors	Research setting and year of study	Study design	Sample size	Topic of document	Results and conclusions	Comments
Delaney et al⁵⁷⁹	UK (2004)	Review and modelling exercises		Dyspepsia	Endoscopy not shown to be cost effective in patients with low risk of malignancy. Restricting endoscopy to those with continuous epigastric pain and/or symptoms of <1 year’s duration would reduce cost/life year gained from £50 000 to £8400. Discrete event simulation used to compare 70 combinations of investigation and prescribing strategies. 61 eliminated by dominance—including all strategies involving endoscopy. Extra cost for each extra month dyspepsia-free shown for remaining 9.Conclusion is that endoscopy needs to be targeted.Markov modelling used to estimate cost/life year saved from endoscopy in men by age (£454 000 at 40 to £15 779 at 70, but by restricting endosopy for those over 70 to those at high risk it falls to £8398). Incremental cost effectiveness ratios for men over 55 and at high risk are all favourable. For women aged 40 = £158 823 and aged 70 = £22 062. Strong conclusion of need to restrict demand for endoscopy in younger age groups	Very good economics. Assumptions spelled out. Sensitivity analyses conducted
Moayyedi et al⁷⁸⁰	UK and non-UK studies	Cochrane review		To review the effectiveness of six classes of drugs in the improvement of both the individual or global dyspepsia symptom score and quality of life scores.	It is estimated that £450m is spent on dyspepsia drugs in the UK each year. There is evidence that anti-secretory treatment is effective in a small proportion of patients with NUD. The evidence is strongest for PPI as the studies were generally of higher quality and the funnel plot did not show any publication bias	We did not identify any economic analysis; this information is important as patients will often need to take drugs long term
Bodger et al⁵⁹⁶	UK (1994)	Prospective observational study (4 month period)	257 Consultations (150 patients)	Prescribing patterns for symptomatic dyspeptic patients.	The drug cost for each patient varied from £2 to £60 a month. Management guidelines may help to promote a more consistent and selective use of newer treatments, and promote more cost effective patient care	The practice sampled represented a reasonable cross section of doctors, though arguably biased towards more “rational” prescribers
Paterson et al⁷⁸¹	UK (1998–99)	RCT pilot study	60	The effects of adding treatment of acupuncture or homeopathy to current treatment	Total mean (SD) cost of acupuncture per patient was £175 (52) and total mean cost for homeopathy per patient was £105 (33)	This study suggested important changes for the design of a full scale study
Bate et al⁷⁸²	UK (England) (1998)	Cohort study	90 Patients with symptoms suggestive of GERD	To assess the diagnostic value of a therapeutic trial of omeprazole 40mg in a dyspeptic population	We conclude that omeprazole can be used as a clinically effective tool in the initial management of GERD and that it is of diagnostic value in patients who present with typical symptoms, such as heartburn, when the diagnosis is based on assessment of symptoms alone	The cost of patients who might have been misdiagnosed was not part of the study. The quality of the economic evaluation was poor
Delaney et al⁵⁷⁹	UK, USA, Canada, and others (2004)	Cochrane review	19 RCTs	Management strategies (combination of initial investigation and empirical treatment) for dyspeptic patients	It is unlikely that early endoscopy would reduce overall economic costs of managing dypspsia over only one year. It is more likely that an initial excess cost would be incurred that might be recouped in some prescribing and consultation reduction in subsequent years. The point at which early endoscopy might become cost neutral cannot be determined from these trials. Delaney reported a full exploration of costs. The additional endoscopies were offset by a significant reduction in PPI prescribing (equivalent to a month’s prescribing), outpatient attendance was also reduced from 0.45 to 0.22 per patient. Overall management by prompt endoscopy cost £420 compared with £340 for empirical management	The rest of the studies did not include a proper economic evaluation