Cost effectiveness of initial endoscopy for dyspepsia in patients over age 50 years: a randomised controlled trial in primary care

Background Dyspepsia can be managed by initial endoscopy and treatment based on endoscopic findings, or by empirical prescribing. We aimed to determine the cost effectiveness of initial endoscopy compared with usual management in patients with dyspepsia over age 50 years presenting to their primary care physician. Methods 422 patients were recruited and randomly assigned to initial endoscopy or usual management. Primary outcomes were effect of treatment on dyspepsia symptoms and cost effectiveness. Secondary outcomes were quality of life and patient satisfaction. Total costs were calculated from individual patientʹs use of resources with unit costs applied from national data. Statistical analysis of uncertainty on incremental cost-effectiveness ratio (ICER) was done along with a sensitivity analysis on unit costs with cost-effectiveness acceptability curves. Findings In the 12 months following recruitment, 213 (84%) patients had an endoscopy compared with 75 (41%) controls. Initial endoscopy resulted in a significant improvement in symptom score (p=0·03), and quality of life pain dimension (p=0·03), and a 48% reduction in the use of proton pump inhibitors (p=0·005). The ICER was £1728 (UK£) per patient symptom-free at 12 months. The ICER was very sensitive to the cost of endoscopy, and could be reduced to £165 if the unit cost of this procedure fell from £246 to £100. Interpretation Initial endoscopy in dyspeptic patients over age 50 might be a cost-effective intervention.