© Ascend Media D yspepsia is a highly prevalent symptom complex defined as pain or discomfort centered in the upper abdomen. 1 New- onset dyspepsia in a previously asymptomatic patient may indicate peptic ulcer disease (PUD), nonulcer dyspepsia (NUD), or (rarely) gastric cancer. It is distinct from gastroesophageal reflux disease (GERD), typically characterized by heartburn or acid regur- gitation, although differentiation may be difficult in some patients. Symptoms of dyspepsia and GERD are experienced by about 40% of the population annually 1 and account for 2% to 5% of primary care visits 2 and $14 billion in annual prescription drug expense. 3 Recognition of Helicobacter pylori infection as the single most common cause of PUD revolutionized management of dyspepsia; the significance of that dis- covery resulted in a Nobel Prize for discoverers Barry J. Marshall and J. Robin Warren. 4 In 1994, a National Institutes of Health 5 consensus conference recom- mended that H pylori infection be eradicated in patients with PUD and that this be accomplished using antibiotics and antisecretory medication. Several national and international gastroenterological organizations have since released more detailed guidelines for the diagnosis and treatment of dyspepsia as the understanding of the contribution of H pylori infection has developed. 1,6-11 One of the key recommendations of various guidelines has been that clinicians use nonendoscopic tests (such as serologic or breath tests) for H pylori infection, unless endoscopy is clinically indicated, and that patients testing positive receive eradication therapy. Compared with early endoscopy and treatment based on endoscopic findings, this less costly test-and-treat approach has demonstrated similar outcomes such as num- ber of physician visits and days lost to sick time. 1,12 Prompt endoscopy is reserved for older patients (≥ 45-55 years) and for patients with alarm features, such as persistent vomiting, bleeding, weight loss, dysphagia, and anemia. Clinical practice guidelines for dyspepsia have been in place for more than 10 years and have been widely disseminated to primary care clini- cians. 13-15 However, little is known about the medical community’s adher- VOL. 13, NO. 1 ■ THE AMERICAN JOURNAL OF MANAGED CARE ■ 37 ■ MANAGERIAL ■ Practice Patterns for Managing Helicobacter pylori Infection and Upper Gastrointestinal Symptoms Colin W. Howden, MD; Steven W. Blume, MS; and Gregory de Lissovoy, PhD, MPH Objective: To assess adherence with guidelines for testing and treatment of Helicobacter pylori infection and upper gastrointestinal symptoms. Study Design: Retrospective longitudinal cohort analysis of patient-level medical and pharmacy claims from 75 US managed care plans. Methods: Persons with new claims for antisecre- tory medication, H pylori tests, or endoscopies were selected from among 2 million plan members continuously enrolled from 2001 to 2004 and were grouped by initial clinical diagnosis (3456 with peptic ulcer disease [PUD], 14 593 with nonulcer dyspepsia [NUD], and 36 233 with gastro- esophageal reflux disease [GERD]). Diagnostic procedures, medications received, and sequencing of specific procedures and medications were examined relative to published guidelines by initial diagnosis, age, and physician specialty. Results: While guidelines recommend testing before treatment, one third of persons receiving antibiotics for H pylori infection had not first been tested for the infection. In one third of all posttreatment testing, primary care practitioners incorrectly used serologic tests, despite their inability to distinguish cured from active infection. Eighteen percent of patients with GERD were tested for H pylori, although there is no causal link between them. Only two thirds of patients aged 50 to 64 years with presumed PUD under- went endoscopy, which guidelines recommend for older adults; yet one third of patients with PUD aged 18 to 49 years, for whom prompt endoscopy is generally not recommended, had an endoscopy within 30 days of their index date. Conclusions: Substantial noncompliance with widely disseminated guidelines calls for better understanding of appropriate indications for H pylori testing and endoscopy to improve patient care and conserve healthcare resources. (Am J Manag Care. 2007;13:37-44) For author information and disclosures, see end of text. In this issue Take-away Points / p43 www.ajmc.com Full text and PDF Web exclusive Appendices A and B