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A Randomized Trial Comparing "Test-and-Treat" With Prompt Endoscopy

Nicolaas L. A. Arents, MD; Jacob C. Thijs, MD, PhD; Anton A. van Zwet, MD, PhD; Marco Oudkerk Pool, MD, PhD; Jan-Mark Götz, MD, PhD; Ger T. van de Werf, MD, PhD; Klaas Reenders, MD, PhD; Wim J. Sluiter, MD, PhD; Jan H. Kleibeuker, MD, PhD

Arch Intern Med. 2003;163:1606-1612.

Background  The value of the "test-and-treat" strategy in the approach to dyspepsia has been evaluated only in a few secondary care studies. Most patients with dyspepsia, however, are treated by their primary care physician. This study evaluated the test-and-treat strategy in primary care.

Methods  Patients consulting their general practitioners for dyspepsia were randomized to either direct open-access endoscopy with Helicobacter pylori testing or a test-and-treat strategy by H pylori serology. In the 12-month follow-up period, any additional treatment or referral for investigations was left at the discretion of the general practitioner. At the end of the study, data were collected concerning the number of endoscopies, changes in symptom severity and quality of life, patient satisfaction, and the use of medical resources.

Results  Two hundred seventy patients were enrolled (129 who received endoscopy and 141 in the test-and-treat group). The prevalence of H pylori infection was 38.3% and 37.2% in the test-and-treat and endoscopy groups, respectively. In the test-and-treat group, 46 patients (33%) were referred for endoscopy during follow-up. Improvement in symptom severity, quality of life, and patient satisfaction was comparable in both groups. Patients in the test-and-treat group paid more dyspepsia-related visits to their general practitioner (P = .005). Patients in the endoscopy group were more often prescribed proton pump inhibitors (P = .007), whereas patients in the test-and-treat group were more often prescribed prokinetic drugs (P = .005).

Conclusions  The test-and-treat strategy proved to be as effective and safe as prompt endoscopy. Only a minority of patients were referred for endoscopy after the test-and-treat approach.

From the Regional Public Health Laboratory, Groningen/Drenthe, the Netherlands (Drs Arents and van Zwet); Department of Gastroenterology, Bethesda Hospital, Hoogeveen, the Netherlands (Dr Thijs); Department of Gastroenterology, Isala Clinics, Zwolle, the Netherlands (Dr Oudkerk Pool); Department of Gastroenterology, Wilhelmina Hospital, Assen, the Netherlands (Dr Götz); and Departments of General Practice (Drs van de Werf and Reenders), Pathology (Dr Sluiter), and Gastroenterology (Dr Kleibeuker), University Hospital, Groningen, the Netherlands.

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