Effect of Outpatient Status on Practice Management of H. pylori-associated Peptic Ulcer Disease

Abstract

Introduction:Helicobacter pylori infection remains an important cause of peptic ulcer disease (PUD). The 2007 and updated 2017 American College of Gastroenterology guidelines indicate that patients with H. pylori-associated PUD should receive eradication therapy followed by confirmation testing to prove H. pylori eradication. The latter is relevant because initial H. pylori treatment is often only 70-85% successful and persistent H. pylori infection may be associated with recurrent ulcers and gastric malignancy. Despite guidelines, confirmation testing rates are modest (30-40%) for largely unexplored reasons. The aim was to identify barriers and predictors of receiving guideline-concordant confirmation testing. Methods: We performed a retrospective cohort study of patients with active H. pylori-associated PUD diagnosed in 2007-2015, who received standard eradication therapy and had follow-up within one year. Our primary outcome of interest was the effect of outpatient vs. inpatient status (at time of peptic ulcer diagnosis) on confirmation testing rates. We also compared confirmation testing rates in patients with vs. without repeat endoscopy and patients with vs. without gastroenterology follow-up. We used logistic regression models with propensity scores to control for age, sex, race, comorbidity status, insurance status, ulcer location and symptom persistence. Results: 67/152 (44%) patients received guideline-concordant confirmation testing. Outpatients (OR 3.9, 95% CI 1.8-8.8, p=0.0009) and patients who had gastroenterology follow-up (OR 9.7, 95% CI 3.2-29.0, p=0.0009) were significantly more likely to receive confirmation testing than their counterparts (Table 1). Repeat endoscopy was not a significant independent predictor of receiving confirmation testing.Table: Table. Independent predictors of receiving confirmation testing to prove H. pylori eradication in patients with H. pylori-associated peptic ulcer diseaseConclusion: This study provides some insight into the discrepancy between recommended and practiced management of H. pylori-associated PUD following eradication therapy. We identified outpatient status and gastroenterology follow-up as independent predictors of receiving guideline-concordant confirmation testing. These findings suggest a potential role for quality improvement initiatives, particularly during the transition of care from inpatient to outpatient setting, in order to optimize adherence to best practices.