Despite guidelines recommending that patients with Helicobacter pylori–associated peptic ulcer disease (PUD) receive post-treatment testing for eradication, only 30 to 40 percent of patients undergo appropriate testing. This is a significant problem because persistent infection is a risk factor for recurrent peptic ulcer disease as well as gastric malignancy and MALT lymphoma, and only 50 to 85 percent of H. pylori treatment is successful. However, the reasons for the low eradication testing rate are unclear.
In a recent retrospective cohort study examining barriers to testing for H. pylori eradiation, Duke clinicians found that patients diagnosed as outpatients and those who received GI follow-up were most likely to receive appropriate testing. The results were published in December 2018 in Helicobacter.
The study was developed by a small group of internal medicine residents seeking to improve the care of patients with peptic ulcer disease related to H. pylori, says the study’s lead author, Katherine Garman, MD, a gastroenterologist at Duke.
“The residents approached me for mentorship, and we designed the study in order to better understand the factors associated with successful eradication testing,” she explains. “Performing the study was an important first step to ensuring that all patients with H. pylori receive the best treatment and follow-up.”
To identify barriers, the clinicians examined testing rates in all patients diagnosed with H. pylori–associated PUD and treated with H. pylori eradication therapy in the Duke University Hospital System between 2007 and 2015. Only patients who had follow-up clinic visits with Duke primary care or gastroenterology within one year of endoscopy were included, and propensity scores were used to control for sex, age, race, ulcer location, and symptom persistence.
Of the 152 patients treated, 44 percent received post-treatment testing—a rate similar to those of previous reports. Two main findings were recorded: Appropriate testing was more likely to be performed in patients diagnosed with PUD as an outpatient vs an inpatient (57 vs 33 percent) and those receiving GI rather than primary care follow-up alone (62 vs 11 percent).
The most likely explanation for the lower rate of post-treatment testing in inpatients, the authors said, was the lack of clear communication about who should be responsible for ordering follow-up testing when patients transitioned from inpatient to outpatient care.
The decreased post-treatment testing in patients following up with primary care may have been caused by several factors, including a relative lack of education among PCPs compared with GIs about current H. pylori guidelines and the broader range of medical issues that need to be covered during a short primary care clinic visit.
Both findings represent opportunities for education and quality improvement initiatives that could help improve testing rates and optimize patient management, the authors concluded.
Moving forward, the authors are brainstorming ways that a positive H. pylori test might trigger alerts in the medical record to prescribe therapy and schedule appropriate follow-up testing. The study team recently partnered with Meira Epplein, PhD, a Duke epidemiologist who studies H. pylori, to design a study to address H. pylori resistance patterns and improve patient outcomes.