Disease management in ulcer disease.

BACKGROUND: Our knowledge of Helicobacter pylori infection indicates that it is possible to eliminate ulcer disease and improve quality of life for ulcer patients. Treatment is evidence-based and cost-effective. However, though we now have the tools, we have not yet been able to eliminate ulcer disease from society. Dissemination of knowledge and treatment implementation have been problematic. In primary care, there is diagnostic and therapeutic chaos regarding this infection. Disagreement exists on indications for treatment. Expenditure on acid-reducing drugs has greatly increased. Clearly we are not treating all ulcer patients properly (undertreatment); instead we have incorporated H. pylori therapy ('test and treat') into our approach to dyspepsia (overtreatment). Anti-H. pylori therapy in patients with non-ulcer dyspepsia may increase costs because most patients still suffer from symptoms after antibiotic therapy, and therefore require further diagnostic procedures and prescription of new drugs. In order to redeem the great promise of H. pylori, we must focus less on new ulcer patients, because the incidence is rapidly decreasing in Western Europe. Prevalence of ulcer disease, however, is still high. Thus we need to focus more on prevalent cases. We ought to seek and treat those persons already known to have ulcer disease. Systematic 'case-finding' strategies must be performed using standard protocols. Only such 'disease management' programmes performed at the primary care level will suffice to eliminate ulcer disease while also being cost-effective.