Esophagogastroduodenoscopy (EGD) is commonly used for assessment of dyspepsia in the general population. Gastroenterology societies recommend different ages for doing EGD. We developed a decision tree model and performed a utility assessment to determine the optimal age at which to conduct EGD for assessing dyspepsia in the general population

We developed a decision tree with two main strategies: “prompt endoscopy, PE”, and “test and treat with managed endoscopy, T&T” with three main outcomes of “no cancer”, “early cancer” (amenable to cure), and “advanced cancer”. We delineated the paths to the outcomes with each strategy and conducted a utility assessment involving gastroenterology physicians and patients referring to a referral gastroenterology clinic. Using the mean utilities obtained for each path and the highest prevalence of gastric cancer among the general dyspeptic population in Iran as a high prevalence area for gastric cancer, we calculated the expected utilities for each strategy. We included a sensitivity analyses testing the performance of the decision tree under various assumptions.

The expected values for PE and T&T, the main strategy nodes, were 0.721 and 0.980 respectively under the base case assumptions, clearly favoring T&T. On sensitivity analysis, when utilities were kept constant and prevalence increased stepwise, the preferred strategy changed at a prevalence of 69.0% for upper GI cancers. When the prevalence of cancer was kept fixed at 1.2% and the utility of EGD was increased stepwise, a utility of 98.0% or more was required for the PE to become the preferred strategy. A third sensitivity analysis in which both prevalence and utility of EGD were increased stepwise revealed that if the prevalence of cancer in the given dyspeptic population is at least 3.0% and the utility of PE is 97.0% or more, then prompt endoscopy has a higher utility.

According to our data, utility of EGD is the most important factor in determining the method of assessing dyspeptic patients in the general population. The T&T strategy is the preferred method in most cases with PE better reserved for those with a very low disutility for EGD.