The Saga Continues
First a recap.
People with chronic stomach aches may be suffering from a treatable infection called Helicobacter pylori gastritis which is often shortened to H. pylori gastritis. Left untreated the gastritis can turn into stomach ulcers and is also linked to an increased risk of stomach cancer.
Diagnosing acute H. pylori gastritis has traditionally been done by patients taking a urea breath test (UBT).
(image source - National Toxicology Program US Dept. HHS, 2018)
Blood test looking for specific H. pylori antibodies can also be done but these tests cannot tell the difference between an active or possibly cured past H. pylori infection.
H. pylori infections are treated with common antibiotics.
In June, 2019 I wrote about extreme differences in wait times for outpatient H. pylori UBTs ranging from two weeks (Dynacare -where patients have to pay for the test) to one month (Brandon Hospital Nuclear Medicine), 4 months (St. Boniface Hospital Nuclear Medicine) and one year (Nuclear Medicine HSC). Nuclear Medicine hospital based UBTs are covered by MB Health. It is unusual, if not irregular, that patients have to pay for an insured health service if it is provided by a private lab versus the public system. This inconsistency is related to what specific services MB Health contracts Dynacare to provide and they do not fully reimburse Dynacare for UBTs.
There was good news in September 2019. WRHA resourced a UBT “blitz” to get the wait times down to an average of about four weeks across the public sector. This was a welcome short-term solution. Work was being done in the background on longer term solutions.
A Shared Health committee recommended the best way to test for H. pylori in MB (i.e. Provincial Coordinated Helicobacter pylori Testing Strategy, November 2019).
From the report’s executive summary:
About one year ago, a Choosing Wisely Working Group was formed to review the various testing types and landscape of H. pylori testing in Manitoba to develop a recommendation that meets the current standard of care for laboratory diagnosis of this infection.
The committee’s conclusions were:
Manitoba should have a coordinated H. pylori testing algorithm that is clear to ordering clinicians and available to patients close to their communities. The tests used should be as minimally invasive as possible, should diagnose active infection and assist care providers to follow a defined treatment plan. In addition, the testing should be delivered by health care professionals whose skills and services are best matched to the service to be provided and spend healthcare funding wisely.
Based on analysis, we propose the following testing algorithm: Serology should be used as the screening test for patients with suspected and previously undiagnosed H. pylori infection. If positive, follow up stool antigen testing (SAT) would be provided to patients, regardless of age. Blood for serology can be drawn at any laboratory location in Manitoba and shipped to CPL. A sample for SAT can be collected by the patient and provided to any laboratory location in Manitoba with the test being performed on site. Patients with a previous diagnosis of H. pylori may access SAT directly without a new or repeat positive serology test.
The recommendations are evidence based (i.e. the proposed sequence of tests is more accurate than current practice), allow for more convenient access to testing across the province and cost less. For example, patients no longer have to travel to Brandon or Winnipeg for a simple outpatient test. Some patients currently fly in from Northern MB for a simple test that could be done in their local clinic or nursing station. Adopting the recommendations will also free up slots in Nuclear Medicine Departments to do other studies which generally involve cancer and cardiac patients.
I understand that COVID-19 had slowed down implementation of innovative solutions that are not related to the pandemic, but this issue has been grumbling along for at least two years and it is time to move on it.
Estimates are that there are currently upwards of a thousand Manitobans waiting for UBT appointments in the public system with wait times in the months, as is the case for many other diagnostic and elective surgical procedures due to the suspension of many elective services due to COVID-19 mitigation measures.
Easier access to a cheaper and more accurate H. pylori diagnosis should make implantation of the current recommendations a “no brainer”.