primary care management of dyspepsia policy context richard stevens ma frcgp general practitioner,...
TRANSCRIPT
Primary Care Management of Dyspepsia
Policy Context
Richard Stevens MA FRCGP
General Practitioner, Oxford
Chairman, Primary Care Society for Gastroenterology
Senior Clinical Fellow, University of Oxford
Primary Care Management of Dyspepsia Policy Context
• Scale of the problem
• Different forms of dyspepsia
• Expert views
• New GP contract
• Forthcoming NICE guidelines
Dyspepsia - Scale of the Problem
• Population
• Primary care
• Secondary care
• Health care system
(and it depends what you call dyspepsia)
Definition of Dyspepsia
• “a symptom complex thought to arise in the upper gastrointestinal tract and includes, in addition to epigastric pain or discomfort, symptoms such as heartburn, acid regurgitation, excessive belching, a feeling of slow digestion, early satiety, nausea and bloating.”
• Can heartburn be distinguished from other dyspeptic symptoms? And does it matter?
Prevalence of Dyspepsia in the Community
Authors Setting Prevalence Definition
Westbrook and Talley 2002
NSW, Australia 11 – 36% Depends…
Penston and Pounder 1996
UK 40% Dyspepsia and GORD (frequent overlap)
Haque et al. 2000 New Zealand 45.2% Dyspepsia = 34.2%. GORD = 30% (frequent overlap)
Kennedy and Jones 2000
UK 28.7% GORD
Dyspepsia in Primary Care
• Prevalence of dyspepsia presenting in primary care is 3.4%*
• 0.5–1.5% of the population on long term PPI
• 1–2% of population have upper GI endoscopy every year
*Meineche-Schmidt and Krag 1998
Dyspepsia in Secondary Care
• Emergency admissions
• OPD(s)
• Provision of diagnostic facilities (why?)
• PPI spend is £450 million p.a. approx.
• Endoscopy capacity…
• 2% of dyspeptics absent from work due to dyspepsia*
*Penson and Pounder 1996
Dyspepsia and the Health Care System
ENDOSCOPY CAPACITY IN THE UK
ENDOSCOPY CAPACITY IN THE UK
Total Nos. Diagnostic OGDs By YearJohn Radcliffe Hospital, Oxford
0 1000 2000 3000 4000 5000 6000
93-94
94-95
95-96
96-97
97-98
0AIPOPOH
Different Forms of Dyspepsia?
• Only matters if it makes a difference– Evidence suggests symptoms do not correlate
with findings– Symptom overlap is common
• Can dyspepsia be distinguished from GORD (and does it matter?)– (Yes, if it alters management)
Dyspepsia Subtypes
• Ulcer-like
• Reflux-like
• Dysmotility-like
• “Uncharacteristic and relapsing dyspepsia”
3 Year Follow up of Dyspeptics in Primary Care
• Postal follow up of patients and GPs
• Results:– 20 – 34% reported no dyspepsia after 3 years– Changes in sub-types were common– Ulcer-like and reflux-like often changed into
dysmotility-like dyspepsia– Dysmotility-like dyspepsia significantly more
stable over time
Meineche-Schmidt and Jorgensen 2002
Current Guidelines on the Management of Dyspepsia
• British Society of Gastroenterology 2002– Test and treat uncomplicated dyspeptics under
the age of 55– Upper GI endoscopies for any patient with
alarm symptoms or over 55– Urea breath test is most appropriate test for
Helicobacter pylori
Upper GI Cancers and Age
• For all three tumour types (oesophagus, stomach and pancreas) 99% of cases occur over 40 years
• 90% of gastric cancers occur over 55 years• The chance of a dyspeptic patient under
the age of 55 having gastric cancer is one in a million
• 55 is the cost effective age for investigation of gastric cancer under the Markov model
Presence of Alarm Symptoms
Age Under 45 Under 55
Number with upper GI Ca.
21/341 65/341
Number with alarm symptoms
20/21 60/65
Retrospective review of notes of patients diagnosed with UGI cancer
Canga and Vikil 2002
GI Cancer Presentation to the Individual GP
• Oesophagus 1 every 5 years
• Stomach 1 every 2 - 3 years
• Pancreas 1 every 4 years
• Colorectal 1 every 1 - 2 years
The New GP Contract and the Management of Dyspepsia
• No quality markers in gastroenterology
• Some quality points for medicines management and cancer
• Will actively divert attention and resources away from GI diseases
• But: Greater role for nurses
Systematic approach to care emphasised
Likely Impact of NICE Dyspepsia in Primary Care Guidelines
• Will stress that dyspepsia is a benign, chronic, relapsing and remitting disease
• Downgrade the value of endoscopies in the management of dyspepsia
• Advocate “test and treat” or “symptom and treat”• UBT for testing for Helicobacter pylori• Annual review is “good medical practice”• Self management plans may be of benefit
In Conclusion
• Dyspepsia is common, expensive and affects patients’ lives
• Dyspepsia is usually benign• Endoscopy may be replaced by “test and
treat” or “symptom and treat”• UBT will have to be more widely available• Reviews and self management plans may be
the future