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A Canadian physician surveyof dyspepsia management

Naoki Chiba MD FRCPC1,2, Lisa Bernard BA3, Bernie J OBrien PhD4, Ron Goeree MA4, Richard H Hunt MD FRCP(Edin) FRCPC2

Can J Gastroenterol Vol 12 No 1 January/February 1998 83

N Chiba, L Bernard, BJ OBrien, R Goeree, RH Hunt. A Cana-dian physician survey of dyspepsia management. Can J Gastro-enterol 1998;12(1):83-90.

OBJECTIVE: To determine the management of patients withnew onset dyspepsia by Canadian family physicians.METHODS: A survey was mailed to 195 family physicians inAugust 1995 to identify how they manage dyspepsia in patients ac-cording to four scenarios: based on presenting symptoms alone; as-suming Helicobacter pylori-positive; known to be H pylori-negative;and endoscopically confirmed nonulcer dyspepsia.RESULTS: A total of 170 of 195 physicians (87.2%) completedthe survey. Physicians reported that 7.3% of their practice is de-voted to dyspepsia and 23% of these dyspeptic patients present forthe first time. Ninety-three per cent of family physicians find asymptom classification of ulcer-, reflux- and dysmotility-like dys-pepsia helpful. The majority of patients are advised to make life-style changes and are treated with antacids or empiric drugtherapy. A H2 receptor antagonist was the drug of choice for ulcerand reflux-like dyspepsia, while prokinetics were often used for re-flux and dysmotility-like dyspepsia. After failure of initial treat-ment, patients were given another course of empiric treatment,commonly with cisapride or omeprazole. Family physicians esti-mated that the mean time to obtain a gastrointestinal consultwas five weeks, and 70% indicated that this time to consult ad-versely influenced their decision to refer. If this time was reducedto less than two weeks, responding physicians would considerreferring all eligible patients. On average, two to 2.5 courses of em-piric therapy were given before referral. If H pylori status wasknown, fewer empiric treatments (mean 1.8) were given beforegastroenterological referral compared with the other scenarios.If the patient had nonulcer dyspepsia, 30% of family physiciansprovided reassurance only and did not prescribe empiric drugtreatment.

CONCLUSIONS: Most newly dyspeptic patients in Canada aretreated with empiric therapy according to symptom classificationand referred for endoscopy after an average two to 2.5 treatmentcourses.

Key Words: Dyspepsia, Helicobacter pylori, Management, Primarycare, Questionnaire, Survey

Sondage sur le traitement de la dyspepsieauprs des mdecins canadiensOBJECTIF : Dterminer de quelle faon les mdecins de famillecanadiens traitent leurs patients atteints de dyspepsie de frache date.MTHODES : Un sondage a t envoy 195 mdecins de famille enaot 1995 afin de les interroger sur la faon dont ils traitent la dyspepsiechez les patients selon quatre scnarios : selon les symptmes au moment dela prsentation seule, en supposant la prsence dHelicobacter pylori, ensupposant que le patient est H. pylori-ngatif et en prsence dunedyspepsie non ulcreuse confirme lendoscopie.RSULTATS : En tout, 170 mdecins sur 195 (87,2 %) ont rpondu ausondage. Selon les rsultats, 7,3 % de la pratique des mdecins rpondantsest consacr la dyspepsie, 23 % des patients dyspeptiques consultent leurmdecin ce sujet pour la premire fois, et 93 % des mdecins de familletrouvent utile le recours une classification des symptmes de dyspepsieassocis un ulcre, lsophagite de reflux et la dysmotilit. La majoritdes patients sont aviss de modifier leur style de vie et sont traits au moyendantiacides ou dun traitement mdicamenteux empirique. Lanti-H2 estle mdicament de choix dans les cas de dyspepsie de type ulcre ou de typesophagite de reflux, alors que les procintiques sont souvent utiliss pourlsophagite de reflux et la dyspepsie de type dysmotilit. Aprs lchec dutraitement initial, les patients reoivent un autre traitement empirique,souvent du cisapride ou de lomprazole. Les mdecins de famille ontestim que lattente moyenne avant dobtenir une consultation chez ungastro-entrologue tait de cinq semaines et 70 % ont indiqu que ce dlaiinfluait ngativement sur leur dcision dadresser leurs patients. Si cette

1Surrey GI Clinic, Guelph, Ontario; 2Division of Gastroenterology, and 4Clinical Epidemiology and Biostatistics, McMaster University,Hamilton, Ontario; 3Innovus Research Inc, Burlington, Ontario

Correspondence and reprints: Dr Naoki Chiba, Surrey GI Clinic, 10521 Surrey Street West, Guelph, Ontario N1H 3R3. Telephone519-836-8201, fax 519-836-1341, e-mail chiban@fhs.mcmaster.ca

Received for publication June 9, 1997. Accepted October 28, 1997

CANADIAN SURVEY

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Dyspepsia, defined as pain or discomfort centred in theupper abdomen, is a common condition. A Canadianstudy found that 38% of subjects complained of mild to mod-erate acid-related symptoms (1), which often leads topatient-driven empiric treatments with over-the-counterantacids and H2 receptor antagonists (2), physician visits,time off work and an adverse effect on the quality of life.Thus, the social and economic costs of dyspepsia are consid-erable (3). When confronted with a new onset dyspeptic pa-tient, the physician cannot know whether an organic diseaseexists or whether the patient has a functional, nonlife-threatening but troublesome disorder. Because history alonelacks diagnostic discriminant value, the family physicianmust decide whether investigations are necessary or whetherdrug therapy without an initial diagnosis, so-called empirictherapy, is appropriate. In a patient with alarm symptoms,such as weight loss, dysphagia, bleeding or microcytic ane-mia, investigation clearly is required, but in their absencethe choice is less clear.

The standard approach has been to follow the 1985 rec-ommendations of the American College of Physicians andprescribe a course of empiric drug therapy, followed by endo-scopy for those failing treatment (4). Do Canadian familyphysicians give the same empiric treatment to all patients ordo they consider treatment according to the symptom sub-groups of ulcer-like, reflux-like and dysmotility-like dyspep-sia? The answer to this question is unknown.

The discovery of Helicobacter pylori has provided the op-portunity to cure patients with duodenal and gastric ulcerdisease. However, most patients with H pylori are asympto-matic or are dyspeptic without organic disease and are classi-fied as having nonulcer dyspepsia (NUD) or functionaldyspepsia. It is important to distinguish undiagnosed dyspep-sia from the diagnosis of NUD, made only after negative in-vestigations. The association between H pylori and NUD iscontroversial, although pooled analysis has shown thatNUD patients have a 23% higher prevalence of H pyloricompared with controls (5). Also, inflammation associatedwith H pylori infection might be expected to disturb antropy-loroduodenal motility and other aspects that may contributeto dyspepsia (6). Reviews of H pylori eradication therapy inNUD have not shown consistent benefit (7,8). The role thatdiagnosis and treatment of H pylori infection plays in themanagement of dyspepsia by Canadian family physicians isunknown.

The goal of this study was to determine the managementof new onset dyspepsia by Canadian family physiciansthrough the use of a structured questionnaire.

MATERIALS AND METHODSA total of 195 family practitioners were selected randomlyfrom across Canada and agreed to participate in an August1995 survey on the management of new onset dyspepsia bymailing in a structured questionnaire.

The Rome criteria (9) defined three dyspepsia subgroupsto aid the diagnosis of dyspepsia. Although the clinical util-ity of these criteria has been questioned (10), they do pro-vide a conceptual framework that may assist physicians inpatient management. In this section of the survey, the dys-pepsia symptom classification of ulcer-like, reflux-like anddysmotility-like was explained. Physicians were askedwhether they found this classification helpful. Other factorsin the history that family physicians might consider helpfulto manage dyspepsia were also asked.

Data on the initial and subsequent management of pa-tients who returned with persistent dyspepsia were obtainedfrom different scenarios. Within each scenario, family physi-cians were given the option of managing all patients thesame way, regardless of specific symptoms, or differently,based on dyspepsia subgroups if they indicated that theywould consider subgroups helpful in their management.Family physicians indicated which medication(s) theywould prescribe.

The typical patient under consideration was a healthy35-year-old presenting with new onset dyspepsia, withoutalarm symptoms and no prior investigations. Initially globalmanagement of new onset dyspepsia was determined, fol-lowed by whether management of a new dyspeptic patientwould vary according to four hypothetical scenarios.

Scenario 1: Family physicians were asked what empiric ther-apy they would prescribe based on presenting symptoms onlyand without investigation.

Scenario 2: Family physicians were to assume that there wasa readily available test for H pylori and to provide informationbased on a positive test for H pylori to determine whether thisinfluenced their management strategy.

Scenario 3: Family physicians were to assume that there wasa readily available test for H pylori and to provide informationbased on a negative test for H pylori to determine whether thisinfluenced their management strategy.

Scenario 4: Family physicians were to provide informationfor management strategies for patients who underwent initialendoscopy with normal findings (NUD), ie, based on theknowledge that ther