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