Dyspepsia Impact On Primary Care

1
Dyspepsia
Impact On Primary Care

• Dr Paul Pickering
• GP, Bridlington
• Prescribing Lead YWC PCT

2
Overview

• The scale of the problem in primary care
• The cost of dyspepsia
• Practice-based dyspepsia clinics

3
The Scale of the Problem

• Dyspepsia prevalence 40 population
• National data shows 3-5 population present to
  their GP with symptoms
• Consultation rates of 355 per 10000 pt yrs at age
  25-44 to 789 per 10000 pt yrs at age 75-84
• Population surveys imply 10 seek assistance from
  their GP
• 1 population referred for endoscopy

4
GI Drug Spend
5
Cost of Dyspepsia

• 1.2 billion/yr with a cost growth of 8-9
• 19 million prescriptions for PPIs
• PPIs account for 34 of the volume but 83 of the
  NHS upper GI spend
• Alginates are 41 of the volume and 4 of the NHS
  upper GI spend
• 40 of PPIs are being prescribed to long term
  users
• Maintenance dose PPI represents the minority

6
Cost of Dyspepsia
7
Cost of Dyspepsia

• Recorded reasons for long term PPI use
• Oesophagitis(2) 17
• Reflux 40
• Non-specific dyspepsia 30
• Peptic ulcer disease 3
• Oesophageal ulcer/stricture 2
• Non-GI problems 1

8
Cost of Dyspepsia

• Findings at endoscopy
• Normal 30
• Mild inflammation/HH 30
• Oesophagitis 10-17
• Malignancy 2-3
• DU 10-15
• GU 5-10

9
National GORD Data
PPI Increase 10,468,167
10
National GORD Data
PPI Increase 951,738 Rx (8.6)
11
National PPI Treatment Versus Maintenance Value
Split
12
National PPI Treatment Versus Maintenance Volume
Split
13
Current NICE Guidance

• Patients with mild symptoms of dyspepsia may be
  treated on either a step-up or step-down basis
• These patients should not normally be treated
  with a PPI on a long-term basis without a
  confirmed clinical diagnosis
• Patients with mild GORD symptoms and/or no proven
  pathology, can be frequently managed by
  alternative therapies such as alginates
• All doctors prescribing PPIs will need to review
  the indications for their use and assess the
  dose, with the aim of reducing or stopping them
  where appropriate

14
Cost of Dyspepsia

• Estimated that if this guidance was implemented
  it could lead to a reduction in PPI prescribing
  by at least 15 and save the NHS 40-50M/yr
• Reality is that the prescribing of PPIs for GORD
  and related conditions has increased by 102M
  since the guidance was published

15
Cost of Dyspepsia

• Apart from the financial implications are there
  any other costs relating to the prescribing of
  PPIs long term in the treatment of dyspepsia
  syndromes?

16
Cost of Dyspepsia

• Acid breakthrough day and night 28
  night-time, 17 after a heavy meal, and 8
  daytime
• Safety and licence
• Masking of alarm symptoms
• Super secretion???
• Abandoning lifestyle modifications

17
Practice-based Dyspepsia Clinics

• Nurse-led
• Stepped protocol
• NICE guidelines
• Systematic review of all patients on PPIs
• Patient education, awareness involvement
• Promotion of a healthy lifestyle
• GP time freed up

18
Practice-based Dyspepsia Clinics

• Stepping-down appropriate patients from treatment
  to maintenance dose PPI
• Stepping-off appropriate patients from
  maintenance dose PPI to an alginate e.g. Gaviscon
  Advance
• Can significant prescribing savings be achieved?

19
Practice-based Dyspepsia Clinics

• PCTS SHARING DATA
• Bexley
• Brighton and Hove City
• Hartlepool
• North Lincolnshire Scunthorpe Study
• Yorkshire Wolds Coast Field House
  Surgery Project

20
Field House Surgery Project

• GP agreement on process and protocol
• Database search on all PPIs
• Establish a disease register
• Identify patients from inclusion criteria
• Send letters to all included patients explaining
  changes to medication and offering nurse-led
  dyspepsia clinics
• Dyspepsia clinics
• Audit results

21
Field House Surgery Project

• INCLUSION CRITERIA
• GORD
• Reflux oesophagitis up to grade 2
• Hiatus hernia
• Patients who have completed ulcer healing
  treatment
• Non-ulcer dyspepsia
• Uninvestigated dyspepsia

22
Field House Surgery Project

• EXCLUSION CRITERIA
• Patients on treatment lt3 months
• Patients awaiting referral or under the care of a
  consultant
• Barretts oesophagus and strictures
• Reflux oesophagitis gtgrade 2
• Patients gt90yrs
• Terminal illness
• Immunosuppression therapy

23
Field House Surgery Project

• PATIENT SELECTION
• 503 patients on PPIs
• 246 patients satisfy inclusion criteria
• 81 patients to be stepped-down
• 165 patients to be stepped-off

24
Field House Surgery Project

• STEP-OFF
• 165 patients
• 129 patients (78) remain stepped-off at 4 months
• 117 patients (71) remain stepped-off at 6 months

• STEP-DOWN
• 81 patients
• 66 patients (81) remain stepped-down at 4 months
• 59 patients (73) remain stepped-down at 6 months

25
Field House Surgery Project

• PPI Cost Savings
• 2465.96 per month
• Potential per year is 29,591.52
• Overall Cost Savings
• Total cost savings per month 1790.96(PPI
  savings cost of other treatments)
• Potential cost savings for the year are
  21,491.52
• 7030 maintenancetreatment dose PPI

26
Scunthorpe Study

• Step-Off
• 58 successfully maintained on Gaviscon Advance
  at 10 months after transferring from rabeprazole
  10 mg
• 51 successfully maintained on Gaviscon Advance
  at 8 months after transferring from lansoprazole
  15 mg
• Step-down
• 90 of patients remained on maintenance dose PPI
  after 7 months

27
Scunthorpe Study

• Overall Cost Savings
• 14,744 projected over the year

28
Practice-based Dyspepsia Clinics

• Establishing a process of review supported by
  NICE guidance.
• Improving patient management
• Breaking the cycle of long term PPI use
• Cost effective and appropriate prescribing
• Savings released to meet anticipated growth in
  prescribing relating to NSF targets and the new
  GMS contract

29
Dyspepsia Clinics and the New GMS Contract

• Records information about patients
  - recording smoking status
• Medicines management
• - medication reviews/meeting PCO
  
• prescribing advisor
• Patient experience
• - patient surveys

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Summary and Conclusions

• The scale of the problem in primary care
• - high prevalence 40 population
• The cost of dyspepsia
• - 548M/yr PPIs/83 upper GI spend
• Practice-based dyspepsia clinics
• - Cost-effective and evidence-based review of
  patients with chronic or relapsing symptoms

31
DyspepsiaImpact on Primary Care

• Dr Paul Pickering
• GP Bridlington
• Prescribing Lead YWC PCT