Primary Care Management of Dyspepsia Policy Context

1
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

2
Primary Care Management of Dyspepsia Policy
Context

• Scale of the problem
• Different forms of dyspepsia
• Expert views
• New GP contract
• Forthcoming NICE guidelines

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Dyspepsia - Scale of the Problem

• Population
• Primary care
• Secondary care
• Health care system
• (and it depends what you call dyspepsia)

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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?

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Prevalence of Dyspepsia in the Community
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Dyspepsia in Primary Care

• Prevalence of dyspepsia presenting in primary
  care is 3.4
• 0.51.5 of the population on long term PPI
• 12 of population have upper GI endoscopy every
  year

Meineche-Schmidt and Krag 1998
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Dyspepsia in Secondary Care

• Emergency admissions
• OPD(s)
• Provision of diagnostic facilities (why?)

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Dyspepsia and the Health Care System

• PPI spend is 450 million p.a. approx.
• Endoscopy capacity
• 2 of dyspeptics absent from work due to
  dyspepsia

Penson and Pounder 1996
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ENDOSCOPY CAPACITY IN THE UK
ENDOSCOPY CAPACITY IN THE UK
10
Total Nos. Diagnostic OGDs By YearJohn Radcliffe
Hospital, Oxford
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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)

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Dyspepsia Subtypes

• Ulcer-like
• Reflux-like
• Dysmotility-like
• Uncharacteristic and relapsing dyspepsia

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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
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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

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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

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Presence of Alarm Symptoms
Retrospective review of notes of patients
diagnosed with UGI cancer
Canga and Vikil 2002
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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

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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

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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

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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