Adherence to best practice guidelines in dyspepsia: a survey comparing dyspepsia experts, community gastroenterologists and primary-care providers

Nationwide survey of physicians' familiarity and awareness of diabetes guidelines in China: a cross-sectional study

OBJECTIVE

This study aims to investigate physicians' familiarity and awareness of four diabetes guidelines and their practice of the recommendations outlined in these guidelines.

DESIGN

A cross-sectional study.

SETTING

An online questionnaire survey was conducted among physicians affiliated with the Specialist Committee for Primary Diabetes Care of China Association of Chinese Medicine, using the snowball sampling method to ensure a broader representation of physicians.

PARTICIPANTS

1150 physicians from 192 cities across 30 provinces in China provided complete data.

RESULTS

Tertiary care hospital physicians (TCPs) exhibited the highest familiarity with the Guideline for the Prevention and Treatment of Type 2 Diabetes Mellitus in China (91.3%), followed by the National Guidelines for the Prevention and Control of Diabetes in Primary Care (76.8%), the Standards of Medical Care in Diabetes (72.2%) and the Guidelines for Prevention and Treatment of Diabetes in Chinese Medicine (63.8%). Primary care practitioners (PCPs) exhibited familiarity with these four guidelines at about 50% or less. Self-reported reference to modern diabetes guidelines by physicians is more frequent than traditional Chinese medicine (TCM) diabetes guidelines, with rates at 73.2% and 33.8%, respectively. Approximately 90% of physicians provided instructions on self-monitoring of blood glucose to their patients with diabetes. Less than one-third of physicians referred patients to a specialised nutritionist. In terms of health education management, TCPs reported having a diabetes health management team at the rate of 75.7%, followed by secondary care hospital physicians at 57.0% and PCPs at 27.5%. Furthermore, approximately 40% of physicians did not fully grasp hypoglycaemia characteristics.

CONCLUSIONS

Familiarity and awareness of the screening guidelines varied among physicians in different hospital settings. Importantly, significant discrepancies were observed between physicians' awareness and their self-reported reference to modern medicine guidelines and TCM guidelines. It is essential to consistently provide education and training on diabetes management for all physicians, particularly PCPs.

Up-Front Endoscopy Maximizes Cost-Effectiveness and Cost-Satisfaction in Uninvestigated Dyspepsia

BACKGROUND & AIMS

Practice guidelines promote a routine noninvasive, non-endoscopic initial approach to investigating dyspepsia without alarm features in young patients, yet many patients undergo prompt upper endoscopy. We aimed to assess tradeoffs among costs, patient satisfaction, and clinical outcomes to inform discrepancy between guidelines and practice.

METHODS

We constructed a decision-analytic model and performed cost-effectiveness/cost-satisfaction analysis over a 1-year time horizon on patients with uninvestigated dyspepsia without alarm features referred to gastroenterology. A RAND/UCLA expert panel informed model design. Four competing diagnostic/management strategies were evaluated: prompt endoscopy, testing for Helicobacter pylori and eradicating if present (test-and-treat), testing for H pylori and performing endoscopy if present (test-and-scope), and empiric acid suppression. Outcomes were derived from systematic reviews of clinical trials. Costs were informed by prospective observational cohort studies and national commercial/federal cost databases. Health gains were represented using quality-adjusted life years.

RESULTS

From the patient perspective, costs and outcomes were similar for all strategies (maximum out-of-pocket difference of $30 and <0.01 quality-adjusted life years gained/year regardless of strategy). Prompt endoscopy maximized cost-satisfaction and health system reimbursement. Test-and-scope maximized cost-effectiveness from insurer and patient perspectives. Results remained robust on multiple one-way sensitivity analyses on model inputs and across most willingness-to-pay thresholds.

CONCLUSIONS

Noninvasive management strategies appear to result in inferior cost-effectiveness and patient satisfaction outcomes compared with strategies promoting up-front endoscopy. Therefore, additional studies are needed to evaluate the drivers of patient satisfaction to facilitate inclusion in value-based healthcare transformation efforts.

Proton Pump Inhibitor Prescribing and Monitoring Patterns Among Gastroenterology Practitioners

GOALS

The aim was to quantify proton pump inhibitor (PPI) practice habits among gastroenterology (GI) practitioners.

BACKGROUND

Reports of side effects have prompted patients and practitioners alike to discontinue PPI use. Emerging evidence-based literature on PPI risks and safety seek to guide practitioners, but the impact of this literature on PPI prescribing patterns has not been evaluated.

STUDY

We performed an anonymous online survey of US GI practitioners across 6 academic and community affiliated medical centers. Demographic data including practice type and number of weekly gastroesophageal reflux disease patients seen were obtained. Survey questions evaluated practitioners' monitoring for PPI side effects, dose adjustments, and sources of information about PPI risks.

RESULTS

The survey response rate was 60% (256/429). The majority of respondents were male (169, 66%) attending physicians (178, 70%) practicing general GI (63, 25%). There were 92 (36%) respondents who reported testing for PPI side effects at least once a year. Most respondents (143, 56%) reported discontinuing PPIs at least 50% of the time because of patients' concerns about PPI side effects. The majority of respondents reported getting their information regarding PPI safety from published journals (239, 98%) as well as colleagues (222, 91%).

CONCLUSIONS

Despite best available evidence suggesting safety of long-term PPI use without routine monitoring, stopping PPIs and monitoring for potential side effects occurs frequently, even within a cohort of mostly academic GI practitioners. Alternative strategies are needed to improve adherence to best practices, especially since gastroenterologists often serve as PPI experts.

Illness perception and health care use in individuals with irritable bowel syndrome: results from an online survey

BACKGROUND

Individual illness perception is known to influence a range of outcome variables. However, little is known regarding illness perception in irritable bowel syndrome (IBS) and its relation to the use of the health care system. This study hypothesised a relationship between illness perception and inappropriate health care use (under-, over- and misuse).

METHODS

An internet-based, cross-sectional study in participants affected by IBS symptoms was carried out (April - October 2019) using open questions as well as validated standardized instruments, e.g. the illness perception questionnaire revised (IPQ-R) and its subscales. Sub-group comparisons were done non-parametrically and effect sizes were reported. Potential predictors of (1) conventional health care utilisation and (2) utilisation of treatment approaches with lacking or weak evidence regarding effectiveness in IBS were examined with logistic regression analyses and reported as odds ratio (OR) and 95% confidence interval.

RESULTS

Data from 513 individuals were available. More than one-third (35.7%) of participants were classified as high utilisers (> 5 doctor visits during the last year). Several indicators of inappropriate health care use were detected, such as a low proportion of state-of-the-art gynaecological evaluation of symptoms (35.0% of women) and a high proportion of individuals taking ineffective and not recommended non-steroidal antirheumatic drugs for IBS (29.4%). A majority (57.7%) used treatment approaches with lacking or weak evidence regarding the effectiveness in IBS (e.g. homeopathy). Being a high utiliser as defined above was predicted by the perceived daily life consequences of IBS (IPQ-R subscale "consequences", OR = 1.189 [1.100-1.284], p ≤ 0.001) and age (OR = 0.980 [0.962-0.998], p = 0.027). The use of treatment approaches with lacking or weak evidence was forecasted by the perceived daily life consequences (OR = 1.155 [1.091-1.223], p ≤ 0.001) and gender (reference category male: OR = 0.537 [0.327-0.881], p = 0.014), however effect sizes were small.

CONCLUSIONS

Daily life consequences, perceived cure and personal control as aspects of individual disease perception seem to be related to individuals' health care use. These aspects should be a standard part of the medical interview and actively explored. To face inappropriate health care use patients and professionals need to be trained. Interdisciplinary collaborative care may contribute to enhanced quality of medical supply in IBS.

Guideline Adherence in Dyspepsia Investigation and Treatment

Introduction

The impact of dyspepsia guidelines on clinical practice may be poor. Provider adherence with dyspepsia guidelines was examined to determine their impact on clinical practice.

Methods

Provider adherence with the 2005 American College of Gastroenterology Guidelines for the Management of Dyspepsia and the 2017 American College of Gastroenterology and Canadian Association of Gastroenterology joint Dyspepsia Management Guidelines was assessed on a national level using data from the National Ambulatory Medical Care Survey (NAMCS). Patient visit data, including reason for visit of dyspepsia, diagnosis of dyspepsia, or diagnosis of H. pylori infection from NAMCS years 2012 through 2015, were used. Provider adherence with dyspepsia management guidelines was determined based upon provision of at least one recommended test or treatment for dyspepsia.

Results

Providers appeared to adhere to the 2005 ACG guidelines for 49.7% of patient visits. Providers appeared to adhere to the 2017 ACG/CAG guidelines for 51.0% of patient visits.

Conclusion

Provider adherence with the 2005 ACG and the 2017 ACG/CAG Dyspepsia Management Guidelines was determined to be low in this study, highlighting the need to increase evidence-based medical treatment and efficient resource use for dyspepsia.

The Use and Misuse of Proton Pump Inhibitors: An Opportunity for Deprescribing

Proton pump inhibitors (PPIs) are proven medications of choice for gastroesophageal reflux disease (GERD), acid-related disorders, erosive esophagitis, Barrett esophagus, prevention of gastrointestinal bleeding while on nonsteroidal anti-inflammatory drugs, eosinophilic esophagitis, peptic ulcer disease, stress ulcer prophylaxis in critically ill patients, and other indications. Best practice guidelines from several sources on the appropriate indications and duration of PPI therapy have been summarized for easy assimilation. Individualized decision with regard to PPI use is illustrated by case vignettes; best approaches are provided. The significant increase in use of PPIs for ill-defined indications over the years, associated adverse outcomes with long-term use, and consequent increase in health care costs have drawn much attention. Adverse outcomes due to PPI therapy may be categorized as unrelated or related to gastric acid inhibition. Examples of outcomes unrelated to acid inhibition include allergic reactions, acute interstitial nephritis, chronic kidney disease, poor cardiovascular outcomes, dementia, and drug interactions; consequences of acid inhibition include gastrointestinal infections, pneumonia, nutrient deficiencies, fractures, spontaneous bacterial peritonitis, and small intestinal bacterial overgrowth. Provider awareness regarding best practice guidelines on PPI use and imparting pertinent education to patients may be the rational approach to safe and effective PPI therapy. In individuals in whom the drug is not indicated, efforts at deprescribing the PPI may be attempted following discussion with the patient. Approaches include stopping the drug, reducing the dose or using "on-demand" therapy after completing the course of treatment for the specific indication. Barriers to successful deprescribing exist. Follow-up is recommended for recurrence of manifestations; in the event of recurrence, the PPI may need to be re-instituted. PPIs are valuable, irreplaceable drugs in the prevention and treatment of certain disorders for specific durations of time. Evidence nevertheless suggests that excessive and inappropriately prolonged use of PPIs is associated with a broad range of adverse effects. Education of provider and patient, stewardship, and motivation are key to appropriate use of PPIs for the right indications. Key implications for practice are offered.

Helicobacter pylori: A Review of Current Diagnostic and Management Strategies

As one of the most prevalent infections globally, Helicobacter pylori (H. pylori) continues to present diagnostic and therapeutic challenges for clinicians worldwide. Diagnostically, the "test-and-treat" strategy is the recommended approach for healthcare practitioners when managing this potentially curable disease. The choice of testing method should be based on several factors including patient age, presenting symptoms, and medication use, as well as test reliability, availability, and cost. With rising antibiotic resistance, particularly of macrolides, care must be taken to ensure that therapy is selected based on regional resistance patterns and prior antibiotic exposure. In the USA, macrolide antibiotic resistance rates in some areas have reached or exceeded a generally accepted threshold, such that clarithromycin triple therapy may no longer be an appropriate first-line empiric treatment. Instead, bismuth quadruple therapy should be considered, while levofloxacin-based or alternative macrolide-containing therapies are also options. Once treated, it is essential to test for eradication as untreated H. pylori is associated with serious complications including peptic ulcer disease, mucosa-associated lymphoid tissue lymphoma, and gastric cancer. This review article aims to consolidate current knowledge of H. pylori infection with a particular emphasis on diagnostic and treatment strategies.

Approach to gastroenterological diseases in primary care

Gastroenterological diseases are a source of morbidity, mortality and costs, and have a high frequency in general practice; for this reason, we have evaluated the current literature regarding the knowledge and management of these disorders by general practitioners, finding little knowledge and adherence to guidelines, highlighting the need for continuous updating in this regard, and greater collaboration between specialists and general practitioners. (www.actabiomedica.it)

Helicobacter pylori Infection: An Update for the Internist in the Age of Increasing Global Antibiotic Resistance

Helicobacter pylori infects approximately half the world's population and is especially prevalent in the developing world. H. pylori is an important cause of global ill health due to its known etiological role in peptic ulcer disease, dyspepsia, gastric cancer, lymphoma, and more recently, recognized in iron deficiency anemia and idiopathic thrombocytopenic purpura. Increased antibiotic usage worldwide has led to antibiotic resistance among many bacteria, including H. pylori, resulting in falling success rates of first-line anti-H. pylori therapies. Eradication failures are principally due to resistance to clarithromycin, levofloxacin, and metronidazole. Several new treatment options or modifications of established regimens are now recommended by updated practice guidelines for primary or secondary therapy. Because these updated recommendations were published in the gastroenterological literature, internists and primary care physicians, who commonly manage H. pylori, may be unaware of these advances. In this review, we outline the changing epidemiology of H. pylori, advise on diagnostic test selection for patients not undergoing endoscopy, and highlight current management options in this era of growing antibacterial resistance.

Low Prevalence of Clinically Significant Endoscopic Findings in Outpatients with Dyspepsia

Background. The value of endoscopy in dyspeptic patients is questionable. Aims. To examine the prevalence of significant endoscopic findings (SEFs) and the utility of alarm features and age in predicting SEFs in outpatients with dyspepsia. Methods. A retrospective analysis of outpatient adults who had endoscopy for dyspepsia. Demographic variables, alarm features, and endoscopic findings were recorded. We defined SEFs as peptic ulcer disease, erosive esophagitis, malignancy, stricture, or findings requiring specific therapy. Results. Of 650 patients included in the analysis, 51% had a normal endoscopy. The most common endoscopic abnormality was nonerosive gastritis (29.7%) followed by nonerosive duodenitis (7.2%) and LA-class A esophagitis (5.4%). Only 10.2% had a SEF. Five patients (0.8%) had malignancy. SEFs were more likely present in patients with alarm features (12.6% versus 5.4%, p = 0.004). Age ≥ 55 and presence of any alarm feature were associated with SEFs (aOR 1.8 and 2.3, resp.). Conclusion. Dyspeptic patients have low prevalence of SEF. The presence of any alarm feature and age ≥ 55 are associated with higher risk of SEF. Endoscopy in young patients with no alarm features has a low yield; these patients can be considered for nonendoscopic approach for diagnosis and management.

Radiographic staging practices of newly diagnosed colorectal cancer vary according to medical specialty

BACKGROUND

Since 2008, multiple guidelines have endorsed incorporation of chest CT in the radiographic staging assessment of newly diagnosed colorectal cancer (CRC). Radiographic staging practices performed after CRC is detected have not been studied.

OBJECTIVE

To evaluate radiographic staging practices for newly diagnosed CRC between gastroenterologists versus non-gastroenterologists.

DESIGN

Observational cohort study.

SETTING

Single, tertiary-care referral center.

PATIENTS

Patients newly diagnosed with a T1 or higher stage CRC at time of colonoscopy between 2008 and 2013.

INTERVENTIONS

Radiographic staging.

MAIN OUTCOME MEASUREMENTS

Radiographic preoperative staging examinations ordered by gastroenterologists in comparison to those ordered by non-gastroenterology specialists.

RESULTS

This study included 277 patients with CRC newly diagnosed by colonoscopy. There were 141 total ordering physicians (68 gastroenterologists and 73 non-gastroenterologists). The majority of preoperative radiographic staging was performed by gastroenterologists (59.2% of patients, n = 164). Colorectal surgeons managed staging in 28.7% of patients (n = 47). Gastroenterologists were more likely to omit a staging chest CT than were non-gastroenterologists (64.6% vs 46.9%; P < .001). Physician practice setting, rectal location of tumor, and advanced endoscopic appearance of tumors were predictors of chest CT inclusion.

LIMITATIONS

Single center, moderate sample size of both providers and patients.

CONCLUSION

Gastroenterologists more frequently ordered the initial radiographic staging studies in newly diagnosed CRC patients. However, gastroenterologists were less likely to include chest CT in the initial staging of CRC despite current guideline recommendations to do so. If confirmed with further studies, educational efforts to improve compliance and standardization may be needed.

Acceptance of inflammatory bowel disease treatment recommendations based on appropriateness ratings: do practicing gastroenterologists agree with experts?

BACKGROUND

Appropriateness criteria for the treatment of Crohn’s disease (CD) and ulcerative colitis (UC) have been developed by expert panels. Little is known about the acceptance of such recommendations by care providers. The aim was to explore how treatment decisions of practicing gastroenterologists differ from those of experts, using a vignette case study and a focus group.

METHODS

Seventeen clinical vignettes were drawn from clinical indications evaluated by the expert panel. A vignette case questionnaire asking for treatment options in 9 or 10 clinical situations was submitted to 26 practicing gastroenterologists. For each vignette case, practitioners’ answers on treatments deemed appropriate were compared with panel decisions. Qualitative analysis was performed on focus group discussion to explore acceptance and divergence reasons.

RESULTS

Two hundred thirty-nine clinical vignettes were completed, 98 for CD and 141 for UC.Divergence between proposed treatments and panel recommendations was more frequent for CD (34%) than for UC (27%). Among UC clinical vignettes, the main divergences with the panel were linked to 5-aminosalicylate (5-ASA) failure assessment and to situations in which stopping treatment was the main decision. For CD, the propositions of care providers diverged from the panel in mild to moderate active disease, for which practitioners were more prone to an accelerated step-up than the panel’s recommendations.

CONCLUSIONS

In about one-third of vignette cases, inflammatory bowel disease treatment propositions made by practicing gastroenterologists diverged from expert recommendations. Practicing gastroenterologists may experience difficulty in applying recommendations in daily practice.

Performance of American Society for Gastrointestinal Endoscopy guidelines for dyspepsia in Saudi population: Prospective observational study

AIM: To evaluate adherence of primary care physicians (PCPs) to international guidelines when referring patients for upper-gastrointestinal endoscopy (UGE), evaluate the importance of alarm symptoms and the performance of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines in a Saudi population.

METHODS: A prospective, observational cross-sectional study on dyspeptic patients undergoing UGE who were referred by PCPs over a 4 mo period. Referrals were classified as appropriate or inappropriate according to adherence to ASGE guidelines.

RESULTS: Total of 221 dyspeptic patients was enrolled; 161 patients met our inclusion criteria. Mean age was 40.3 years (SD ± 18.1). Females comprised 70.1%. Alarm symptoms included low hemoglobin level (39%), weight loss (18%), vomiting (16%), loss of appetite (16%), difficulty swallowing (3%), and gastrointestinal bleeding (3%). Abnormal endoscopy findings included gastritis (52%), duodenitis (10%), hiatus hernia (7.8%), features suggestive of celiac disease (6.5%), ulcers (3.9%), malignancy (2.6%) and gastroesophageal reflux disease (GERD: 17%). Among patients who underwent UGE, 63% met ASGE guidelines, and 50% had abnormal endoscopic findings. Endoscopy was not indicated in remaining 37% of patients. Among the latter group, endoscopy was normal in 54% of patients. There was no difference in proportion of abnormal endoscopic findings between two groups (P = 0.639).

CONCLUSION: Dyspeptic patients had a low prevalence of important endoscopic lesions, and none of the alarm symptoms could significantly predict abnormal endoscopic findings.

Management of Gastrointestinal Disorders in Central and Eastern Europe: Self-Reported Practice of Primary Care Physicians

Background

Gastrointestinal disorders account for 7–10% of all consultations in primary care. General practitioners’ management of digestive disorders in Central and Eastern European countries is largely unknown.

Aims

To identify and compare variations in the self-perceived responsibilities of general practitioners in the management of digestive disorders in Central and Eastern Europe.

Methods

A cross-sectional survey of a randomized sample of primary care physicians from 9 countries was conducted. An anonymous questionnaire was sent via post to primary care doctors.

Results

We received 867 responses; the response rate was 28.9%. Over 70% of respondents reported familiarity with available guidelines for gastrointestinal diseases. For uninvestigated dyspepsia in patients under 45 years, the “test and treat” strategy was twice as popular as “test and scope”. The majority (59.8%) of family physicians would refer patients with rectal bleeding without alarm symptoms to a specialist (from 7.6% of doctors in Slovenia to 85.1% of doctors in Bulgaria; p<0.001). 93.4% of respondents declared their involvement in colorectal cancer screening. In the majority of countries, responding doctors most often reported that they order fecal occult blood tests. The exceptions were Estonia and Hungary, where the majority of family physicians referred patients to a specialist (p<0.001).

Conclusions

Physicians from Central and Eastern European countries understood the need for the use of guidelines for the care of patients with gastrointestinal problems, but there is broad variation between countries in their management. Numerous efforts should be undertaken to establish and implement international standards for digestive disorders’ management in general practice.

The role of primary care physicians in early diagnosis and treatment of chronic gastrointestinal diseases

Chronic gastrointestinal disorders are a source of substantial morbidity, mortality, and cost. They are common in general practice, and the primary care physician (PCP) has a central role in the early detection and management of these problems. The need to make cost-effective diagnostic and treatment decisions, avoid unnecessary investigation and referral, provide long-term effective control of symptoms, and minimize the risk of complications constitute the main challenges that PCPs face. The literature review shows that, although best practice standards are available, a considerable number of PCPs do not routinely follow them. Low rates of colorectal cancer screening, suboptimal testing and treatment of Helicobacter pylori infection, inappropriate use of proton pump inhibitors, and the fact that most PCPs are still approaching the irritable bowel disease as a diagnosis of exclusion represent the main gaps between evidence-based guidelines and clinical practice. This manuscript points out that updating of knowledge and skills of PCPs via continuing medical education is the only way for better adherence with standards and improving quality of care for patients with gastrointestinal diseases.

Endoscopic findings in uninvestigated dyspepsia

Background

It is important to know the causes of dyspepsia to establish the therapeutic approach. Dyspepsia is a frequent syndrome in our country, where there are restrictions to endoscopy and high prevalence of Helicobacter pylori (H. pylori) infection. This study aimed to assess the endoscopic findings of the syndrome, in an outpatient screening clinic of a tertiary hospital in São Paulo.

Methods

Outpatients with uninvestigated dyspepsia, according to Rome III criteria, answered a dyspepsia questionnaire and underwent esophagogastroduodenoscopy. The Rapid Urease Test was applied to fragments of the antral mucosa and epidemiological data were collected from the studied population. Organic dyspepsia findings were analyzed with different variables to verify statistically significant associations.

Results

Three hundred and six patients were included and 282 were analyzed in the study. The mean age was 44 years and women comprised 65% of the sample. Forty-five percent of the patients reported alarm symptoms. Functional dyspepsia was found in 66% of the patients (20% with normal endoscopy results and 46% with gastritis), 18% had GERD and 13% had ulcers (duodenal in 9% and gastric in 4%). Four cases of gastric adenocarcinoma were identified (1.4%), one without alarm characteristics, 1 case of adenocarcinoma of the distal esophagus and 1 case of gastric lymphoma. The prevalence of H. pylori was 54% and infection, age and smoking status were associated with organic dyspepsia. The age of 48 years was indicative of alarm signs.

Conclusions

The endoscopic diagnosis of uninvestigated dyspepsia in our setting showed a predominance of functional disease, whereas cancer was an uncommon finding, despite the high prevalence of H. pylori. Organic dyspepsia was associated with infection, age and smoking status.

Early referral for esophageal pH monitoring is more cost-effective than prolonged empiric trials of proton-pump inhibitors for suspected gastroesophageal reflux disease

INTRODUCTION

The most cost-effective diagnostic algorithm for gastroesophageal reflux disease (GERD) remains controversial. We hypothesized that prompt referral for esophageal pH monitoring is more cost-effective than prolonged empiric courses of proton-pump inhibitors (PPIs).

DISCUSSION

A cost model was created based on a cohort of 100 patients with possible GERD who underwent pH monitoring. The additional costs incurred from pH monitoring were compared to the potential savings from avoiding unnecessary PPI usage in patients with a negative pH study. The costs of PPI therapy reach equivalence with pH monitoring after 6.4 to 23.7 weeks, depending on the PPI regimen. A total of 21,411 weeks of PPIs were prescribed beyond the recommended 8-week trial, of which 32 % were for patients who had a negative 24-h pH monitoring study. If the sensitivity of pH monitoring was 96 %, early referral for pH monitoring would have saved between $1,197 and $6,303 per patient over 10 years. This strategy remains cost-effective as long as the sensitivity of pH monitoring is above 35 %. Prompt referral for pH monitoring after a brief empiric PPI trial is a more cost-effective strategy than prolonged empiric PPI trials for patients with both esophageal and extraesophageal GERD symptoms.

Functional dyspepsia: the economic impact to patients

BACKGROUND

Although highly prevalent, little is known about the economic impact of functional dyspepsia (FD).

AIMS

To quantify FD patients' health care utilisation patterns and to estimate direct and indirect costs of FD to patients.

METHODS

ICD-9 codes identified adult patients with dyspepsia. A validated questionnaire was mailed to patients who met Rome III criteria for FD.

RESULTS

Three hundred and fifty-five patients met all inclusion criteria. The response rate was 63%. The respondents' mean age was 50 (14) years; 75% were women; 52% of respondents rated their FD as moderate. Patients reported 3 visits (mean) to their PCP over 12 months; 75% reported having blood work, 92% an EGD, 59% an ultrasound and 40% a CT scan. The direct cost of testing using Medicare reimbursement rates per patient was $582. To treat FD symptoms, 89% tried dietary changes, 89% over-the-counter medications, 87% prescription medications and 25% alternative therapies. Mean patient expenditure over the last year was $246 for OTC medications (range $0-12,000), $290 for co-payments (range $0-9,000) and $110 for alternative treatments (range $0-3,741). Total mean direct cost yearly to patients was $699. In the 7 days prior to completing the questionnaire, respondents reported a mean of 1.4 h absence from work. Extrapolating the results to the US population, we conservatively calculate the costs of FD were $18.4 billion in 2009.

CONCLUSIONS

Functional dyspepsia patients incur significant direct and indirect costs and work productivity is impaired by dyspeptic symptoms.

Diversity of endoscopy center operations and practice variation across California's safety-net hospital system: a statewide survey

Background

Little is known about endoscopic services provided or operational practice variation within California public hospital endoscopy centers.

Methods

A survey was distributed to all 18 California public hospitals with endoscopy centers to assess operational practices.

Results

Eight of 18 hospitals responded to the survey. Six of the eight responding hospitals used a closed access system for patient referrals. Mean wait time for an endoscopic procedure was 42.4 ± 37.7 days (N = 8) with a mean procedure no-show/cancellation rate of 14.5 ± 8.0% (N = 7). All responding public hospitals performed colonoscopy, esophagogastroduodenoscopy, PEG tube placement, and endoscopic retrograde cholangiopancreatography (ERCP) with two hospitals performing endoscopic ultrasound. There was significant practice variation in the documentation of endoscopic quality and performance measurements among the responding hospitals. Multiple methods were used to communicate pathology results to patients: GI clinic visit (6/8), primary physician (4/8), telephone (2/8) or letter (1/8).

Conclusion

Our study highlights the diversity and practice variations of endoscopy center operations at California public hospitals and serves as a catalyst for future collaborations among safety-net hospitals.

The epidemiology, diagnosis, and cost of dyspepsia and Helicobacter pylori gastritis: a case-control analysis in the Southwestern United States

BACKGROUND

Dyspepsia is among the most common complaints evaluated by gastroenterologists, but there are few studies examining its current epidemiology, evaluation, and costs. We examined these issues in a large managed care system in the Southwestern United States.

METHODS

We conducted a retrospective case-control analysis of adults with incident dyspepsia or a Helicobacter pylori-related condition in years 2006 through 2010 using utilization data. Medical record abstraction of 400 cases was conducted to obtain additional clinical information.

RESULTS

A total of 6989 cases met all inclusion and exclusion criteria. Women had a substantially higher risk of dyspepsia than men (14 per 1000 per year vs 10 per 1000; p < .001), and the incidence of dyspepsia increased with age such that persons in their seventh decade had almost twice the risk of those aged 18-29. Hispanic persons had a significantly higher risk of dyspepsia and positive H. pylori testing. Dyspepsia cases had a higher prevalence of other chronic comorbidities than their matched controls. Dyspepsia patients had healthcare costs 54% higher than controls even before the diagnosis was made, and costs in the initial diagnostic period were $483 greater per person, but subsequent costs were not greatly affected. Among those aged 55 and younger, the "test and treat" approach was used in 53% and another 18% had an initial esophagogastroduodenoscopy, as compared to 47 and 27%, respectively, among those over the age of 55.

CONCLUSIONS

Women and older adults have a higher incidence of dyspepsia than previously appreciated, and Hispanics in this region also have a higher risk. Current guidelines for dyspepsia evaluation are only loosely followed.

Reasons for non-use of proven pharmacotherapeutic interventions: systematic review and framework development

RATIONALE, AIMS AND OBJECTIVES

The quality of patient care and safety is dependent on addressing both errors of commission (e.g. overuse of medications) and errors of omission (e.g. patients receiving too little care). Despite guidelines recommending the use of certain proven pharmacotherapeutic interventions, a large gap exists between the patients that have an indication for, and those that actually receive such interventions. To address how the rate of implementation of proven interventions can be improved is dependent on a comprehensive knowledge of the factors contributing to their underuse. The aim of the review is to create an evidence-based framework of reasons why eligible patients do not receive proven pharmacotherapeutic interventions.

METHODS

A systemic review of the published reasons for non-use based on the Cochrane methodology.

RESULTS

The systematic review identified 67 articles meeting the inclusion criteria. The reasons for non-use were extracted from the studies and a framework was created from the results.

CONCLUSIONS

The factors associated with lack of implementation of proven pharmacotherapeutic interventions are complex and heterogeneous but can be understood from the perspectives of clinicians, patients and health care delivery systems. Efforts to increase the utilization of proven interventions should focus on disease/intervention-specific programmes that take into account the identified modifiable clinician, patient and system factors.

Efficacy of a simethicone, activated charcoal and magnesium oxide combination (Carbosymag®) in functional dyspepsia: results of a general practice-based randomized trial

BACKGROUND

A simethicone, activated charcoal and magnesium oxide combination (Carbosymag(®)) has been used for almost 20 years in functional dyspepsia, but there is limited scientific evidence of efficacy.

AIM

We evaluated the efficacy of Carbosymag(®) in 18- to 49-year-old patients with functional dyspepsia.

METHODS

A total of 276 dyspeptic patients consulting a general practitioner and meeting the Rome III criteria were included in this prospective placebo-controlled study. Variations in overall and individual dyspeptic symptoms were evaluated after 1 month of treatment.

RESULTS

At the end of the treatment period, overall dyspeptic symptom intensity was significantly lower in the Carbosymag(®) group (P=0.01). The intensity of post-prandial fullness, epigastric pain, epigastric burning and abdominal bloating was significantly reduced in the Carbosymag(®) group relative to the placebo group (P<0.05). The number need to treat to induce a 70-% decrease in overall dyspeptic symptoms by Carbosymag(®) was 7 (IC 95%: 4-32).

CONCLUSION

A simethicone, activated charcoal and magnesium oxide combination (Carbosymag(®)) was significantly more effective than a placebo on overall symptom intensity in dyspeptic patients consulting a general practitioner.

Practice patterns for the evaluation and treatment of eosinophilic oesophagitis

BACKGROUND

Although consensus guidelines for eosinophilic oesophagitis have been published, it remains unclear whether gastroenterologists follow these recommendations.

AIM

To assess academic and community practice patterns for the evaluation and treatment of eosinophilic oesophagitis and to compare these practices with current guidelines.

METHODS

This was a prospective study of academic and community gastroenterologists using a self-administered online survey.

RESULTS

A total of 60% (34 of 57) of academic and 29% (38 of 133) of community gastroenterologists completed the survey. Only 24% of academic and 3% of community gastroenterologists follow consensus guidelines to diagnose eosinophilic oesophagitis (P = 0.007). A proton pump inhibitor trial or negative pH study prior to diagnosis was required by just 25% of all gastroenterologists. A majority (60%) do not use the recommended threshold of 15 eosinophils per high powered field to diagnosis eosinophilic oesophagitis. Half (51%) mistakenly require a positive endoscopic finding. For first-line treatment, about half of the gastroenterologists surveyed treat with a swallowed topical steroid (53% academic, 56% community; P = N.S.), consistent with the guidelines.

CONCLUSIONS

There is variability in practice patterns for both diagnosis and treatment of eosinophilic oesophagitis. Ongoing education and research concerning diagnosis and treatment are needed.

Measuring quality of care in patients with nonvariceal upper gastrointestinal hemorrhage: development of an explicit quality indicator set

OBJECTIVES

With an increasing emphasis on quality in health care and recognition of inconsistencies in the management of patients with nonvariceal upper gastrointestinal hemorrhage (NVUGIH), it is critical to establish a set of explicit quality indicators (QIs) in NVUGIH.

METHODS

We conducted a nine-member, multidisciplinary expert panel and followed modified Delphi methods to systematically identify a set of QIs for NVUGIH. The panel performed independent ratings of each candidate QI using a nine-point RAND appropriateness scale, then met in person and re-voted using an iterative process of discussion. The final set comprised QIs with a median RAND Appropriateness Score >or=7 and no disagreement among experts.

RESULTS

Among 116 candidate QIs, the panel rated 26 as valid measures of quality care. The selected QIs cover pre-endoscopy, endoscopy, and post-endoscopy care, including diagnosis, early resuscitation, risk stratification, endoscopic care, Helicobacter pylori management, and proton pump inhibitor therapy.

CONCLUSIONS

We have developed an explicit set of evidence-based QIs in NVUGIH, providing physicians and institutions with a tool to identify processes amenable to quality improvement. This tool is intended to be applicable in all institutions providing care for NVUGIH patients.

Is irritable bowel syndrome a diagnosis of exclusion?: a survey of primary care providers, gastroenterologists, and IBS experts

OBJECTIVES

Guidelines emphasize that irritable bowel syndrome (IBS) is not a diagnosis of exclusion and encourage clinicians to make a positive diagnosis using the Rome criteria alone. Yet many clinicians are concerned about overlooking alternative diagnoses. We measured beliefs about whether IBS is a diagnosis of exclusion, and measured testing proclivity between IBS experts and community providers.

METHODS

We developed a survey to measure decision-making in two standardized patients with Rome III-positive IBS, including IBS with diarrhea (D-IBS) and IBS with constipation (C-IBS). The survey elicited provider knowledge and beliefs about IBS, including testing proclivity and beliefs regarding IBS as a diagnosis of exclusion. We surveyed nurse practitioners, primary care physicians, community gastroenterologists, and IBS experts.

RESULTS

Experts were less likely than nonexperts to endorse IBS as a diagnosis of exclusion (8 vs. 72%; P<0.0001). In the D-IBS vignette, experts were more likely to make a positive diagnosis of IBS (67 vs. 38%; P<0.001), to perform fewer tests (2.0 vs. 4.1; P<0.01), and to expend less money on testing (US$297 vs. $658; P<0.01). Providers who believed IBS is a diagnosis of exclusion ordered 1.6 more tests and consumed $364 more than others (P<0.0001). Experts only rated celiac sprue screening and complete blood count as appropriate in D-IBS; nonexperts rated most tests as appropriate. Parallel results were found in the C-IBS vignette.

CONCLUSIONS

Most community providers believe IBS is a diagnosis of exclusion; this belief is associated with increased resource use. Experts comply more closely with guidelines to diagnose IBS with minimal testing. This disconnect suggests that better implementation of guidelines is warranted to minimize variation and improve cost-effectiveness of care.