1. Endoscopy – Should Everyone Be Tested? Primary Care Management of Dyspepsia Symposium Roland Valori Consultant Gastroenterologist Gloucestershire Royal Hospital December 2003

2. What will be covered ·Specific issues ·Health economics of endoscopy

3. Specific issues ·Iron deficiency ·Positive coeliac serology ·B12 deficiency ·Age threshold for endoscopy ·Barrett’s oesophagus ·Gastric ulcer

4. Iron deficiency selecting patients for endoscopy ·All males ·All non-menstruating females ·Selected menstruating females: –positive coeliac serology –GI symptoms –Family history –? older patient

5. Positive coeliac serology ·Need for duodenal biopsy depends on –type of serology available –degree of suspicion of coeliac

6. Duodenal biopsy and coeliac serology when to endoscope Degree of suspicion of coeliac highmediumlow Anti-gliadin +yes - +/-no Anti- endomysial +yes - no TT- Glutaminase +yes +/- - no

7. B12 deficiency ·Always do –intrinsic factor antibodies –coeliac serology ·Follow rules for coeliac serology ·Barium follow through –if there are GI symptoms

8. ·“The challenge for GPs is to maximise detection of serious and treatable disease while minimising cost and adverse effects of investigation” Logan and Delaney, BMJ 2001;323:695-7

9. Number of significant symptoms at time of diagnosis No of Patients = 25 Wt loss14 Dysphagia8 Anaemia7 GI Bleed3 Previous surgery3 Mass3 Perforation1 Cerebral mets1 No of Symptoms No of Patients Christie et al, Gut 1997;41:513-7

10. The threshold should be 55 the evidence ·Christie et al, Gut 1997;41:513-7 ·Gillen et al, Am J Gastroenterol 1999;94:75-9 ·Effective Health Care bulletin 2000: Volume 6 ·Two-week wait rule for upper GI cancer –http://www.doh.gov.uk/cancer ·Draft NICE guidelines 2003

11. Barrett’s oesophagus ·Two issues –surveillance endoscopy of Barrett's to identify early cancer –screening patients with GORD to identify Barrett's suitable for surveillance

12. BSG Barrett’s oesophagus guidelines “it is recommended that endoscopic surveillance every 2-3 years should be considered in patients with endoscopically visible CLO, particularly those fit enough to undergo oesophagectomy should HGD or carcinoma be detected” Draft guidance

13. BSG Barrett’s oesophagus guidelines ·Surveillance recommendation is based on case series evidence ·Cost-effectiveness is highly sensitive to annual incidence of carcinoma in Barrett's –>1% not too expensive –0.5-1.0% £62,000/QALY –<0.5% prohibitively expensive incidence 0.26-0.4%: BMJ 2003; 326:892-4

14. Endoscopy and bowel cancer ·Using endoscopy as part of a screening strategy, mortality from bowel cancer can be reduced by 15% endoscopy can prevent bowel cancer

15. Effect of FOBT screening on incidence of colorectal cancer New cases of CRC Odds ratioConfidenc e interval control507 annual screening 4170.800.70 – 0.90 biennial screening 4350.830.73 – 0.94 NEJM 2000;343:1603-07

16. Bowel cancer screening ·In November 2002 Alan Milburn announced that there would be a bowel cancer screening programme –£1300 – 2500/QALY –£23 – 42 million/year

17. Bowel cancer screening ·Endoscopic workload expressed as procedures or sessions per year per million population: Screening method FOBTFS flexible sigmoidoscopy 06000 colonoscopy (at steady state) 1500450 ‘endoscopy sessions’ 300690 10% increase 20% increase

18. Waiting list: second wave pilot site X (population of 330,000) total waiting = 937 waiting >13 weeks= 247

19. Implementing screening ·Not until the symptomatic service is ‘sorted’: –modernisation of endoscopy services –more and better trained endoscopists –quality assurance process @

20. Modernisation ·Is all about –getting it right for the patient –using capacity efficiently –controlling demand using cost/benefit evidence –resourcing the demand capacity gap properly

21. Modernisation ·Is all about –getting it right for the patient –using capacity efficiently –controlling demand using cost/benefit evidence –resourcing the demand capacity gap properly

22. Annual open access endoscopy referral rate for West Gloucestershire GP practices (1996-7) Endoscopy referrals per 1000 patients per year Practices (Intervention arm of serology RCT) 2x2x 4x4x 0.65%/year 1x

23. Endoscopic findings in a random adult population ·Sweden ·Random sample invited for OGD* ·1001/1363 accepted ·Age range 20-81 ·Mean age 53.5 ·51.3% women * Independent of symptoms Aro P et al, DDW 2002

24. Endoscopic diagnosis Stroud (344) Sweden (1001) Forest of Dean (391) Waldon, Aro and Wilkinson Stroud and FOD - symptom-based selection Swedish study - random selection

25. Problems with nihilistic approach ·Dealing with people ·Dealing with GPs who are dealing with people ·Endoscoping influences behaviour, it may lead to: –reduced worry –fewer symptoms –reduced consultation –reduced medication use

26. Alternative strategies to manage dyspepsia ·Early endoscopy ·Empirical treatment ·Test and treat ·Test and ‘scope

27. Alternative strategies to manage dyspepsia ·Early endoscopy ·Empirical treatment ·Test and treat ·Test and ‘scope Choices Health economics

28. Choices (decisions) Efficacy Cost Resource Beliefs Willingness to pay Perspectives

29. Cost Efficacy LOSER WINNER x

30. Cost £ Efficacy Patient Sx-free at 12/12 BMJ 2002;324:1012-6 T/T vs treat Endo vs treat >50 T/T vs Endo Endo vs treat <50 x x

31. Conclusions ·Do not ignore iron deficiency

32. Conclusions ·Beware of Barrett's propaganda –surveillance can do harm as well as good –we do not know the balance of good and harm –cost-effectiveness depends on the incidence of cancer in the population surveyed Whatever, it is hugely expensive compared with other interventions

33. Conclusions ·Early endoscopy for patients with dyspepsia aged >55 –it appears to be ‘cost-effective’ –cancer is much more likely to be found

34. Conclusions ·For younger patients: –if typical reflux symptoms treat empirically –if non-specific dyspepsia test for Hp and treat –endoscope if patient or doctor has concerns about cancer patient needs to take regular NSAIDs

35. Conclusions ·If you want to save the life of a patient with dyspepsia arrange a flexible sigmoidoscopy

36. Hp and reflux disease ·The net effect is to reduce the number of subjects with milder GORD symptoms, but to increase the (smaller) number with more severe symptoms Richard Harvey, DDW/SWGG 2002