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

3. Dyspepsia - Scale of the Problem Population Primary care Secondary care Health care system (and it depends what you call dyspepsia)

4. 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?

5. Prevalence of Dyspepsia in the Community AuthorsSettingPrevalenceDefinition Westbrook and Talley 2002 NSW, Australia11 – 36% Depends… Penston and Pounder 1996 UK40% Dyspepsia and GORD (frequent overlap) Haque et al. 2000New Zealand45.2% Dyspepsia = 34.2%. GORD = 30% (frequent overlap) Kennedy and Jones 2000 UK28.7% GORD

6. 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

7. Dyspepsia in Secondary Care Emergency admissions OPD(s) Provision of diagnostic facilities (why?)

8. 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

9. ENDOSCOPY CAPACITY IN THE UK

10. Total Nos. Diagnostic OGDs By Year John Radcliffe Hospital, Oxford

11. 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)

12. Dyspepsia Subtypes Ulcer-like Reflux-like Dysmotility-like “Uncharacteristic and relapsing dyspepsia”

13. 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

14. 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

15. 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

16. Presence of Alarm Symptoms AgeUnder 45Under 55 Number with upper GI Ca. 21/34165/341 Number with alarm symptoms 20/2160/65 Retrospective review of notes of patients diagnosed with UGI cancer Canga and Vikil 2002

17. GI Cancer Presentation to the Individual GP Oesophagus1 every 5 years Stomach1 every 2 - 3 years Pancreas1 every 4 years Colorectal1 every 1 - 2 years

18. 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

19. 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

20. 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