Use of H2-receptor antagonists in patients with dyspepsia and heartburn: a cost comparison

The benefit of negative tests in non-ulcer dyspepsia

OBJECTIVES

Negative diagnostic tests are usually evaluated by their ability to advance a diagnostic search, or they are considered redundant expenditures in establishing a definitive diagnosis. It has remained difficult to assess their benefit in terms of their own merit and the reassurance that they provide to a patient. The aim of the present study is to develop a mathematical model for quantifying the impact of diagnostic tests on a patient's health-related quality of life (HRQL).

METHODS

An influence diagram is used to model how non-ulcer dyspepsia (NUD) and its medical care affect HRQL. Diagnostic tests and medical therapy benefit HRQL by alleviating fear of disease and NUD symptoms. Medical care can also adversely affect HRQL, lead to expenses in time and money, and compromise a patient's sense of autonomy. HRQL is modeled as the focal point of multiple influences detracting from its value.

RESULTS

Negative diagnostic tests can improve HRQL in NUD. The improvement of HRQL by diagnostic tests depends on a multitude of individual influences and the interactions between them, such as the severity of NUD symptoms andfear of disease, as well as the impact of medical care itself on HRQL. If a patient harbors a strong fear of serious disease or cancer, more extensive testing is likely to improve the patient's well-being and appears a worthwhile endeavor. Other patients, however, would be served perfectly well by empirical therapy only. For the vast majority of subjects with NUD who never seek medical advice, the unpleasantness of the disease itself does not outweigh the anticipated downside of obtaining medical care.

CONCLUSION

The analysis illustrates the applicability of the influence diagram in modeling disease behavior. This method helps to assess the benefit of negative tests beyond their means of generating information.

Current indications for acid suppressants in dyspepsia

Anti-secretory drug use is common in patients with uninvestigated and functional dyspepsia, but the value of such agents has been controversial. Four large studies have evaluated the symptomatic outcome after a short course of acid inhibition in patients with uninvestigated dyspepsia presenting in primary care. All of these studies demonstrated a superior symptom response to proton pump inhibitor therapy compared with placebo and acid-alginates or H(2)-receptor antagonists. In patients with documented functional dyspepsia, 17 parallel group trials have evaluated an H(2)-receptor antagonist against placebo, with mixed results. A recent Cochrane review based on eight controlled trials concluded that there was a significant benefit of H(2)-blockers over placebo with a relative risk reduction of 30%, but as gastro-oesophageal reflux disease was not excluded, the conclusions are questionable. Six controlled studies have compared symptom relief after a short course of proton pump inhibitor therapy compared with placebo. Overall, there does appear to be a therapeutic gain with proton pump inhibitors over placebo, although how much of this is explained by undiagnosed gastro-oesophageal reflux disease remains unclear. There is conflicting evidence on the value of symptom subgrouping as a predictor of response to acid suppression. Overall, there is little convincing evidence that Helicobacter pylori infection influences the therapeutic outcome of acid-suppressant therapy. In conclusion, there appears to be a subgroup of patients with functional dyspepsia who will respond to acid suppression over and above placebo, but further work is required to characterize these responders.

What have we learned from recent dyspepsia trials?

Dyspepsia is a common disorder and a frequent complaint of patients presenting for primary care. Understanding of the role of Helicobacter pylori has led to re-evaluation of management strategies for these patients. This article highlights results from clinical trials that have helped to clarify the role of empiric therapy, endoscopy, radiography, and H. pylori eradication in patients with nonulcer dyspepsia.

Helicobacter pylori test-and-eradicate versus prompt endoscopy for management of dyspeptic patients: a randomised trial

BACKGROUND

Strategies based on screening for Helicobacter pylori to manage dyspeptic patients in primary care have been proposed, but the clinical consequences are unclear. We did a randomised trial to assess the efficacy and safety of a test-and-eradicate strategy compared with prompt endoscopy in the management of patients with dyspepsia.

METHODS

500 patients presenting in primary care with dyspepsia (> or = 2 weeks of epigastric pain, no alarm symptoms) were assigned H. pylori testing plus eradication therapy or endoscopy. Symptoms, quality of life, patients' satisfaction, and use of resources were recorded during 1 year of follow-up.

FINDINGS

250 patients were assigned test-and-eradicate, and 250 prompt endoscopy. The median age was 45 years and 28% were H. pylori infected. 1 year follow-up was completed by 447 patients. We found no differences in symptoms between the two groups (median registered days without dyspeptic symptoms=0.63 [IQR 0.27-0.81] in the test-and-eradicate group vs 0.67 [0.36-0.86] in the prompt endoscopy group; mean difference 0.04 [95% CI -0.01-0.10], p=0.12). Nor did we find any difference in quality of life or numbers of sick-leave days, visits to general practitioners, or hospital admissions. In the test-and-eradicate group, 27 (12%) of the patients were dissatisfied with management, compared with eight (4%) in the endoscopy group (p=0.013). After 1 year, the use of endoscopies in the test-and-eradicate group was 0.40 times (95% CI 0.31-0.51) the use in the endoscopy group, the use of H. pylori tests increased by a factor of 8.1 (5.7-13.1), the use of eradication treatments increased by a factor of 1.5 (0.9-2.7), and the use of proton-pump inhibitors was 0.89 (0.59-1.33) times the use in the endoscopy group. 43 (91% [80-98%]) of 47 peptic-ulcer patients would have been identified by endoscopy or treated by eradication therapy.

INTERPRETATION

A H. pylori test-and-eradicate strategy is as efficient and safe as prompt endoscopy for management of dyspeptic patients in primary care, although fewer patients are satisfied with their treatment.

Review article: the initial management of uninvestigated dyspepsia in younger patients-the value of symptom-guided strategies should be reconsidered

Several major management guidelines on dyspepsia (upper abdominal pain or discomfort) recommend an initial 'test-and-treat' policy (non-invasive Helicobacter pylori testing with eradication therapy if positive) in uninvestigated patients less than about 45 years old. However, the evidence that this is the optimal strategy is limited. Data from the few available randomized controlled trials provide evidence that this policy improves symptomatology more than a 'test-and-endoscope' approach (in which only H. pylori-positive patients undergo early endoscopy) in those with upper abdominal pain. The balance of cost-effectiveness data from clinical studies and decision analyses indicates that both 'test-and-treat' and empirical anti-secretory therapy approaches are more cost-effective than the 'test-and-endoscope' strategy. Therefore, given concerns about the safety of widespread H. pylori eradication, initial empirical anti-secretory therapy may be a cost-effective alternative to the 'test-and-treat' policy in some younger dyspeptic patients. The effectiveness of such an empirical approach might well be improved by symptom-guided therapy and there is growing evidence that the predominant dyspeptic symptom may provide this guide. The diagnostic, therapeutic and economic utility of this approach merits further clinical investigation.

The effectiveness of endoscopy in the management of dyspepsia: a qualitative systematic review

PURPOSE

Dyspepsia is a common primary care condition, yet its optimal management is poorly defined. We reviewed the literature to answer the following questions about patients with dyspepsia: 1) Does endoscopy result in improved patient outcomes? 2) Does endoscopy result in a reduction in the use of subsequent medical resources? 3) Does endoscopy result in improved medical decision making? 4) Is endoscopy cost effective?

METHODS

We performed a systematic review of English-language articles in the MEDLINE, HEALTHSTAR, and EMBASE computerized bibliographic databases from January 1985 to July 1998. We included all studies, including decision analyses, with information about the effectiveness of endoscopy, as measured by its impact on patient outcomes, resource utilization, clinical decision making, or cost effectiveness. Two independent reviewers abstracted data from each study, and assessed its methodologic quality.

RESULTS

Twenty-one studies met the inclusion criteria. For 3 of the 4 clinical questions, the weight of evidence does not support the effectiveness of endoscopy. The largest randomized clinical trial comparing endoscopy with empiric therapy demonstrates equivalent symptoms and quality of life at 1 year, with increased patient satisfaction and lower costs for initial endoscopy. Suboptimal study design, including lack of appropriate comparison groups, limit studies measuring the impact of endoscopy on resource utilization and decision-making. Decision analyses indicate that noninvasive H pylori testing followed by anti-H pylori therapy or empiric antisecretory therapy is more cost effective than initial endoscopy.

CONCLUSIONS

With the exception of one randomized clinical trial, the preponderance of available data does not support the effectiveness of endoscopy in the management of dyspepsia. Prospective clinical trials that evaluate patient outcomes and resource utilization, and take H pylori status into account, are needed to determine the effectiveness of endoscopy in the management of dyspepsia.

Meta-analysis of antisecretory and gastrokinetic compounds in functional dyspepsia

In view of therapeutic advances, we carried out meta-analysis of results from 18 randomized, controlled clinical studies to update a previous meta-analysis and to provide an overview of clinical trials involving treatment of functional dyspepsia. The studies were included only if they satisfied inclusion and exclusion criteria and assessed treatment of functional dyspepsia with the antisecretory compounds cimetidine and ranitidine and the gastrokinetic compounds cisapride and domperidone. Outcomes of each of these trials were classified in terms of differences in therapeutic success between active treatment and placebo. For antisecretory treatments, the 95% confidence intervals for the difference in therapeutic success between active treatment and placebo were inconsistent for cimetidine, but analysis of both ranitidine trials gave favorable results. For the gastrokinetic compounds cisapride and domperidone, the differences in success rates were generally higher and more in favor of active treatment than placebo. By combining the results from both antisecretory treatments and comparing them with the combined results for gastrokinetic compounds, we observed that gastrokinetic compounds had a greater difference in success rates than did antisecretory agents. Overall, our meta-analysis shows that antisecretory treatment with cimetidine or ranitidine offers little advantage over placebo, whereas gastrokinetic treatment with cisapride or domperidone is significantly better than placebo for treatment of functional dyspepsia.

Lansoprazole 30 mg daily versus ranitidine 150 mg b.d. in the treatment of acid-related dyspepsia in general practice

AIM

To compare lansoprazole 30 mg daily with ranitidine 150 mg b.d. in the treatment of acid-related dyspepsia in general practice.

METHODS

In a double-blind, parallel group, randomized, mutlicentre study conducted in 32 general practices in the UK, 213 patients were randomized to receive lansoprazole 30 mg daily, and 219 to receive ranitidine 150 mg b.d., for 4 weeks. All patients had experienced symptoms of reflux-like or ulcer-like dyspepsia on at least 4 of the 7 days prior to the study; 75% had experienced dyspepsia in the past, and 74 of the lansoprazole patients and 77 of the ranitidine patients had documented histories of acid-related disorders, investigating by either radiology or endoscopy.

RESULTS

After 2 weeks 55% of the lansoprazole patients and 33% of the ranitidine group were symptom-free (P = 0.001, chi 2 = 7.12) with corresponding 4-week figures of 69% and 44%, respectively (P = 0.001, chi 2 = 18.03). Similar figures were found at both 2 and 4 weeks for daytime and night-time heartburn and epigastric pain scores; in the lansoprazole group, at 4 weeks, 80% of patients were free of daytime heartburn and 81% of night-time epigastric pain, compared with 55% (P = 0.001, chi 2 = 15.44) and 65% (P = 0.01, chi 2 = 6.10) in the ranitidine group.

CONCLUSION

Superior symptom relief for patients presenting with ulcer-like and reflux-like symptoms in general practice is provided by lansoprazole 30 mg daily compared with ranitidine 150 mg twice daily.

General practitioners' approach to dyspepsia. Survey of consultation frequencies, treatment, and investigations

BACKGROUND

The aim of this study was to investigate the frequency of patient visits for dyspepsia in primary care. The diagnostic approaches made and drug treatment given by general practitioners were recorded.

METHODS

In a cross-sectional study 36,230 patients over 15 years of age visited their health center in an area serving a population of 506,000 inhabitants, between 6 and 19 May 1991. The frequency of dyspepsia was 2.1% (n = 766). These patients formed the basis of this study.

RESULTS

The incidence of dyspepsia leading to a health center visit was 20.9/1000 inhabitants/year. Patients older than 45 years consulted their general practitioners for dyspepsia more often than younger patients. Men older than 45 years of age had had their symptoms longer before seeking medical advice than younger men or women of the same age (p = 0.03 and p < 0.05, respectively). In association with the first visit, older (over 45 years) patients were evaluated more frequently (p = 0.03) by upper gastrointestinal endoscopy than younger (15-44 years) ones. Upper abdominal ultrasound was performed almost as often as upper gastrointestinal endoscopy. Sucralfate was prescribed for dyspeptic symptoms more often than H2-blockers or omeprazole, which were mainly used in patients with a definitive diagnosis.

CONCLUSIONS

The frequency of medical visits for dyspepsia increased with age. Older men sought medical advice for dyspepsia after a longer delay than others. Upper abdominal endoscopy was performed in association with the first visit in older patients more often than in younger ones.

Problems with implementing guidelines: a randomised controlled trial of consensus management of dyspepsia

OBJECTIVE

To determine the feasibility and benefit of developing guidelines for managing dyspepsia by consensus between general practitioners (GPs) and specialists and to evaluate their introduction on GPs' prescribing, use of investigations, and referrals.

DESIGN

Randomised controlled trial of effect of consensus guidelines agreed between GPs and specialists on GPs' behaviour.

SETTING

Southampton and South West Hampshire Health District, United Kingdom.

SUBJECTS

179 GPs working in 45 practices in Southampton district out of 254 eligible GPs, 107 in the control group and 78 in the study group.

MAIN MEASURES

Rates of referral and investigation and costs of prescribing for dyspepsia in the six months before and after introduction of the guidelines.

RESULTS

Consensus guidelines were produced relatively easily. After their introduction referral rates for upper gastrointestinal symptoms fell significantly in both study and control groups, but no significant change occurred in either group in the use of endoscopy or radiology, either in terms of referral rates, patient selection, or findings on investigation. No difference was observed between the control and study group in the number of items prescribed, but prescribing costs rose by 25% (from 2634 pounds to 3215 pounds per GP) in the study group, almost entirely due to an increased rate of prescription of ulcer-healing agents.

CONCLUSION

Developing district guidelines for managing dyspepsia by consensus between GPs and specialists was feasible. However, their acceptance and adoption was variable and their measured effects on some aspects of clinical behaviour were relatively weak and not necessarily associated with either decreased costs or improved quality of care.