Work productivity improvement after acid suppression in patients with uninvestigated dyspepsia.

INTRODUCTION: Lost productivity accounts for a significant part of the costs caused by gastrointestinal symptoms. We aimed to describe selfreported productivity in patients presenting with dyspepsia. MATERIAL AND METHODS: Data were sourced from a randomized, double-blinded study of two weeks of esomeprazole 40 mg or placebo in 805 primary-care patients with uninvestigated dyspepsia. Work productivity was tested using the Work Productivity and Activity Impairment questionnaire. Treatment effect on work productivity loss was tested according to the likelihood of treatment response. RESULTS: A total of 401/805 employed patients were included in the analysis. The average work productivity loss in the past seven days was 10.5 working hours/week. The productivity loss grew with increasing severity of symptoms at baseline. Following two weeks of treatment, the mean improvement in work productivity was significantly higher for both absenteeism (1 hour versus 0.1 hour, p < 0.05) and presenteeism (5.3 hours versus 4.3 hours, p < 0.05) in patients treated with esomeprazole versus placebo. The most substantial improvement was seen in patients who, based on baseline symptoms, were assessed to be likely treatment responders. CONCLUSION: Dyspepsia symptoms represent a significant economic burden in terms of lost productivity. The RESPONSE algorithm is successful in determining which patients will benefit from acid suppression in terms of enhanced productivity.

Long-term outcome of multidisciplinary intervention of chronic non-cancer pain patients in a private setting.

Background and aim The present study reports on chronic non-cancer patients who were referred to a private pain clinic, according to a waiting time guarantee and treated within one month from referral. Based on evaluation by members of the multidisciplinary staff at our pain clinic a pain management program could be offered individually or as group therapy. Methods Health related quality of life, psychometric tests, use of pain medication; socio-economic status and number of consultations in general practice were recorded at referral to the clinic and by postal questionnaires at follow-up 21 months later. The primary treatment outcome (treatment success) was defined as an improvement of at least 40 points in the physical component and/or the mental component of SF-36 from baseline to follow-up. Secondary outcome measures were changes in Beck's Anxiety Inventory and Beck's Depression Inventory, use of analgesics, work status and transfer income and number of consultations at the GP's office due to the chronic pain condition. Results A total of 306 patients were included: 141 were treated individually and 165 were treated in groups. At follow-up, data were obtained from 189 patients (62%). Comparing baseline to follow-up data, 62% of group treated patients were treated successfully, compared with 41% of individually treated patients. Anxiety and depression were significantly improved in group treated patients but not in those treated individually. significantly more patients had work income (and less patients transfer income) among group treated, compared with individually treated. At follow-up use of antidepressants and anticonvulsants was increased whereas use of tranquilizers and strong opioids was decreased in all patients. Number of consultations at their GPs due to chronic pain was significantly reduced in all patients. Conclusions Multidisciplinary treatment in a private pain clinic seems to have a long-term effect in relation to biological, psychological and social aspects of the chronic pain condition. Treatments based on group therapy may offer better results than individual treatment courses. Implications The effect of group therapy should be explored further.

Functional dyspepsia: not all roads seem to lead to rome.

BACKGROUND: The Rome criteria have been introduced to create order in the heterogeneity of functional dyspepsia. The applicability of these symptom-based classification systems remains controversial. GOAL: To evaluate the successive Rome criteria for functional dyspepsia in a large pool of patients with endoscopically verified functional dyspepsia. STUDY: Patients referred to a secondary care district hospital were asked to fill out a questionnaire on gastrointestinal symptoms 2 weeks before upper gastrointestinal endoscopy. Patients were classified according to the Rome I, II, and III criteria for functional dyspepsia. RESULTS: Nine hundred and twelve (70%) patients had no organic disorder explaining their symptoms. According to the Rome I, II, and III criteria, 371 (41%), 735 (81%), and 551 (60%) of these patients had functional dyspepsia, respectively. Twenty-five percent of patients had functional dyspepsia according to all 3 Rome criteria, whereas 15% was not classifiable at all. Forty-four percent and 42% of the patients, respectively, had epigastric pain syndrome and postprandial distress syndrome according to the Rome III criteria; however, 26% of all patients met both criteria and 40% was not classified at all. CONCLUSIONS: The symptom-based Rome classification of functional dyspepsia does not lead to an easily applicable and consistent system that is useful in clinical practice or scientific research.

The diagnosis of IBS in primary care: consensus development using nominal group technique.

BACKGROUND: The criteria used to identify and diagnose irritable bowel syndrome (IBS) in primary care are unclear, even though most patients are managed entirely in this setting. OBJECTIVE: To use a validated method of consensus development [Nominal Group Technique (Rand version)] (NGT-R) in order to construct a diagnostic framework for IBS appropriate to primary care. METHODS: NGT-R is a formal method of consensus development, which uses structured interaction within a group combined with statistical derivation of group judgements. The group comprised 10 GPs with a special interest in gastroenterology and two gastroenterologists, from 10 European countries. Mailed questionnaires elicited judgements on 242 scenarios for the diagnosis of IBS, within four domains of symptoms, social and lifestyle features, psychological features and investigations. Feedback of group decisions was followed by structured face-to-face interaction and private rescoring of the questionnaire. Consensus was defined as 10/12 ratings within one of three bands, 1-3 (disagreement), 4-6 (equivocal) or 7-9 (agreement). RESULTS: The defining features of IBS in primary care are alteration in bowel habit, bloating and abdominal pain, or discomfort or annoyance (the last reflecting important cultural differences in symptom description). These symptoms need to be present for at least 4 weeks. Supportive characteristics include female sex, family history of IBS, frequent clinic attendances, a recent major life event and a history of somatization behaviours. Abdominal examination was considered necessary in all patients and rectal examination, haemoglobin estimation and colonoscopy in those aged > 55 years. The subtypes of IBS are recognized, but the diagnostic process differs only in minor ways. Final consensus was reached on 46% of statements. CONCLUSION: The basis of IBS diagnosis in primary care differs from, and is less exclusive than, existing criteria. Few features are deemed essential for diagnosis, while psychosocial features, patient characteristics and contextual factors are important in increasing diagnostic probability. There are important cultural differences in the description of key symptoms. These results provide information on the defining characteristics of IBS and the diagnostic process, as it occurs in primary care, and can guide clinical practice.

Empiric treatment with high and standard dose of omeprazole in general practice: two-week randomized placebo-controlled trial and 12-month follow-up of health-care consumption.

OBJECTIVES: Patients with acid-related symptoms in general practice are often treated empirically with a standard dose of proton pump inhibitors (PPIs). The effect of higher doses is not known. The study compared the immediate symptom relieving as well as the long-term effect of standard and double dose of omeprazole in such patients. METHODS: Consecutive patients with dyspeptic symptoms, normally treated by the general practitioner with PPIs or H2-blockers were randomized to treatment with omeprazole 40 mg, 20 mg, or placebo in the morning for 2 wk. Patients with alarm symptoms, IBS, and PPI-treated patients were excluded. Dyspeptic symptoms and Helicobacter pylori status were recorded. The study endpoint was complete relief of the dyspeptic symptoms, which initiated the consultation. Relapse rates and health-care consumption were recorded during 12-month observation. RESULTS: Eight hundred and twenty-nine patients were randomized. Complete relief of the predominant symptom was obtained by 66%, 63%, and 35% in patients treated with omeprazole 40 mg, 20 mg, and placebo, respectively. No difference was found comparing H. pylori-positive and -negative patients. Relapse rates were high and health-care consumption during 12 months was related to the treatment outcome, but not to the omeprazole dose or the H. pylori status. CONCLUSIONS: Compared to placebo, omeprazole 40 mg and 20 mg were equally and significantly better in relieving acid-related symptoms; the numbers needed-to-treat (NNT) were 3.2 (40 mg) and 3.7 (20 mg). Relief of the dyspeptic complaint was followed by significantly reduced health-care consumption during 12-month observation.

"Alarm symptoms" in dyspepsia. How does the general practitioner investigate?

OBJECTIVE: Alarm symptoms are present in 10% of patients consulting a general practitioner (GP) because of dyspepsia. The options for the GP are: perform "own" investigation, refer to a specialist or secondary care, or maintain watchful waiting. DESIGN: Postal questionnaire to GPs obtaining information from the records of patients who had consulted earlier owing to dyspepsia and reported one or more alarm symptoms at the consultation. SETTING: 92 general practices throughout Denmark. SUBJECTS: In 7240 consecutive consultations in 1991-1992 a total of 749 patients reported 881 alarm symptoms. Follow-up data 3 years later were obtained from 81%. MAIN OUTCOME MEASURES: The management of alarm symptoms by GPs: "own" investigation, referral to specialist, or expectance; procedures used in "own" investigations, patient characteristics related to such decisions, and gastrointestinal diseases diagnosed by this management. RESULTS: 67% of the patients with alarm symptoms were investigated promptly (8% by referral to specialists) and 33% were left uninvestigated, with great variations between alarm symptoms. The single most preferred GP investigation was endoscopy. A gastrointestinal diagnosis was obtained in 35% of the patients; 3% of these were malignancies while 9% were peptic ulcers. CONCLUSION: The decision on whether and how to investigate alarm symptoms is complex and relates to specific symptom, type of dyspepsia, age, gender and dwelling of the patient.