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Primary care of adults with chronic acid-related disorders could be improved if more doctors followed treatment guidelines

Individuals with acid-related disorders, including gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), and dyspepsia, account for 2-5 percent of all primary care visits. They also consume substantial health care resources, particularly for acid suppressing medication such as histamine-2 blockers (H2Bs) and proton pump inhibitors (PPIs). Primary care of older adults with chronic acid-related disorders could be improved if more physicians followed current treatment guidelines, according to findings from a study supported in part by the Agency for Healthcare Research and Quality (HS10391).

Because of the increased risk of gastric cancer in patients older than 45 or 50 years of age with upper gastrointestinal (GI) symptoms, current guidelines recommend that these patients be examined, preferably with endoscopy (a thin flexible tube is placed down the patient's esophagus, and a tiny camera is used to visualize the stomach and duodenum). Other guidelines recommend that PUD patients be tested and treated for infection with a type of bacteria, Helicobacter pylori (H. pylori), to prevent ulcer recurrence and complications. Yet about 80 percent of the 5,064 adults in a Massachusetts managed care organization (MCO) who were dispensed H2Bs, PPIs, or both for 1 year or more (chronic users) were not managed according to these guidelines.

Part of the reason these patients may have been under-investigated is because H2Bs and PPIs are so effective at relieving or at least controlling symptoms, suggest the Massachusetts researchers. They found that the prevalence of chronic acid-related disorders in the primary care MCO was 2.3 percent. GERD (59 percent) was the most common condition, followed by dyspepsia (35 percent) and PUD (6 percent). However, 81 percent of dyspepsia patients 50 years or older had not been investigated by endoscopy. Also, 34 percent of patients with chronic PUD did not have a documented test for H. pylori.

More details are in "Chronic acid-related disorders are common and underinvestigated," by Sumit R. Majumdar, M.D., M.P.H., Stephen B. Soumerai, Sc.D., Francis A. Farraye, M.D., M.Sc., and others, in the American Journal of Gastroenterology 98(11), pp. 2409-2414, 2003.

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