Do Primary Care Physicians Underprescribe Antibiotics for Peptic Ulcer Disease?

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Original Research

Do Primary Care Physicians Underprescribe Antibiotics for Peptic Ulcer Disease?

J Fam Pract. 2002 March;51(3):249-253

By

Leonardo Palombi, MD

Report from an Italian Research Network

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References

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ABSTRACT

OBJECTIVE: To determine how often primary care physicians prescribe eradication therapy for peptic ulcer disease (PUD) and nonulcer dyspepsia (NUD).

STUDY DESIGN: During a 2-year period (1998–2000) we analyzed data concerning patients with PUD or NUD seen by 80 Italian primary care physicians uniformly distributed throughout the country. We classified patients as having a definitive or presumptive diagnosis on the basis of the completeness of the diagnostic workup and interpreted the prescription of antibiotics for dyspepsia as evidence of attempted eradication of Helicobacter pylori.

POPULATION: Consecutive ambulatory patients.

OUTCOME MEASURED: The frequency with which predefined groups of patients received eradication therapy.

RESULTS: Of 6866 patients, 690 (10%) received eradication therapy. Of 2162 patients with PUD, 596 (27.6%) received eradication therapy; of 4704 patients with NUD, however, only 94 (2%) received this treatment (P = .0001). A total of 341 (37.7%) of 904 PUD patients with a definitive diagnosis were given eradication therapy and 255 (20.3%) of 1258 PUD patients with a presumptive diagnosis were given therapy (P < .0001). In NUD patients, 7 of 743 (0.9%) with a definitive diagnosis received eradication therapy, while 87 (2.2%) of 3961 of those with a presumptive diagnosis received the same therapy (P = 0.025).

CONCLUSIONS: While Italian primary care physicians appropriately target eradication therapy for H pylori infection in patients with peptic ulcer disease rather than nonulcer disease, the intervention was still underused in these patients. Improvements in this prescribing behavior are needed.

Data from the medical literature^1-3 and from 2 ad hoc international consensus conferences^4,5 suggest that antibiotic therapy aimed at eradication of Helicobacter pylori causes persistent healing of peptic ulcer and should therefore be the treatment of choice for patients with peptic ulcer disease (PUD). While administering eradication therapy to H pylori–positive patients with nonulcer dyspepsia (NUD) remains under debate,^6,7 such therapy is generally not recommended.

How these findings are used in clinical practice is largely unknown. Two surveys have reported rates of eradication therapy given by primary care physicians (PCPs) of close to 90% in PUD patients and 50% in NUD patients.^8,9 This information is strongly biased, however, in fact that it was derived from answers to specific questions asked by mail. Responses indicate treatment under ideal conditions rather than real ones. To our knowledge, no reliable analysis on this subject is available.

Our work evaluated the frequency with which eradication therapy was administered in Italy to dyspeptic patients with and without PUD from September 1998 to September 2000. We assessed whether the performance of a complete diagnostic workup affected the rate at which eradication therapy was prescribed. We also evaluated the combination therapies that physicians used.

Methods

The study population included 7336 patients with a PCP’s diagnosis of PUD or NUD from September 1998 to September 2000. A total of 470 (6.4%) of these patients were referred to a gastroenterologist and excluded, leaving a final study population of 6866 patients.

Selection of physicians and data collection

In 1994, software designed by a team of epidemiologists and computer experts from Tor Vergata University, Rome, Italy, was given to 19,000 Italian PCPs. The software was designed to help physicians collect data from their patients during each visit.¹⁰ Data on the number of visits to PCPs during 1993 were obtained. One year later, 2000 physicians agreed to compare the percentage of patients included in their database with the total number of visits and to return their accumulated databases for quality control.

Among the 371 physicians with a quality database of good quality (defined as including at least 95% of their patients in the database and declaring a similar number of patients as in the previous year, 1993), 120 agreed to participate in our study. New software was designed to gather data concerning the performance of eradication therapy for H pylori in the past, the requests and results of upper gastrointestinal endoscopy and abdominal sonography, and the prescribed treatment. The diagnosis was required in the database (ie, it was not possible to have access to subsequent fields in the absence of these data). Furthermore, the software was able to recognize the pharmacologic class of each drug from its generic name. Regarding antibiotic prescriptions for patients in whom a diagnosis of PUD or NUD had been made, the physician was asked if the treatment was intended for the diagnosed disease or for unrelated conditions.

From the start of the study, physicians were asked to include in the new database all patients coming to the office for an initial visit to evaluate dyspepsia of at least 3 months’ duration. If new data concerning diagnostic procedures or treatment emerged during subsequent visits, these were added to the database. It was possible for the PCP to change the diagnosis on the basis of new findings. The diagnosis made during the last visit was considered the final diagnosis.