ABSTRACT
OBJECTIVES: A considerable proportion of the medication budget of Dutch general practitioners is spent on prescribed long-term acid suppressant drugs. We investigated the magnitude of long-term prescription of acid suppressant drugs in general practice and the frequency and means of confirming the primary working diagnosis.
STUDY DESIGN: We used a retrospective descriptive study of 24 general practices in the Amsterdam region.
POPULATION: We identified those receiving long-term acid suppressant therapy (12 or more weeks/year) from a total of 46,813 patients by extracting data from pharmacy databases.
OUTCOMES MEASURED: We measured the amount and duration of prescriptions for each medication, indications for prescription, and investigations performed by general practitioners.
RESULTS: Of the 46,813 patients, 922 (2%) received long-term acid suppressant therapy. The duration of prescription varied from 12 weeks in 8% of patients to > 52 weeks in 23% of patients (mean = 33 weeks). In 25% of patients, no investigations were performed; 75% of patients underwent endoscopy or ingested a barium meal. The predominant diagnoses in investigated patients were ulcer disease (39%), gastroesophageal reflux disease (49%), and functional dyspepsia (gastritis, normal aspect; 18%). Helicobacter pylori status was available in 29% of patients with ulcer disease. Eradication therapy was reported in 44% of these patients.
CONCLUSIONS: Among patients of physicians in general practice in the Amsterdam region, 2% used long-term acid suppressants. Patients with ulcer disease may stop taking acid suppressants after apparent successful H pylori eradication. Tapering strategies must be developed for patients with mild reflux disease or functional dyspepsia.
KEY POINTS FOR CLINICIANS
- In Dutch general practice, 2% of patients take long-term acid suppressant drugs.
- One third of patients taking long-term acid suppressant drugs have peptic ulcer disease and may not need medication as soon as Helicobacter pylori has been eradicated.
- One fourth of patients taking long-term acid suppressant drugs have never undergone endoscopy or barium study.
- Because patients often do not tolerate sudden cessation of chronic acid suppressant drug use, tapering strategies must be developed.
The average Dutch general practice includes approximately 2350 patients. Of these, 2 to 3 per week, on average, visit their general practitioner (GP) with a complaint of dyspepsia.1 According to the guidelines of the Dutch College of General Practitioners, the treatment of dyspepsia is directed toward symptom relief, usually on an empirical basis, except for patients with symptoms such as sudden weight loss or hematemesis that suggest cancer; these are referred for endoscopy.2 Medication is prescribed in a stepwise fashion from less potent antacids and prokinetics to the more potent H2-blockers and proton pump inhibitors. During our study, long-term treatment with acid suppressant drugs (ASDs) was indicated only for relapsing ulcers or ulcerlike complaints, relapsing esophagitis, and relapsing gastroesophageal refluxlike symptoms.2
ASDs are responsible for a disproportionate share of the medication budget of Dutch GPs because of their high cost, their high frequency of prescription, and their use on a long-term basis.3 We therefore wondered whether the indication for prescribing an ASD was always appropriate. The aim of our study was to describe how commonly ASDs are prescribed and to describe the initial working diagnosis, the diagnostic tests performed to confirm the working hypothesis, and the final diagnosis for each patient.
Methods
Patients
We retrospectively collected data from 24 general practices in Amsterdam from September 1994 to August 1995 on patients taking long-term ASDs (12 or more weeks during the previous year). ASDs included antacids, mucosa-protective agents, prokinetics, H2-blockers, and proton pump inhibitors.4
Patients were identified from a medication database obtained from all cooperating pharmacists that included patient demographics; type, dose, and duration of medications; and use of possible risk-bearing comedications (aspirin, nonsteroidal anti-inflammatory drugs, or prednisone for more than 6 weeks during the study year). In this way we were able to identify almost all patients from the participating general practices who received long-term treatment with ASDs.
Confirmation of gastrointestinal diagnosis
In the Netherlands, a GP receives all available medical information on his patients (ie, letters from specialists, results from any examinations performed) and stores this information in the patient’s medical history file. When a patient switches to another GP, the entire medical history is sent to this new physician. Our principal investigator used these medical history files to determine the diagnosis and reason for the ASD prescription and the diagnostic tests (including Helicobacter pylori investigations) that were ordered to confirm the working diagnosis. Gastroscopy or barium meal radiography at any time during a patient’s life was considered the investigation for confirmation of the diagnosis. If the prescription started after this investigation or as a consequence of it, the investigation was considered the reason for initiating the current long-term treatment. Verification and completion of the obtained data took place in a face-to-face evaluation between the principal investigator and the GP, ensuring the completeness and reliability of the data.