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Dyspepsia Impact On Primary Care

Dyspepsia Impact On Primary Care. Dr Paul Pickering GP, Bridlington Prescribing Lead YW&C PCT. Overview. The scale of the problem in primary care The cost of dyspepsia Practice-based dyspepsia clinics. The Scale of the Problem.

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Dyspepsia Impact On Primary Care

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  1. Dyspepsia Impact On Primary Care Dr Paul Pickering GP, Bridlington Prescribing Lead YW&C PCT

  2. Overview • The scale of the problem in primary care • The cost of dyspepsia • Practice-based dyspepsia clinics

  3. The Scale of the Problem • Dyspepsia prevalence 40% population • National data shows 3-5% population present to their GP with symptoms • Consultation rates of 355 per 10000 pt yrs at age 25-44 to 789 per 10000 pt yrs at age 75-84 • Population surveys imply 10% seek assistance from their GP • 1% population referred for endoscopy

  4. GI Drug Spend

  5. Cost of Dyspepsia • £1.2 billion/yr with a cost growth of 8-9% • 19 million prescriptions for PPIs • PPIs account for 34% of the volume but 83% of the NHS upper GI spend • Alginates are 41% of the volume and 4% of the NHS upper GI spend • 40% of PPIs are being prescribed to long term users • Maintenance dose PPI represents the minority

  6. Cost of Dyspepsia

  7. Cost of Dyspepsia Recorded reasons for long term PPI use • Oesophagitis(2) 17% • Reflux 40% • Non-specific dyspepsia 30% • Peptic ulcer disease 3% • Oesophageal ulcer/stricture 2% • Non-GI problems 1%

  8. Cost of Dyspepsia Findings at endoscopy • Normal 30% • Mild inflammation/HH 30% • Oesophagitis 10-17% • Malignancy 2-3% • DU 10-15% • GU 5-10%

  9. National GORD Data PPI Increase = £10,468,167

  10. National GORD Data PPI Increase = 951,738 Rx (8.6%)

  11. National PPI Treatment Versus Maintenance Value Split

  12. National PPI Treatment Versus Maintenance Volume Split

  13. Current NICE Guidance • Patients with mild symptoms of dyspepsia may be treated on either a step-up or step-down basis • These patients should not normally be treated with a PPI on a long-term basis without a confirmed clinical diagnosis • Patients with mild GORD symptoms and/or no proven pathology, can be frequently managed by alternative therapies such as alginates • All doctors prescribing PPIs will need to review the indications for their use and assess the dose, with the aim of reducing or stopping them where appropriate

  14. Cost of Dyspepsia • Estimated that if this guidance was implemented it could lead to a reduction in PPI prescribing by at least 15% and save the NHS £40-50M/yr • Reality is that the prescribing of PPIs for GORD and related conditions has increased by £102M since the guidance was published

  15. Cost of Dyspepsia Apart from the financial implications are there any other costs relating to the prescribing of PPIs long term in the treatment of dyspepsia syndromes?

  16. Cost of Dyspepsia • Acid breakthrough day and night – 28% night-time, 17% after a heavy meal, and 8% daytime • Safety and licence • Masking of alarm symptoms • Super secretion??? • Abandoning lifestyle modifications

  17. Practice-based Dyspepsia Clinics • Nurse-led • Stepped protocol • NICE guidelines • Systematic review of all patients on PPIs • Patient education, awareness & involvement • Promotion of a healthy lifestyle • GP time freed up

  18. Practice-based Dyspepsia Clinics • Stepping-down appropriate patients from treatment to maintenance dose PPI • Stepping-off appropriate patients from maintenance dose PPI to an alginate e.g. Gaviscon Advance • Can significant prescribing savings be achieved?

  19. Practice-based Dyspepsia Clinics PCTS SHARING DATA • Bexley • Brighton and Hove City • Hartlepool • North Lincolnshire – Scunthorpe Study • Yorkshire Wolds & Coast – Field House Surgery Project

  20. Field House Surgery Project • GP agreement on process and protocol • Database search on all PPI’s • Establish a disease register • Identify patients from inclusion criteria • Send letters to all included patients explaining changes to medication and offering nurse-led dyspepsia clinics • Dyspepsia clinics • Audit results

  21. Field House Surgery Project INCLUSION CRITERIA • GORD • Reflux oesophagitis up to grade 2 • Hiatus hernia • Patients who have completed ulcer healing treatment • Non-ulcer dyspepsia • Uninvestigated dyspepsia

  22. Field House Surgery Project EXCLUSION CRITERIA • Patients on treatment <3 months • Patients awaiting referral or under the care of a consultant • Barrett’s oesophagus and strictures • Reflux oesophagitis >grade 2 • Patients >90yrs • Terminal illness • Immunosuppression therapy

  23. Field House Surgery Project PATIENT SELECTION • 503 patients on PPIs • 246 patients satisfy inclusion criteria • 81 patients to be stepped-down • 165 patients to be stepped-off

  24. STEP-OFF 165 patients 129 patients (78%) remain stepped-off at 4 months 117 patients (71%) remain stepped-off at 6 months STEP-DOWN 81 patients 66 patients (81%) remain stepped-down at 4 months 59 patients (73%) remain stepped-down at 6 months Field House Surgery Project

  25. Field House Surgery Project • PPI Cost Savings • £2465.96 per month • Potential per year is £29,591.52 • Overall Cost Savings • Total cost savings per month = £1790.96(PPI savings – cost of other treatments) • Potential cost savings for the year are £21,491.52 • 70%:30% maintenance:treatment dose PPI

  26. Scunthorpe Study • Step-Off • 58% successfully maintained on Gaviscon Advance at 10 months after transferring from rabeprazole 10 mg • 51% successfully maintained on Gaviscon Advance at 8 months after transferring from lansoprazole 15 mg • Step-down • 90% of patients remained on maintenance dose PPI after 7 months

  27. Scunthorpe Study • Overall Cost Savings • £14,744 projected over the year

  28. Practice-based Dyspepsia Clinics • Establishing a process of review supported by NICE guidance. • Improving patient management • Breaking the cycle of long term PPI use • Cost effective and appropriate prescribing • Savings released to meet anticipated growth in prescribing relating to NSF targets and the new GMS contract

  29. Dyspepsia Clinics and the New GMS Contract • Records & information about patients - recording smoking status • Medicines management - medication reviews/meeting PCO prescribing advisor • Patient experience - patient surveys

  30. Summary and Conclusions • The scale of the problem in primary care - high prevalence 40% population • The cost of dyspepsia - £548M/yr PPIs/83% upper GI spend • Practice-based dyspepsia clinics - Cost-effective and evidence-based review of patients with chronic or relapsing symptoms

  31. DyspepsiaImpact on Primary Care Dr Paul Pickering GP Bridlington Prescribing Lead YW&C PCT

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