Abstract

The PhD study was carried out at the Department and Research Unit of General Practice, University of Aarhus. This dissertation aims to: 1) describe the prevalence and consultation rate of dyspepsia in Denmark, 2) describe the reasons to consult and not to consult general practice (GP) of people with dyspepsia, 3) evaluate the clinical efficacy of empirical therapy with proton pump inhibitors (PPI) versus endoscopy for management of dyspepsia in primary care and 4) evaluate the cost-effectiveness of the two strategies.

The descriptive part of the study is a cross-sectional study, and the efficacy and cost-effectiveness of the strategies were evaluated in a randomized controlled trial (RCT).

The studies were conducted from June 2000 to August 2002 in the County of Aarhus, Denmark. A random sample in the community of 3000 adults ≥ 18 years received questionnaires in the descriptive arm of the study. The RCT study included 368 people with dyspepsia from 32 practices in whom the GPs assessed that the symptoms were sufficiently grave to warrant acid suppression therapy or Helicobacter pylori -testing.

The three-month prevalence rate for self-reported dyspepsia was 39%. Among these, 37% reported having consulted their GPs due to dyspeptic symptoms. One third consulted due to recurrence of well-known dyspeptic symptoms, one third wanted an explanation of the symptoms and one third feared an ulcer or cancer. The most frequent reasons for not consulting the GPs were knowledge about the dyspeptic symptoms, and an expectation that the symptoms would disappear.

According to the patients' assessment, endoscopy entailed a significant improvement in gastrointestinal symptoms scores after one year. GPs and patients assessed that more people were free of dyspeptic symptoms after one year in the endoscopy than in the PPI group, although the difference was not significant. Upon inclusion the predominant symptom was pain/discomfort among two thirds and reflux among one third of the patients. The endoscopy strategy seems to be more effective than the PPI-strategy when reflux was not the predominant symptom upon inclusion, whereas the PPI strategy was more effective when reflux was the predominant symptom. During the study period patients in the two groups consumed the same amount of PPI, but at the end of the study period PPI consumption was actually highest in the endoscopy group.

Patients in the endoscopy group had 1.3 fewer days with dyspeptic symptoms compared with patients in the PPI group. The average cost per patient in the endoscopy group exceeded the corresponding cost in the PPI group by 390 euros. The incremental cost-effectiveness ratio using the endoscopy strategy compared with the PPI strategy was 300 euros per symptom-free days. The PPI strategy was more cost-effective than the endoscopy strategy.