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Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Background:  Although dyspepsia is common, management patterns in the United States are unknown.

Aim:  To determine the pattern of dyspepsia evaluation and treatment over 20 years in a population-based cohort, and test the hypothesis that the management was influenced by dyspepsia subgroup and gender.

Methods:  The validated Bowel Disease Questionnaire was mailed to a random sample of Olmsted County, Minnesota residents (1988–1990). Of the 835 survey respondents, 213 subjects were identified as having dyspepsia according to Rome I Criteria. The medical chart of each dyspeptic subject who had not denied research authorization (n = 206) was reviewed to identify all episodes of care for dyspepsia symptoms 10 years before and 10 years after the date the Bowel Disease Questionnaire was completed. Of these 206 subjects (mean age 47 years, 48% female), 34% had ulcer-like dyspepsia, 32% had dysmotility-like dyspepsia, and 37% had reflux-like dyspepsia.

Results:  Nearly half (n = 98, 48%) had episodes of care for dyspepsia symptoms over 20 years. Of these 98 subjects, 49% had upper gastrointestinal endoscopy, 4% motility studies and 12% were tested for Helicobacter pylori. At the first visit of the episode of care closest to Bowel Disease Questionnaire completion, 72% were seen in primary care, 16% in emergency medicine and 2% in gastroenterology. In addition, 13% were referred to gastroenterology clinic within this episode. During the study period, 70% were given an ‘acid’ diagnosis, 7% a ‘motility’ diagnosis and 54% a ‘functional’ diagnosis; 78% received acid suppression agents (28% proton pump inhibitors), 18% psychotropic agents and 7% prokinetic agents. No significant association was found between gender and test usage, specialty referral or type of treatment, although women were three times less likely to receive proton pump inhibitors (odds ratio 3.3, 95% CI: 1.2–9.1). Symptom severity, frequency and pattern were risk factors for health care seeking in dyspepsia.

Conclusions:  Delivery of care for dyspepsia was similar among dyspepsia subgroups and in men and women.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Upper abdominal pain or discomfort is common in the general population. The annual prevalence of recurrent upper abdominal pain or discomfort in the United States and other Western countries is approximately 25%.1 Although fewer than half of dyspepsia sufferers seek medical care for their complaints in the United States and Europe, the problem is responsible for 2–5% of visits to primary care physician.2 Therefore, dyspepsia and its management are important clinical issues for both primary care physicians and gastroenterologists.

Most patients presenting with dyspepsia suffer from functional dyspepsia (FD) or gastro-oesophageal reflux disease (GERD).1 The factors that determine whether a patient with dyspepsia consults a physician are poorly defined. There is a general tendency for females to report more gastrointestinal (GI) symptoms including upper abdominal pain or discomfort and women seek health care for FD and irritable bowel syndrome (IBS) significantly more often than do men.3 Symptom severity is also an important factor, but probably only explains a small proportion of health care seeking behaviour associated with dyspepsia.4, 5 Psychosocial factors have also been found to characterize those who seek help vs. those who do not.2, 4–6 A serious deficiency of studies measuring health care seeking for dyspepsia is the heavy reliance on unvalidated self-report indicators of physician consultation.

Further, the pattern of evaluation and treatment of community patients with dyspepsia who seek health care is unknown in the United States. Clinic-based studies from Europe report low rates of specialist consultation or investigation for dyspepsia.7, 8 Data taken from gastroenterology clinic-based studies are limited by referral bias and thus, may not accurately reflect the pattern of disease in the community.

Some clinical and pathophysiological studies suggests the existence of two main subgroups in patients with FD, characterized by: (i) male gender, predominant epigastric pain, normal gastric emptying; and (ii) female gender, predominant non-painful symptoms, delayed gastric emptying, and a significant overlap of symptoms with other functional bowel disorders.9–14 Based on this evidence, it is likely that gender-related differences exist in the pattern of evaluation and treatment of dyspepsia; however, gender-based differences have not been evaluated in the management of dyspepsia.

The aims of this study were: (i) to evaluate management of dyspepsia in the community by linking population-based data on reported symptoms with comprehensive clinic data; and (ii) to determine whether delivery of health care for dyspepsia was similar among the dyspepsia subgroups and for men and women.

Methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Study setting

Population-based epidemiological research in Rochester, Minnesota is possible because of its relative geographical isolation from other urban centres and the fact that nearly all medical care is delivered to local residents by a small number of providers. Almost all primary and specialty medical care in Olmsted County is delivered by the two organizations participating in this research, the Olmsted Medical Center and the Mayo Medical Center. The dossier-style records of two organizations contain the details of care delivered by all providers within the organizations, including the Mayo hospitals (Saint Marys and Rochester Methodist) and the Olmsted Community Hospital affiliated with Olmsted Medical Center. The local medical clinics also provide their records for review in approved studies, and these were used to identify the sources of medical care of all the individuals identified, who had provided an authorization for use of their medical records in research. Over 98% of subjects had provided this authorization.15, 16 The Rochester Epidemiology Project (REP), a diagnostic indexing and medical records-linkage system that exists at the Mayo Clinic, affords access to medical records from all sources of care for community residents. The potential of this data retrieval system for population based studies has been described in detail.15

Study design and subjects

This was a retrospective study that evaluated a population-based cohort of Olmsted County, Minnesota residents. The subset with dyspepsia was previously identified from a population-based survey. Using the REP record linkage, an age- and sex-stratified random sample of 1120 persons aged 30–64 years were selected randomly in 1988.17 Those subjects with major psychosis or dementia in the past, major organic medical disease including active cancer, ulcerative colitis, severe congestive heart failure, severe coronary artery disease and/or major abdominal surgery including nephrectomy, renal transplantation or bowel resection were excluded. The Bowel Disease Questionnaire (BDQ) was mailed to the remaining eligible subjects during November 1988 through January 1990 (n = 1021). This questionnaire has been shown to be understandable, easily completed, and highly reliable. It has also been shown to have adequate content, as well as predictive and construct validity for the measurement of GI symptoms.18

Of the 835 survey respondents, 213 individuals were identified as having symptoms diagnostic of dyspepsia according to the Rome I Criteria.19 Dyspepsia subgroups definition was used according to Talley et al.5 After excluding those who denied research authorization, the remaining 206 subjects were included in the current study.

Data abstraction

In the current study, we performed a retrospective medical chart review of each subject with dyspepsia (n = 206) to identify all episodes of care for dyspepsia symptoms 10 years before and 10 years after the date he or she completed the survey (BDQ). An episode of care was defined as the period between the first and last visit related to dyspepsia symptoms. The following information was abstracted from each episode of care for dyspepsia symptoms during the study period: date of visit, type of clinic seen (primary care, gastroenterology, emergency medicine etc.), specialty referrals (gastroenterology, psychiatry etc.), GI procedures (upper GI endoscopy, barium studies, Helicobacter pylori, etc.), diagnoses (‘acid’, ‘motility’, ‘functional’) and prescriptions (antisecretory agents, antacids, H. pylori eradication, psychotropic agents etc.). Diagnosis and treatment given during each episode of care for dyspepsia symptoms were categorized broadly as ‘acid’, ‘motility’, and ‘functional’ according to Table 1.

Table 1.  Diagnosis and treatment categories
AcidMotilityFunctional
Peptic ulcer diseaseNausea/ vomitingFunctional dyspepsia
Gastro-oesophageal diseaseGastroparesisNon-ulcer dyspepsia
GastritisOesophageal spasmDyspepsia
Drug-inducedGastric motility disorderAbdominal pain
DuodenitisReglanIrritable bowel syndrome
ErosionsCisaprideIndeterminate abdominal pain
OesophagitisCardizemBloating/gas
Hiatal hernia Epigastric distress/ discomfort
Antacids Psychotropics
Proton pump inhibitors Dicyclomine
H2-blockers Propantheline
Helicobacter pylori eradication Rx Metamucil
  Dannatol
  Simethicone

Data analysis

The first analysis in the current study focused on the subjects with dyspepsia at the time of initial BDQ. Logistic regression models were fit to identify demographic, psychosocial, and symptom factors associated with whether a subject consulted a physician for dyspepsia symptoms during either the 10 years before or the 10 years after the date of BDQ completion.

The second analysis focused on the subset of subjects with dyspepsia at the time of the initial BDQ who consulted a physician for dyspepsia symptoms during the 20-year period. Logistic regression models were fit to identify whether gender was associated with patterns of dyspepsia management (specialty referral, test usage, diagnosis given and treatment with antisecretory or psychotropic agents). Each dyspepsia management variable was specified as a binary (yes or no) outcome and evaluated in a separate model. The models were evaluated with and without adjusting for age and a somatization score.

The BDQ included a somatic symptom checklist (SSC) which consists of 12 non-GI and six GI symptoms or illnesses and subjects were instructed to indicate how often (0 = not a problem to 4 = occurs daily) each symptom occurred and how bothersome (0 = not a problem to 4 = extremely bothersome when occurs) each symptom was assessed over the previous year using separate 5-point scales.20 A somatization score was derived from the responses to the non-GI symptoms or illnesses by summing the mean score for ‘how often’ and the mean score for ‘how bothersome’. Likewise, a GI symptoms score was derived from the responses to the GI symptoms or illnesses by summing the mean score for ‘how often’ and the mean score for ‘how bothersome’.

The strength of the associations were summarized by calculating odds ratios (OR) and their 95% confidence intervals (CI). All calculated P-values were two-sided, and P-value <0.05 was considered statistically significant.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Of the 206 subjects (mean age 47 years, 48% female), 34% had ulcer-like dyspepsia, 32% had dysmotility-like dyspepsia, and 37% had reflux-like dyspepsia. Their mean somatization score (derived based on the responses to non-GI complaints on the SSC) was 1.3. Demographics and symptom characteristics of subjects identified as having dyspepsia are summarized in Table 2.

Table 2.  Demographic, psychosocial, and symptom data on the subjects at the time the Bowel Disease Questionnaire was completed (returned 11/1988–1/1990)
CharacteristicAvailable SampleMedical encounter within (+/−) 10 years of the BDQNo medical encounter within (+/−) 10 years of the BDQ
Male (n = 108)Female (n = 98)Total (n = 206)Male (n = 50)Female (n = 48)Total (n = 98)Male (n = 58)Female (n = 50)Total (n = 108)
  1. BDQ, Bowel Disease Questionnaire; HS, high school.

  2. * The dyspepsia subgroups were defined according to the Rome I criteria and are not mutually exclusive.

  3. † The somatization score was derived based on the responses to the Somatic Symptom Checklist.

Mean (±s.d.) age (years)46.7 (9.8)47.8 (9.9)47.2 (9.8)48.2 (9.1)48.4 (9.8)48.3 (9.4)45.3 (10.3)47.3 (10.0)46.2 (10.2)
Dyspepsia subgroups*
Ulcer-like36 (33%)35 (36%)71 (34%)20 (40%)21 (44%)41 (42%)16 (28%)14 (28%)30 (28%)
Dysmotility-like34 (31%)32 (33%)66 (32%)20 (40%)21 (44%)41 (42%)14 (24%)11 (22%)25 (23%)
Reflux-like46 (43%)31 (32%)77 (37%)29 (58%)21 (44%)50 (51%)17 (29%)10 (20%)27 (25%)
Non-specific33 (31%)30 (31%)63 (31%)9 (18%)8 (17%)17 (17%)24 (41%)22 (44%)46 (43%)
Somatization Score†
 Mean (±s.d.)1.2 (0.9)1.4 (0.9)1.3 (0.9)1.2 (1.0)1.7 (1.0)1.4 (1.1)1.2 (0.8)1.2 (0.7)1.2 (0.8)
 Median1.01.31.20.91.51.31.01.11.1
Employed94 (87%)74 (76%)168 (82%)43 (86%)41 (85%)84 (86%)51 (88%)33 (66%)84 (78%)
Education
 <HS7 (6%)5 (5%)12 (6%)3 (6%)3 (6%)6 (6%)4 (7%)2 (4%)6 (6%)
 HS25 (23%)36 (37%)61 (30%)14 (28%)19 (40%)33 (34%)11 (19%)17 (34%)28 (26%)
 >HS76 (70%)57 (58%)133 (65%)33 (66%)26 (54%)59 (60%)43 (74%)31 (62%)74 (69%)

Health care seeking

Of the 206 subjects with dyspepsia, 24 (12%) had a physician consultation during 1 year before or after the BDQ survey. Over 20 years, 98 (48%) had consulted a physician for dyspepsia symptoms. Patients with frequent abdominal pain, a higher GI symptom score (derived from the GI responses of the SSC), and each specified subgroup of dyspepsia (whether ulcer-like, dysmotility-like, or reflux-like) were univariately more likely to have sought consultation for dyspepsia symptoms (Table 3). Subjects who sought consultation for dyspepsia symptoms also tended to have higher somatization scores (P = 0.04). However, after adjusting for the somatization score and age, only the variables for the GI symptom score and employment were identified for entry into the model using a stepwise variable selection method. Among the 98 subjects with an episode of care, the characteristics examined were similar between males and females with an exception that females were more likely to have higher somatization scores than males (P = 0.004, Wilcoxon rank sum test).

Table 3.  Univariate analysis of demographic, psychosocial and symptom factors for their association with having sought care (physician visit or consultation) for dyspepsia symptoms during the 20-year period
Factors at the time of the BDQOdds ratio*95% CIP-value
  1. BDQ, Bowel Disease Questionnaire.

  2. * The odds of seeking care for dyspepsia symptoms during the 20-year period.

  3. † Defined from the Somatic Symptoms Checklist score.

  4. ‡ Odds per 1 unit increase in the score.

  5. § Odds per 10-year increase in age.

Irritable bowel syndrome1.3(0.7, 2.5)0.38
Severe or very severe abdominal pain1.9(0.9, 3.9)0.080
Pain >6 times in the past year2.4(1.4, 4.4)0.023
Interruption in activities because of other illness1.8(1.0, 3.2)0.05
Gastrointestinal symptoms score2.0‡(1.5, 2.6)<0.001
Somatization score†1.4‡(1.0, 1.9)0.046
Dyspepsia Subgroups (Rome I)
 Ulcer-like1.9(1.0, 3.3)0.035
 Dysmotility-like2.4(1.3, 4.4)0.005
 Reflux-like3.1(1.7, 5.6)<0.001
 Non-specific0.3(0.1, 0.5)<0.001
Age1.2§(0.9, 1.7)0.13
Female gender1.1(0.6, 1.9)0.70
Employed1.1(0.8, 3.5)0.15
Education greater then high school0.7(0.4, 1.2)0.21

At the first visit of the episode of care closest to the BDQ completion (either before or after), 72% of the 98 subjects were seen in the primary care clinic, 16% in the emergency medicine and 2% in the gastroenterology clinic for dyspepsia symptoms (Table 4). Within this episode of care, 13% were referred to gastroenterology and 3% to psychiatry. Dyspepsia was the reason for consultation in three-fourths of gastroenterology referrals. Men were slightly more likely than females to have a gastroenterology referral within the episode of care closest to the BDQ completion (18% vs. 8%, P = 0.16).

Table 4.  Specialty visits and referrals within the episode of care closest to the completion of the Bowel Disease Questionnaire
DepartmentSpecialty seen at first visit of episodeReferrals within this episode
Male (n = 50)Female (n = 48)Total (n = 98)Male (n = 50)Female (n = 48)Total (n = 98)
  1. NA, not available.

Primary care34 (68%)37 (77%)71 (72%)4 (8%)3 (6%)7 (7%)
Gastroenterology2 (4%)02 (2%)9 (18%)4 (8%)13 (13%)
Psychiatry0001 (2%)2 (4%)3 (3%)
Urgent care1 (2%)1 (2%)2 (2%)NANANA
Emergency medicine11 (22%)5 (10%)16 (16%)NANANA
Behavioural therapyNANANA01 (2%)1 (1%)
Other03 (6%)3 (3%)3 (6%)1 (2%)4 (4%)
Unknown1 (2%)2 (4%)3 (3%)000

Over the 20-year period, 83% of the subjects had one to three episodes of care.

Sixteen per cent had four to six episodes of care and one subject had nine episodes of care for dyspepsia symptoms. Among the 57 subjects with two or more episodes of care during the 20-year period, the median duration of care was 8.1 years (range, 0.2–19.6 years) and the median number of episodes of care per year was 0.4 (range, 0.1 – 8.6). The distribution of the duration of care and the number of episodes of care per year were similar between males and females (P =0.45 and P = 0.56, respectively, Wilcoxon rank sum test).

Pattern of dyspepsia management

Of the 98 subjects who sought care for dyspepsia symptoms during the 20-year period, 65% had upper GI barium study, 49% had upper GI endoscopy and 34% had both; 4% had motility study and 12% were tested for H. pylori. No one had oesophageal pH monitoring. There were no significant differences in test usage (ordered vs. never) between males and females, with the exception that males were slightly more likely than females to have an upper GI barium study ordered during the study period (72% vs. 58%, P = 0.16).

During the 20-year period, an ‘acid’ diagnosis was given to 70% of the 98 subjects, a ‘motility’ diagnosis to 7%, and a ‘functional’ diagnosis to 54%; 34% of the subjects were given more than one dyspepsia diagnosis and 6% were not given a dyspepsia diagnosis. A similar proportion of males (30%) and females (31%) were given both ‘acid’ and a ‘functional’ diagnosis (with or without a ‘motility’ diagnosis). However, males were slightly more likely to be given ‘acid’ diagnosis than females (76% vs. 65%, P = 0.22) and males were less likely to be given a ‘functional’ diagnosis than females (48% vs. 60%, P = 0.22).

Ninety-one per cent of subjects seeking care for dyspepsia symptoms over the 20-year period received prescriptions; histamine-2 receptor antagonist (H2RA) agents were prescribed in 59%, antacids in 45% and proton pump inhibitors (PPI) in 28% (Table 5). Less than 10% received prokinetic agents or H. pylori eradication treatment and 18% received psychotropic agents. Males were significantly more likely than females to be treated with PPI (36% vs. 19%, OR 2.4, 95% CI 1.0–6.2, P = 0.056), even after adjusting for age and the somatization score (OR 3.3, 95% CI 1.2–9.1, P = 0.023). In addition, there was a tendency for females to be more likely than males to be treated with psychotropic agents (25% vs. 12%, P = 0.10 univariate; P = 0.26 after adjusting for age and the somatization score).

Table 5.  Type of prescription received by subjects who sought care for dyspepsia symptoms during the 20-year period, by gender
Type of treatmentMale (n = 50)Female (n = 48)Total (n = 98)
Any treatment46 (92%)43 (90%)89 (91%)
Antacid20 (40%)24 (50%)44 (45%)
H2 Blockers30 (60%)28 (58%)58 (59%)
Proton pump inhibitors18 (36%)9 (19%)27 (28%)
Prokinetic agent4 (8%)3 (6%)7 (7%)
Psychotropic agent6 (12%)12 (25%)18 (18%)
Helicobacter pylori eradication4 (8%)5 (10%)9 (9%)
Other treatment15 (30%)13 (27%)28 (29%)

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Most data on health care seeking for dyspepsia have been derived from studies relying on self-report questionnaire.3,21,22 This is the first study to link population-based data on symptom reporting with accurate clinical data on health care seeking. Studies based on self-report indicators of physician consultation report that approximately one in four dyspepsia sufferers in the community had consulted a physician in the past 1 year for their complaints;3, 21–23 however, our findings suggest a lower physician consultation rate for dyspepsia symptoms (12.5% over the prior year). Studies based on self-report questionnaires are limited by recall bias, and a lack of specificity for the physician visit being due to dyspepsia symptoms; thus, over or underreporting of physician consultation rates for dyspepsia symptoms limits past studies.

In our study, symptom severity, frequency and pattern (e.g. ulcer-like, dysmotility-like) were important independent factors in determining health care seeking for dyspepsia. Other factors including age, gender and socioeconomic status were similar between those who had sought care vs. those who had not. Other studies suggest that symptom severity, increasing age, lower social class, fear of serious disease, a family history of cancer and possibly psychological distress are important;2–6, 24 however, a major deficiency of past studies measuring health care seeking for dyspepsia has been the heavy reliance on self-report indicators of physician consultation.

Psychosocial factors have been found to characterize those who seek help vs. those who do not6 but not all studies agree. Dyspepsia sufferers particularly women who sought care had higher somatization score than those who did not seek care. Somatization is reported to result in the increased use of health care,25 presumably because somatizers express their psychological distress through bodily symptoms.26

In Europe, the vast majority of patients with dyspepsia are managed by primary care physicians, with referral rates at first consultation for specialist care or investigations of 4–17%.7, 8 In our study, approximately 80% of subjects with dyspepsia in the community had consulted a primary care physician and 13% were referred for specialist care. However, nearly half of patients seen by a primary care physician had GI testing including endoscopy. No other data on the patterns of consultation or investigation of dyspepsia sufferers in the community are available in the United States, but the rates are likely to vary across different parts of the country because of the wide array of health care choices made by patients and physicians.

Peptic ulcer or GERD is found on upper GI endoscopy in 20–40% of patients presenting with dyspepsia.1 In our study ‘acid’ diagnoses were given to 70% of patients with dyspepsia who had consulted a physician for their complaints but nearly half of patients with an ‘acid’ diagnoses had overlapping ‘functional’ or ‘motility’ diagnoses. Furthermore, diagnoses were not based on endoscopic findings in all patients who had consulted.

A diagnosis of either gastric or oesophageal malignancy was not made in any person. Subjects had sought care over a 20-year period, although our study population was relatively young (mean age of 47 years, range 31–66 years). Cancer appears to be a very rare cause of symptoms among younger dyspepsia suffers in the community, confirming data in those presenting for endoscopy.27

European studies suggest that general practitioners prescribe medication in 70% of patients with dyspepsia;7,28 however, 91% of patients received prescriptions in our study. No other data are available from the United States on rates of prescriptions in dyspepsia sufferers. Antacids and H2RA are the most commonly prescribed agents for patients seeking care for dyspepsia symptoms in primary care setting.7, 8, 29 In our study, H2RAs were prescribed in more than half of the patients who sought care whereas PPI were given to less than one-third of patients. A low rate of prescriptions for prokinetic or psychotropic agents has been reported in the literature,7, 8 we also observed similar rate of prescription for these agents.

The clinical usefulness of dyspepsia subgroups, however defined, remains controversial. Population-based studies report marked overlap among the subtypes.5 Whether or not physicians manage these patients based on the symptom subgroups remains unclear. In our study, 42% of consulters (subjects seeking care) had ulcer-like dyspepsia based on self-reported symptoms; however, 70% patients were given an ‘acid’ diagnosis and 80% were treated as an ‘acid’ problem by physicians. A similar pattern was observed with consulters who had dysmotility-like dyspepsia; based on self-reported symptoms, 42% of consulters had dysmotility-like dyspepsia but just 13% were given a ‘motility’ diagnosis or treatment. These findings suggest that patients were not managed according to their symptom subgroup; however, approximately half of patients who were given ‘acid’ diagnoses and treatment had overlapping ‘motility’ or ‘functional’ diagnosis and treatment.

In this study, a similar number of men and women with either ulcer-like, reflex-like or dysmotility-like dyspepsia sought care for their symptoms. Some studies have reported a male preponderance for ‘reflux-like’ and ‘ulcer like’ dyspepsia and a female preponderance for ‘dysmotility-like dyspepsia,3, 5, 9, 10, 30, 31 while others have found no difference in the prevalence of dyspepsia subgroups between men and women.22–34 A number of studies that analysed gender-related differences in the prevalence of dyspepsia subgroups adopted definitions of subgroups that were modified from what was originally proposed, and this may have influenced their findings.

Some epidemiological and pathophysiological studies9, 12–14, 35, 36 have suggested the existence of gender-based subgroups in patients with dyspepsia, with men characterized by predominant epigastric pain, normal gastric emptying, and response to acid suppression therapy and women by predominant non-painful symptoms, delayed gastric emptying, and significant overlap with other functional GI disorders such as non-cardiac chest pain and IBS. We, however, did not find any difference between males and females in test usage, psychiatry or gastroenterology referrals, or health care utilization. Compared with men, women received significantly less prescriptions for PPIs and more prescriptions for psychotropic agents. A trend was noted in favour of higher numbers of men receiving ‘acid’ or ‘acid’ only diagnosis or treatment compared with women, although the difference was not significant. No gender effect was observed in patients with ‘motility’ diagnosis or treatment; however, only few subjects were given ‘motility’ diagnosis or treatment. Indeed, the evidence that gastric emptying is related to specific symptoms is very tenuous.37, 38

The present study was based on a random sample of the population and therefore reduces any referral bias associated with the attendance at academic medical centres. The database available in Olmsted County allows longitudinal tracking of the medical care (in-patient and out-patient) provided to individual patients. Virtually all medical care for the study sample occurred in Olmsted County and was documented in our records. A limitation is the majority of the population of Olmsted County is white (96% in 1990) and, therefore, our results will not apply to the non-white population. The data resources of the REP are able to enumerate 96% of the population of Olmsted County from which our sample was drawn. Subjects who were likely to provide unreliable data and those with organic medical disease were excluded because they might have had GI symptoms that could be confused with dyspepsia or IBS. As we followed this cohort over time, some people moved and thus, our data may be biased to include people more likely to have stable residency. Young adults (under age 30) and elderly people (over age 64) were not part of the study sample, so the results cannot be extrapolated to these age groups. Further, GI symptoms may change over time39 and thus, the longer the interval between the population survey and the actual episode of care, the less likely it is the population will remain representative.

In conclusion, in this first US study evaluating the management of dyspepsia in the community linking population-based self reported symptom data and medical records review data, half of dyspepsia sufferers did not seek care for their complaints. Symptom severity and frequency were important independent predictors of those seeking health care for dyspepsia. Similar care was delivered to men and women, and the primary care physicians delivered most of the health care related to dyspepsia.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

This study was funded by a grant from the Mayo Clinic provided to Dr Ahlawat as Scholarly Clinician Award; sponsored in part by Novartis Pharmaceuticals; and supported by a grant from the National Institutes of Health (Rochester Epidemiology Project grant AR30582).

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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