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Biomedical subjects

A P Hungin

Publications and source records attributed to A P Hungin.

15 recordsLinked to original sources
PubMed2001

Nonsteroidal anti-inflammatory drugs: overused or underused in osteoarthritis?

Arthritis and musculoskeletal disorders are common. Arthritis currently accounts for 2% to 3% of all cases of disability, and the numbers are rising. Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used, with 75 million prescriptions annually in the United States and 25 million in the United Kingdom. The volume of side effects noted, most of which are gastrointestinal and can be serious, imply the overuse of these drugs, especially in relation to the estimated prevalence of osteoarthritis (OA), where pain relief may be considered more important than an anti-inflammatory effect. There are conflicting data about the efficacy of NSAIDs compared with analgesics alone for pain relief. However, the interpretation of data comparing the two drug classes is limited by shortcomings in research methodologies and by difficulties in incorporating the anti-inflammatory effect of NSAIDs into the outcomes. The efficacy of paracetamol for some patients has been underestimated; however, although those with mild disease may find paracetamol adequate, most patients with OA are likely to gain more benefit from NSAIDs.

Acetaminophen↗
PubMed2001

The management of irritable bowel syndrome: a European, primary and secondary care collaboration.

OBJECTIVE: To develop recommendations for the diagnosis and management of irritable bowel syndrome for European doctors delivering primary care. These recommendations can be adapted by local medical groups according to their language, custom and health-care systems. METHODS: Twenty-one general practitioners and gastroenterologists from Europe attended a workshop planned by a steering committee. After a state-of-the-art symposium, four working groups considered the following aspects of irritable bowel syndrome management: what to tell the patient, diagnosis, non-medical treatment and psychosocial management. Current and future drug management was reviewed by the steering committee. The resulting recommendations were considered at two plenary sessions during the meeting, and by circulation of the material during development of the manuscript. RESULTS: The process permitted a unique dialogue between general practitioners and gastroenterologists, in which it was necessary to reconcile the specialists' emphasis on thoroughness with the practical, epidemiological and economic realities of primary care. Despite this dichotomy, consensus was achieved. CONCLUSIONS: European general practitioners and gastroenterologists have produced recommendations that emphasize education of the patient, a positive symptom-based diagnosis, diet and lifestyle advice, psychological support and a critical analysis of current specific psychological and pharmacological treatments.

Colonic Diseases, Functional↗
PubMed2001

Management of dyspepsia across the primary-secondary healthcare interface.

Primary care remains at the frontline of care for most patients and the need to contain healthcare costs has led to a re-evaluation of the divide between primary and secondary care. Dyspepsia has a community prevalence of 25-50%, and forms 5% of the primary care physician's workload, 10% of whom are referred to a specialist. Problems presenting in primary care tend to be undifferentiated; those who do not have alarm symptoms and are under the age of 55 years are unlikely to have serious pathology. Management is largely symptom driven, on an empirical basis rather than on a diagnostic model as in secondary care where investigation rates are higher. The predictive value of symptoms for a specific diagnosis is small; primary care physicians include gastro-oesophageal reflux disease as part of the dyspepsia complex and the overall expenditure on acid suppression therapy is relatively large. The availability of open-access investigations such as endoscopy has influenced specialist referral rates and the ability to diagnose and treat patients with Helicobacter pylori-related problems has opened further opportunities. However, variations in the availability of the recommended diagnostic tests and the implications to primary care clinical practice of some of the new management recommendations (Maastricht II) in some national settings illustrate the divide with secondary care. The gap between primary and secondary care is narrowing in gastroenterology and the two groups need to continue collaboration to attain effective and cost-effective management for their patients.

Cost-Benefit Analysis↗
PubMed2000

Inflammatory bowel disease: epidemiology and management in an English general practice population.

BACKGROUND: Inflammatory bowel diseases have significant long-term morbidity and healthcare resource consequences. Studies based on secondary care records may have underestimated the contribution of general practitioners (GPs) to its management. AIMS: To describe the epidemiology and management of inflammatory bowel disease using GP records as the primary data source. METHODS: A systematic search of GP clinical records in northern England, identifying cases of inflammatory bowel disease, patient consultation behaviour, prescribing patterns, and extent of specialist care. RESULTS: In a population of 135 723, the incidence of ulcerative colitis was 13. 9/100 000 per year (CI: 7.5-20.3) and for Crohn's disease 8.3/100 000 per year (CI: 3.4-13.2). The age-sex adjusted point prevalence for ulcerative colitis on 1st January 1995 was 243.4/100 000 (CI: 217.4-269.4) and for Crohn's disease 144.8/100 000 (CI: 124.8-168.8). The mean number of consultations (s.d.) with specialists and GPs were similar, both in the first 12 months after referral (specialists 3.94 +/- 3.15, GPs 3.34 +/- 3.55) and in the most recent 12 months (1.02 +/- 2.02, 1.04 +/- 2.04). Only 29.9% of all patients were definitely under specialist care. CONCLUSIONS: Prevalence rates, but not incidence rates, for inflammatory bowel disease are substantially higher than previously described in UK populations. General practitioners make a significant contribution to meeting the healthcare needs of these patients.

Adult↗
PubMed2000

The interaction between research and practice: a pan-European approach to managing H.pylori infection in primary care.

The transposition of evidence into clinical care presents many challenges. New knowledge may be immediately translatable to the practice setting, with barriers to be overcome before implementation. The early guidelines on Helicobacter pylori management presented an overview but were not able to take into account local factors and health care traditions, such as the non-availability of tests and established primary-secondary care relationships. Primary care is a specific specialty across most of Europe, existing within different health care systems and clinical traditions. The creation of H. pylori management guidelines, aimed at European primary care but adaptable to local national circumstances, presented a challenge in methodology and formulation. The process exposed similarities but also tensions between differing health care systems, as well as variations in the conditions in which GPs practise. Clinical differences, such as varying ulcer prevalence and drug resistance rates, highlighted the importance of guidelines being adaptable. This paper analyses the European Society for Primary Care Gastroenterology process of pan-European primary care agreement towards H.pylori management and how diverse views, traditions and national settings were reconciled through an evidence-based approach.

Cultural Diversity↗
PubMed2000

Detection of upper gastrointestinal cancer in patients taking antisecretory therapy prior to gastroscopy.

BACKGROUND: The incidence of early gastric cancer has not increased despite better access to endoscopic facilities for general practitioners. Many patients receive a course of symptomatic treatment while waiting for gastroscopy. AIMS: To ascertain the effect of antisecretory therapy on the diagnostic process and findings for patients with upper gastrointestinal cancer. METHODS: A consecutive case study survey of the primary care records of 133 patients who had died of upper gastrointestinal cancer during 1995-97 in the South Tees health district in the north-east of England (population 300 000). RESULTS: From the 133 patients identified, 116 had died from adenocarcinoma of the oesophagus (31) or stomach (85). Failure to reach the diagnosis of cancer at the index gastroscopy was associated with prior acid suppression therapy. Only one of 54 patients on no treatment or antacids alone was erroneously diagnosed as suffering from benign disease, whereas 22 of 62 patients treated with acid suppression were diagnosed as suffering from benign disease but at varying times later turned out to have adenocarcinoma. Twenty of 45 patients taking a proton pump inhibitor had a delayed diagnosis compared with two of 17 taking an H(2) receptor antagonist. The commonest lesion seen at index gastroscopy in those in whom the diagnosis was initially missed was gastric ulcer. Healing occurred in six patients taking a proton pump inhibitor, despite their later diagnosis of malignancy. CONCLUSIONS: The treatment of dyspeptic symptoms with acid suppression prior to gastroscopy masks and delays the detection of gastric and oesophageal adenocarcinoma on endoscopy in one third of patients.

Adenocarcinoma↗
PubMed1999

Co-prescription of H2 receptor blockers and proton pump inhibitors with warfarin in general practice.

Acid-suppressing drugs and anticoagulants are used increasingly in general practice. Warfarin is potentiated by some acid-suppressing drugs, notably cimetidine and omeprazole, through interference of the cytochrome P450 system. This study aimed to ascertain the extent of co-prescribing of warfarin and acid-suppressing drugs in general practice. We conducted a retrospective survey of the records of all patients prescribed acid-suppressing drugs over a 2-year period to ascertain those who had also taken warfarin; we also made a cross-sectional survey of all patients on warfarin to ascertain those who had taken acid-suppressing drugs. From a general practice population of 45 574 patients in northern England, 3423 (7.5%) had been prescribed acid-suppressing drugs during the previous 24 months. Of 274 patients who had been on warfarin, 44 (16.1%) had also taken acid-suppressing drugs (26 H2 receptor blockers and 18 proton-pump inhibitors). The commonest reasons for anticoagulation were thrombo-embolic disease (40.9%), atrial fibrillation (36.4%), valvular heart disease (18.2%), and surgical prophylaxis (4.5%). The indications for concurrent acid-suppressing drugs were: 'dyspepsia' 38.6%, reflux 22.7%, oesophagitis 13.6%, duodenal ulcer 13.6%, gastric ulcer 4.5%, unknown 6.8%. There have been no studies from primary care to evaluate the possible clinical effects of the concomitant use of acid-suppressing drugs and warfarin; some fluctuations in coagulation control, particularly in patients taking the combinations intermittently, may be due to this.

Anticoagulants↗
PubMed1999

Long-term prescribing of proton pump inhibitors in general practice.

BACKGROUND: Proton pump inhibitors (PPIs) constitute the largest sector of the National Health Service (NHS) community drugs bill (238 m Pounds; 5.6%). Little is known of the long-term prescribing component of this. AIM: To study the extent, the reasons for, and the cost implications of the long-term prescription of PPIs in general practice. METHOD: Subjects on long-term therapy were identified by searches of computerized and paper records from three practices, comprising 21 GPs with 46,650 patients, representing a population cross section in north-east England. RESULTS: Two hundred and nine (0.45%) patients were on long-term PPIs (range between practices = 0.3% to 0.55%): 87% were on omeprazole, 13% lansoprazole; average age = 60 years (male = 56 years, female = 64 years; range = 14 to 91 years); male to female ratio = 47:53. The main indications were 'reflux' (39%), 'oesophagitis' (17%), non-specified 'dyspepsia' (24%), 'peptic ulcer' (8%). During the study year, 1952 prescriptions (28-day courses) were issued: a mean of nine per patient (range = 1 to 8). Sixteen per cent of patients requested fewer than six prescriptions, 27% requested between six and nine prescriptions, and only 21% requested sufficient prescriptions for the entire year. The average cost was 3707 Pounds per general practitioner per annum, or 320,000 Pounds for the district, representing 40% of the total PPI bill. CONCLUSION: Of the total population, 0.45% were prescribed long-term PPIs; most for symptom relief. The long-term component comprised 40% of all PPI costs estimated at 100 million Pounds per annum for the United Kingdom. Most patients took their treatment only intermittently. More research is needed into strategies for rationalization of long-term PPI therapy. For most patients, doctors can advise on-demand rather than regular once-daily therapy.

Adult↗
PubMed1999

Factors influencing compliance in long-term proton pump inhibitor therapy in general practice.

Long-term proton pump inhibitor (PPI) prescribing in general practice is common, but only a minority of patients request their prescriptions regularly. This study determined factors linked with compliance using questionnaires and diary cards. The chief factors determining whether or not patients took their PPIs were the presence or severity of symptoms and the desire to remain in personal control, together with a fear of side-effects and lack of knowledge about the drugs. As most such prescribing is for uncomplicated gastro-oesophageal reflux disease, on-demand therapy should now be formally advocated.

Adolescent↗
PubMed1998

Irritable bowel syndrome, gastro-oesophageal reflux, and bronchial hyper-responsiveness in the general population.

BACKGROUND: Associations have been shown between irritable bowel syndrome (IBS) and gastro-oesophageal reflux, between gastro-oesophageal reflux and asthma, and more recently between IBS and bronchial hyper-responsiveness (BHR). AIMS: To explore the inter-relations between these conditions. SUBJECTS: A randomly selected community sample of 4432 adults. METHODS: A validated postal symptom questionnaire investigating the associations between IBS, gastro-oesophageal reflux symptoms, and symptomatic BHR. RESULTS: 3169 questionnaires (71.7% response) returned by 1451 men and 1718 women were analysed. One year prevalences, in men and women respectively, of IBS were 10.5% and 22.9%, of dyspepsia 26.3% and 25. 25%, of gastro-oesophageal reflux symptoms 29.4% and 28.2%, of BHR 13.2% and 14.6%, and of chronic bronchitis 8.3% and 4.9%. Logistic regression showed independent associations between IBS and BHR, gastro-oesophageal reflux symptoms, and dyspepsia. There was no significant independent association between IBS and chronic bronchitis. In men and women the odds ratio with 95% confidence interval (CI) for IBS and gastro-oesophageal reflux symptoms was 2.6 (2.1-3.1; p<0.001) and for IBS and BHR 2.1 (1.7-2.7; p<0.001). These associations held on stratifying for sex and consultation behaviour. IBS, gastro-oesophageal reflux symptoms, and bronchial hyper-responsiveness occurred more frequently together than expected, 2.5% (95% CI 2.41-2.57) of the sample having all three conditions compared with an expected prevalence of 0.7% (95% CI 0.66-0.71). The conditions were independently associated with each other. CONCLUSIONS: These observations may indicate the presence of an underlying disorder producing symptoms in gastrointestinal and respiratory systems.

Adult↗
PubMed1997

Guidelines for dyspepsia management in general practice using focus groups.

BACKGROUND: There is a paucity of published guidelines on managing dyspepsia in general practice. Existing guidelines emphasize the role of investigations and drugs rather than management approaches. Focus groups are a means of uncovering the way in which the participants think and work in the pragmatic-setting, and have not previously been formally used in creating guidelines. AIM: To develop guidelines for the management of dyspepsia and to assess the use of focus groups of general practitioners (GPs) in order to do so. METHOD: Initial evidence-based guidelines were proposed by a group of four GPs with an audit facilitator, and used for discussion in three focus groups using a standard format. An anthropological analysis of the proceedings led to modifications of the original guidelines, based on knowledge, perceptions and attitudes. The study was set in three distinct locations involving 30 GPs. The outcome measures consisted of feedback, categorized by types of responses, from the analysis of the focus groups and the creation of guidelines. RESULTS: The resulting guidelines were patient centred and based on the principles of good consultation. They encompassed patients' fears and doctors' clinical uncertainties, and allowed flexibility in the individual patient's management. The focus group methodology exposed a substantial number of GPs to guideline development, and had the added benefits of dissemination, peer review and educational challenge. CONCLUSION: It was possible to develop guidelines for dyspepsia using focus groups. The methodology had the added benefits of ownership, peer review, exposure of educational gaps and locality factors, and dissemination of good practice. It included steps from evidence review to implementation strategies. The development of this technique could lead to a strategy towards the creation and application of evidence-based and professionally acceptable clinical guidelines and practice on a locality basis nationally.

Dyspepsia↗
PubMed1995

Reasons for variations in the use of open access gastroscopy by general practitioners.

This study aimed to investigate the wide variation between general practitioners (GPs) in their use of open access gastroscopy by assessing (i) their partnership share, workload, and the aggregated practice request rate; (ii) correlations with their professional and practice characteristics; and (iii) a comparison with referral rates to medicine, surgery, and all specialties. All 145 GPs and their practice managers were sent a questionnaire and hospital held data on all requests for open access gastroscopy over one year were reviewed. During the year, the 145 GPs made 1210 requests for open access gastroscopy, varying from one to 44 per GP. There were 987,880 practice consultations altogether, an average of 22,451 per practice or 7127 per whole time practitioner. Requests for open access gastroscopy formed 2.4% of all referrals, an average of one per 1000 consultations, or eight per GP. Of a total of 49,123 referrals to all specialties (371 per GP) 4218 (8.5%) were to medicine, and 6444 to surgery (13.1%). The following factors did not correlate with requests: vocational training, a concurrent hospital post, length of service, or receipt of the deprivation allowance by the practice. When the open access gastroscopy referral rate was aggregated for each practice the variation between practices was narrowed to essentially twofold. Requests for open access gastroscopy form a small proportion of all referrals (2.4%). Aggregated practice request rates are relatively uniform compared with the wide variation between individual GPs, suggesting a disproportionate gastroenterology workload between partners. The open access gastroscopy service does not seem to be subject to misuse from most GPs if a variation in practice usage is used as a measure.

Family Practice↗
PubMed1994

What happens to patients following open access gastroscopy? An outcome study from general practice.

BACKGROUND: Open access gastroscopy allows general practitioners to request a gastroscopy without prior referral to a specialist. The effect of open access gastroscopy upon patient management is poorly explored. Most studies have been hospital based and have focused on diagnostic yields and on means of tightening requests to reduce inefficient use. A user evaluation can only be made by measuring outcomes in primary care. AIM: A study was undertaken to determine the impact of open access gastroscopy in general practice and in particular, the value of a normal result. METHOD: All general practices in South Tees District Health Authority were asked to participate. Any of their patients who had had open access gastroscopy in the year prior to July 1990 were identified from the hospital computer and their general practitioner notes examined. Patient management during the year prior to the open access gastroscopy was compared with the year after. The main outcome measures were: detection rate and grade of lesion, change in graded score of prescribed drugs, consultation rate for dyspepsia and non-dyspepsia problems, and further hospital referral and investigations. Outcomes among those with normal and abnormal gastroscopy results were compared. RESULTS: The study sample comprised 715 patients, 36% of whom had a normal gastroscopy result, 34% a major abnormality and 26% a minor abnormality (4% of patients had miscellaneous diagnoses). It was found that 39% of all patients, and 60% of those with normal findings on open access gastroscopy had their drug treatment stopped or reduced in grade after the investigation. Of those with a major endoscopic abnormality 58% increased their treatment score. Consultations for dyspepsia in the year before and after gastroscopy fell by 57% overall among those with a normal gastroscopy result, by 37% among those with a minor finding and by 33% in those with a major finding. There was a 21% fall in consultations for all reasons among those with a normal gastroscopy result but those with a minor abnormality had a 23% increase in non-dyspepsia consultations. Of all patients 19% were referred to hospital subsequently. CONCLUSION: Open access gastroscopy has a major effect upon patient management in general practice, and a normal endoscopy result has an important an impact as an abnormal one. Open access gastroscopy is associated with a rationalization of drug therapy, reduced consultations and a low hospital referral rate.

Dyspepsia↗