fy Aven fumes or Carmeesrineicov 12301 by A Cal of Gastoentelogy Ye 9 No 8. S208 sno. 9274O1 ESTES STRATEGIES FOR DIAGNOSIS AND SHORT AND LONG TERM TREATMENT The Role of the Specialist in the Diagnosis and Short and Long Term Care of Patients With Gastroesophageal Reflux Disease John Deat, M.D. Department of Gastrointestinal Medicine, Royal Adelaide Hospital, Adelaide, Australia ‘ABSTRACT Advances in knowledge about reflux disease and its treat- ment allow a better focused discussion about cost-effective management compared to 5 yr ago. These developments also offer opportunities for patient management to be more firmly based in a primary care setting, with consequent reductions of cost. This opportunity arses from the recog nition that endoscopy isan insensitive test for refiux disease, and from @ more complete understanding of the treatment effieacy of proton pump inhibitors. Symptom patter eval- uation and @ test of therapy with « proton pump inhibitor is now recognized a the best mainsteam option for diagnosis, and is an approach that is well suited to primary care. Currently, though, specialists are more familiar wth his, 50 there isa need for effective transfer ofthese strategies into primary care, along with the message that endoscopy will not show any diagnostically reliable changes in more than half of patients with troublesome reflux-induced symptoms, though itis the only reliable method for recognition of the complications of reflux esophagitis. Most patients with trou- blesome reflux-induced symptoms require long term man- agement, either with antireflux surgery or with medication given daily only whenever symptoms are troublesome, oF in short intermittent courses. The specialists role inthis is to ‘advise the patient and his or her primary care doctor as tothe available option fr effective contol of reflux disease, with due regard tothe costs of the therapy and patient preference. The routine delivery of loug term medical therapy should be in primary care, because there is no need for specialized testing or assessment inthe course of this treatment. (Am J Gastroenterol 2001;96¢suppl):S22-S26, © 2001 by Am. Col. of Gastroenterology) INTRODUCTION ‘Compared wo $ yr ago, advances in knowledge about gas- troesophageal reflux disease (henceforth referred to as reflux disease) make it possible for discussion on the cost-effective treatment of reflux disease to be substantially better focused (1, 2. The scope of existing knowledge also allows more eficetive evaluation ofthe respective roles of the primary care doctor and specialist in the management ofthis condi- tion, Most important among these advances in knowledge are 1) better definition of the entire patient population suf- fering from reflux di recognition that reflux- target for therapy and that, in the majority of patients, these have a distinctive pattern; 3) improved awareness that most reflux disease patients require long term treatment; 4) avail- ability of new comparative data on the outcomes of different strategies for the use of medical therapy; 5) more authori- tative data on the efficacy, costs, and risks of laparoscopic antireflux surgery and proton pump inhibitor (PPI) therapy for long term management; and 6) improved though still limited understanding of the contribution that endoscopy makes to the management of reflux disease. ‘The improved insights into reflux disease summarized above are advancing thinking about the respective roles of the primary care doctor and specialist in the management of reflux disease patients, but the division of labor between primary and specialist care is a complex matter, this division being determined by aspects of the health care system within Which the patient is being treated, and the degree of exper- tise of the primary care doctor and specialist in the delivery of care to reflux disease patients. It appears that this exper- tise varies widely among individuals. This i to be expected, given the recent accrual of important information. RELEVANCE OF THE SETTING OF HEALTH CARE DELIVERY Major variables inthe organization of the way in which care is being delivered to particular patients, which vary widely among and even within countries, are 1) whether the patient has direct access to a specialist or whether access depends ‘on formal referral from a primary care doctor; 2) the cost of ‘endoscopy and specialist consultation; 3) whether there are highly structured or de facto controls on the access of patients to specialist services; and 4) whether the costs of specialist services are bome mainly by the patient, from a finite budget allocated tothe primary care doctor, or whether a third party bears these costs without controlling access PATIENT-DEPENDENT FACTORS ‘The patient's own views about his or her reflux disease are also likely to impact significantly on the roles of the primaryuf. ing ay ost ‘ll Py ed of of sin ¥ ANG ~ August, Supp, 2001 care doctor and specialist, hough this has been litle re- searched. Patient-dependent factors probably include 1) the level of concem of the patient about the significance and risk that his or her reffux disease poses, and the patient's per- ception of the expertise of the primary care doctor in man- aging these; 2) the patient's readiness to accept a symptom- ‘based diagnosis and his or her beliefs about the importance ‘of having an endoscopy or some other specialized investi- gation; 3) how reassured the patient is by a convincing response to treatment delivered in primary care, a8 a sub- stitute for endoscopy; 4) how reflux disease presents in the individual patient, and therefore the degree of uncertainty bout that diagnosis; and 5) the age ofthe patient, and other factors that impact on the risk of there being significant complications or other life-threatening disorders that would require prompt diagnosis by endoscopy. RELEVANT FACTORS IN THE PRIMARY CARE DOCTOR ‘The abilities and confidence of the primary care doctor in the management of refiux disease will also have a significant impact on the role thatthe specialist is asked to play. Most important factors in the primary care doctor are 1) confi- dence with making a reliable symptom-based diagnosis of reflux disease, and the availabilty of sufficient consultation time to be able to do this effectively; 2) the perception of both the value of endoscopy for diagnosis of reflux disease and the risks of not doing this procedure: 3) understanding of the role of specialized tests other than endoscopy in the mainstream assessment of gastroesophageal reflux disease; 4) the level of understanding ofthe hierarchy of efficacy of current therapies, and how to use this hierarchy in routine ‘management; and 5) awareness that reflux disease is pre= dominantly 4 chronic problem that requires development of a long term management plan tailored to patient character- istics and response. “The complex factors listed above that influence the roles of the primary care doctor or specialist in any particular health care delivery setting all need to be considered. Most crucial, though in any setting, is the information about reflux disease that provides fundamental guidance for the most cost-effective use of health care resources for its manage- ment. Communication of this information to doctors and health care system managers is needed, and essential for appropriate tailoring of the respective roles of primary care doctors and specialists to costs and other factors that inf ence the structure of a particular health care system. DIAGNOSIS ‘Symptom Analysis ‘Symptom analysis is the most sensitive of practical diag- nostic methods for use by all dactors involved in the care of patients with reflux disease, as the patterning of reflux indueed symptoms is distinctive in the majority of patients (1-3). Indeed, it could be argued thatthe symptom pattern ‘Strategies for Diagnosis and Short and Long Term Treatment $23 of refiux disease is the most specific of any GI disorder. The data that support this bold claim are, however, somewhat indirect, and there is a need for better research studies that are primarily focused on determining the sensitivity and specificity of optimal symptom analysis in reflux disease. Heartburn is the most prevalent and distinctive symptom, which, when present, should be considered to be reflux induced until proven otherwise (1). Other aspects of the symptom patterning, such as the occurrence of regurgitation and its relationship to heartburn, and provocation of symp- toms by type and amount of food are also important. Reli- able recognition of heartburn is therefore very important, and recent studies have shown that this requires well- structured approach to the patient interview (4), Self-admin- istered questionnaires are a promising approach for transfer fof an expert structure for recognition of reflux-induced symptoms to both primary care doctor and specialist (4, ‘Symptom analysis is not only the most sensitive method for diagnosis of reflux disease, but itis also highly cost effective. Unfortunately, in many practice settings the 1ow absolute value placed on the physician interview and its value relative to endoscopy has diverted physicians from effective use of symptom analysis for evaluation of reflux disease, particularly when access to endoscopy is relatively simple and prompt. In Australia, an ongoing relative values, study in gastroenterology has substantially upgraded the value of the physician-patient interview in specialist care, an initiative that, if accepted, should lead to better sympton based diagnosis of reflux disease Because the cost of symptom analysis is included in the consultation cost, diagnosis of reflux disease by this means, without endoscopy, is very cost-effective. Though the spe- cialist sees a filtered population of patients, reliance on & symptom-based diagnosis would also seem to be reasonable in a proportion of reflux disease patients seen in specialist practice. Though no formal data exist on the attitude of specialists to reliance on symptom analysis for diagnosis of reflux disease, it appears that there is a reluctance 10 use this because of the negative pressures of medicolegal risk and expectations of the patients that they will have a specialist procedure. Also, denial of personal income of the specialist results from the decision not to perform endoscopy in many specialist practice settings, and specialists have difficulty with acceptance of the diagnostic uncertainty that they per- ceive as associated with # symptom-based diagnosis—a practice that runs counter to the conventional model of specialist medical training. The primary care doctor is much more experienced with dealing with diagnostic uncertainty ‘The diagnostic gains that endoscopy provides ate dealt with in the next section. It has been traditional teaching that sympiom analysis should also screen for alert symptoms or findings such as dysphagia, weight loss, anemia, and atypical or recently developed symptoms (1, 2). It has been believed that these symptom patterns identify patients at substantially higher risk for having diseases other than reflux disease, or com-S26 Dont plications of this. Thus, conventional clinical wisdom has been that the subgroup of patients with aler symptoms merits prompt endoscopy. A recent smdy now gives formal confirmation of the appropriateness of this strategy (5) ‘There appears to be inadequate understanding of the merits of the symptom-based diagnosis of reflux disease relative to endoscopy and pH monitoring among both spe- cialists and primary care doctors (sce below). Education Programs that convey the merits of symptom evaluation hold promise for substantial improvement ofthe cost-ffee- tiveness of the diagnosis of reflux disease. Value of Endoscopy Performance of endoscopy normally requires referral to @ specials. This may be a “technical” referral, solely for performance of endoscopy, ora referal for fll consultation on the patient's problem as Well. Thus, the cost of involve- ‘ment of a specialist in the initial management of refx disease may be substantially influenced by whether a re- quest for endoscopy by the specialist carries a mandate for the specialist to carry out a formal consultation. Expecta- tions of the diagnostic sensitivity of endoscopy for reflux disease are poorly matched to the realty. I has been shown consistently that 40-60% of patients with troublesome typ- jealreflox symptoms screened in the primary care seting have no clear-cut esophageal mucosal abnormality (1-3, 6). Thus, endoscopy is avery insensitive test for reflux disease ‘The belie that there must be an esophageal endoscopic corelte of troublesome reflox-induced symptoms can also Jead to rejection ofthe diagnosis of reflux disease triggering an inappropriate and costly search for other causes of the symptoms. Such inappropriate interpretation of a negative endoscopy i probably relatively ueommon among special. ists now, as they are better informed about the high preva- lence of endoscopy-negative reflux disease, and the faet hat it usually responds well to standard therapies for refx disease (1,2) Primary care doctors are less wel informed about these realities, and so may choose inappropriate ical strategies when given the result of an endostopy with- ‘oot also being told that a normal endoscopy by no means excludes the possibilty of refx disease. Such a comment requires the endoscopist to have some insight into the pa- tints symptom pater, ‘When esophagitis is present, endoscopy gives firm con- firmation ofthe diagnosis. Also, provided a formal grading system is used (0 define the severity of the esophagitis, endoscopy gives helpful guidance about the level of risk from the esophagitis and communicates the endoscopic findings in an explicit, standardized way in that individual Patient (1). Grading of esophagitis also can guide the eli cian inthe choice of long term management that best con. ‘trols these risks (7), as well as the patient's symptoms. Effective inital and fong term therapy should minimize the mount of drugs used, reduce numbers of subsequent doctor Visits, and reduce the perceived need for repeat endoscopies (8-10). [AIG - Val. 96, No.8, Suppl, 2003 ‘A technically well-performed endoscopy will also screen the esophagus for Baret’s esophagus, albeit at a significant additional cost for processing of histopathology samples. If no esophageal columnar metaplasia is found, this potential problem can be forgotten, but if itis present, the specialist faces a dilemma as to how the increased risk for devclop- ment of esophageal adenocarcinoma should be managed. There ae serious doubis as to whether surveillance endos- copy is cost justified (11), yet an expectation thatthe spe~ cialist undertake this (12)- There is very limited formal research into how the risks of having or developing Barret’s esophagus mold the use of endoscopy, both initial and repeated, but a strong impression that this leads to an inap- propriate level of utilization when the specialist is fre to decide how to use endoscopy. So-called short segment Bar- reit's esophagus has attracted considerable attention in the last 3 yr; the issues around this are even more complex than classie Barrett's esophagus (1, 2, 1, 12). Essentially, there ae insufficient data to guide the specialist a to whether this should be screened for and surveyed, even though around 20% of reflux disease patients have been found to have short-seginent Barret’s esophagus. Specialists are under- standably unsure and primary care dactors bewildered about the appropriate strategies for management of all types of Barret’s esophagus, but concern about this is probably an important driver of utilization of endoscopy Barium Contrast Radiology For several reasons, a barium study should be regarded as an inappropriate primary test for reflux disease: most impor- tantly, it has very low sensitivity and specificity for this diagnosis, even though it is useful for screening for other upper GI pathology (1). Despite the long known major limitations of a barium study in this setting, itis stil re- quested quite frequently by Australian primary care doctors. Esophageal Motility and pH Montworing Neither of these tests is justified for routine diagnosis of reflux disease (1, 2). They are relatively costly and incon- ‘venient and, for routine initial management, add nothing t0 ‘2 thorough symptom assessment, followed by a trial of ‘therapy with a PPI. It appears that there is substantial over- utilization of these tests by specialists, especially pH mon- itoring. Primary care doctors contribute some pressure for Use of these tests, through not having a clear understanding of their practical valve. Esophageal motility studies and pH monitoring are valu- able investigations if initial management has failed, or if symptoms could be arising from an esophageal motor dis- order other than reflux disease. Such patients are a small ‘minority and require assessment by a specialist INTIAL TREATMENT A step-up approach to initial therapy appears to remain the dominant strategy in primary care, regardless ofthe severity