Cardin F, Zorzi M, Furlanetto A, Guerra C, Bandini F, Polito D, Bano F, Grion A M, Toffanin R
Servizio di Gastroenterologia, Ospedale Geriatrico, ULSS 16, Padova, Italy.
Scand J Gastroenterol. 2002 Nov;37(11):1269-75. doi: 10.1080/003655202761020533.
Spontaneous physician behaviour can affect guideline applicability, implementation strategies and application costs, particularly in relation to widespread pathologies chiefly managed by general practitioners (GPs). Of the array of dyspepsia management guidelines, the closest to general practice, partly owing to proposing committee composition, are the European Society for Primary Care Gastroenterology (ESPCG) guidelines.
To evaluate variability in dyspepsia management among GPs in Padua and divergence in spontaneous prescriptive behaviour from the ESPCG dyspepsia guideline, we prospectively studied the behaviour of 39 GPs over a 3-month period of outpatient activity, through questionnaires on each consultation. Test-group representativeness was preliminarily defined in terms of antisecretory drug expenditure.
1790 forms on dyspepsia-related consultations were studied in a population of 51,193 registered patients; 1264 patients with a history of dyspeptic pathology consulted their GP (19% duodenal ulcer (DU), 9% gastric ulcer (GU), 54% gastro-oesophageal reflux disease (GERD), 32% non-ulcer dyspepsia (NUD), 1% cholelithiasis), while 526 patients presented with symptoms of dyspepsia with no previous gastroscopy (EGDS) (42% were aged <45 years), of whom 42% had twice consulted their GP. Empirical management by prescription of symptomatic drugs was the most common procedure in DU (33%), GU (73%) and NUD (74%) relapses. Helicobacter pylori eradication therapy was prescribed in only 2% of patients with a history of organic or functional dyspepsia. 145 patients with uninvestigated dyspepsia were referred for second-level endoscopy and 43 for H. pylori testing. Forty-four percent of endoscopies prescribed for uninvestigated patients did not comply with the ESPCG guideline; full compliance would have determined a 105% rise in endoscopies. Prescriptive variability between GPs was high (based on the Goodman-Kruskal (0.41, P < 0.001) and Cramer tests (V = 0.51, P < 0.005)) and agreement between observed and expected prescriptions according to ESPCG criteria was as low as V = 0.11. On the basis of the most frequently observed behaviours, we developed three options of the ESPCG guideline and compared them to spontaneous prescriptions.
Highest compliance emerged where the clinical approach for all patients with uninvestigated dyspepsia was symptomatic therapy at first presentation followed by a different attitude at second presentation, setting a higher cut-off age than in the guideline (which in our case proved, on mathematical calculation, to be 55 years).
医生的自发行为会影响指南的适用性、实施策略和应用成本，尤其是对于主要由全科医生（GP）管理的常见病症。在一系列消化不良管理指南中，最贴近全科医疗实践的当属欧洲初级保健胃肠病学学会（ESPCG）指南，这在一定程度上得益于其推荐的委员会组成。
为了评估帕多瓦地区全科医生在消化不良管理方面的差异，以及其自发处方行为与ESPCG消化不良指南的差异，我们通过对每次会诊进行问卷调查，前瞻性地研究了39名全科医生在3个月门诊活动期间的行为。试验组的代表性最初根据抗分泌药物支出进行定义。
在51193名注册患者中，研究了1790份与消化不良相关会诊的表格；1264名有消化不良病史的患者咨询了他们的全科医生（19%为十二指肠溃疡（DU），9%为胃溃疡（GU），54%为胃食管反流病（GERD），32%为非溃疡性消化不良（NUD），1%为胆石症），而526名患者出现消化不良症状但之前未进行过胃镜检查（EGDS）（42%年龄<45岁），其中42%的患者曾两次咨询他们的全科医生。对于DU（33%）、GU（73%）和NUD（74%）复发患者，最常见的处理方式是凭经验处方对症药物。在有器质性或功能性消化不良病史的患者中，仅2%的患者接受了幽门螺杆菌根除治疗。145名未经检查的消化不良患者被转诊进行二级内镜检查，43名患者进行幽门螺杆菌检测。为未经检查的患者开具的内镜检查中有44%不符合ESPCG指南；若完全符合指南，内镜检查数量将增加105%。全科医生之间的处方差异很大（基于古德曼 - 克鲁斯卡尔检验（0.41，P < 0.001）和克莱默检验（V = 0.51，P < 0.005）），根据ESPCG标准观察到的处方与预期处方之间的一致性低至V = 0.11。根据最常观察到的行为，我们制定了ESPCG指南的三种方案，并将其与自发处方进行比较。
对于所有未经检查的消化不良患者，最高的依从性出现在初次就诊时采用对症治疗，然后在第二次就诊时采取不同态度，设定比指南更高的年龄界限（在我们的案例中，经数学计算为55岁）。
