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Evaluation of young patients with rectal bleeding: A Markov model
AI088 AGA ABSTRACTS
GASTROENTEROLOGY Vol. 118, No.4
5038
5040
THE PREVALENCE OF FUNCTIONNAL DIGESTIVE SYMPTOMS (FDS) IN A PRECARIOUSNESS FRENCH POPULATION. Jean-Louis Legoux, Hubert Allemand, Frederic Los, Catherine Pecout, Martine De1herme, Jacques Frexinos, CHU de Bordeaux, Pessac, France; Public Health, Besancon, France; Sofres, Montrouge, France; Parke-Davis, Courbevoie, France; Occupational Health, Paris, France; CHU de Toulouse, Toulouse, France.
RELATIONSHIPS BETWEEN SYMPTOM SUBGROUPS AND MANAGEMENT STRATEGY OUTCOME IN PRIMARY CARE DYSPEPSIA. Nicoline T. Lewin-van de Broek, Erik Buskens, Theo J. Verheij, Niek J. de Wit, Andre 1. Smout, Mattijs E. Numans, Julius Ctr, Univ Med Ctr, Utrecht, Netherlands; Dept Gastroenterology, Univ Med Ctr, Utrecht, Netherlands. Background: The first step in the management of uncomplicated dyspepsia in primary care often consists of prescribing empirical therapy. Such therapy is usually based on the patient s symptoms and the presumed underlying pathology that causes these symptoms. Questions have arisen about the value of subgrouping when choosing a management strategy for primary care dyspepsia. Methods: We performed a randomized trial to compare the results of four management strategies in dyspeptic primary care patients and to estimate the value of subgrouping. Patients were allocated to either (I) empirical treatment in which therapy was based on the presented symptoms, or empirical treatment with (2) omeprazole or (3) cisapride regardless of the presented symptoms, or (4) prompt endoscopy followed by the appropriate treatment. Patients were classified into refluxlike, ulcer-like, and non-specific subgroups per strategy by using baseline data registered by the general practitioner. Yield was measured as the number of strategy failures. Findings: Of 349 included patients, 326 were analysed. No statistically significant difference was found between the strategies or between the symptom subgroups. However, patients in the reflux-like subgroup showed a trend towards a better outcome in all strategies. Ulcer-like dyspepsia seemed to benefit from omeprazole. The non-specific subgroup seemed to benefit from cisapride, but also had the highest proportion of strategy failure. Prompt endoscopy did not appear useful in any SUbgroup. Interpretation: The use of symptom subgroups seems to be a sensible approach when choosing empirical therapy. Patients with reflux-like symptoms appear to respond well to empirical therapy.
A previous survey of 4817 subjects representative of the general French population (GFP) aged 15 years and over demonstrated a high prevalence of FDS : 65 % of the population (28 millions) and 45 % (12,5 millions) of whom declared discomfort from the condition. At the same time, the same questionnaire was proposed to precariousness people (PP). This study compare the results of the both surveys. Methods: 907 consecutive precariousness persons (on income support, on an unemployed training scheme for 16-25 year olds or unemployed for more than 6 months), covered by the French social security system, attending 10 free health-care centers during the period of the survey (26/10 - 5/12/1996), and able to read French, were included in the study and completed the questionnaire used for the GFP (describing sociodemographic data and their gastrointestinal disorders : symptoms, duration, frequency, experience, discomfort and health-care consequences). Patients presenting with symptoms presumed to be organic in origin were excluded. Results: 52% PP reported FDS vs 65% in the GFP (p < 0.01). The sex ratio was 0.55. Pain was more frequent than in the GFP (60 vs 51 %, p 25 years olds, p 35 years olds (60% vs 48.5%, p<0.02) and in subjects which live alone (67 % vs 56 %, p
5039 COMPARISON OF THE KNOWLEDGE AND PRACTICES OF INTERNAL MEDICINE (1M) TRAINEES IN GREECE AND THE US CONCERNING H. PYLORI (HP) INFECTION. Grigoris I. Leontiadis, Virender K. Sharma, Colin W. Howden, George E. Kitis, Dept of Gastroenterology, G Papanikolaou Hosp, Thessaloniki, Greece; Univ of Arkansas for Med Sci, Little Rock, AR; Northwestern Univ, Chicago, IL. Background: The practices of US 1M residents concerning Hp infection have recently been reported (Am J Gastroenterol 1999; 94: 2618). The prevalence of Hp infection is higher in Greece than the US and national guidelines for the management of Hp infection are in place. Objectives: To assess the level of understanding of Greek 1M trainees surrounding Hp infection and to compare these with US 1M residents. Methods: We applied a slight modification of a questionnaire developed for US 1M residents to 116 1M trainees in Greece. Results: 78 were men; 71 planned careers in primary care; all were within 5 years of the start of postgraduate training. 38% used office-based tests for Hp (cf 64% in US; P
5041 EVALUATION OF YOUNG PATIENTS WITH RECTAL BLEEDING: A MARKOV MODEL. James D. Lewis, Alphonso Brown, J. S. Schwartz, Univ of Pennsylvania, Philadelphia, PA. Background: The optimal diagnostic strategy for young patients with rectal bleeding is unknown. Our model examines the relative cost-effectiveness of alternative diagnostic strategies. Methods: A Markov model was used to simulate the natural history of patients with rectal bleeding from benign diseases and/or colonic neoplasms. The base case is a 35 year old with otherwise asymptomatic hematochezia. The model assumes that persons with anal disease (hemorrhoids or fissure) are less likely to have a colonic neoplasm present at the time of bleeding. Diagnostic strategies included no evaluation, colonoscopy (COL), flexible sigmoidoscopy (FS), barium enema (BE), anoscopy, and all feasible combinations of these modalities. Estimates for variables in the model were obtained from the medical literature. Direct costs associated with performance of diagnostic procedures were based on Medicare reimbursement rates. Results: No evaluation yields the lowest life expectancy (figure). Strategies using anoscopy to triage persons with anal disease to no further evaluation yield lower life expectancies than a strategy of FS in all patients, at comparable costs. A strategy of FS plus BE yields the greatest life expectancy at a cost of $20,175 per year of life gained versus BE alone. In the base case, a strategy of FS plus BE yields greater life expectancy at reduced cost compared to COL. However, the incremental cost-effectiveness ratio comparing FS plus BE to COL is sensitive to estimates of the sensitivity of the tests. Using the maximum estimate of sensitivity of COL and the minimum estimate of the sensitivity of BE, a strategy of COL yields greater life expectancy at a cost of $18,812 per year of life gained. Conclusion: Evaluation of the colon of young patients with rectal bleeding yields an increase in life expectancy at cost comparable to screening for colon cancer. Based on our model, we recommend evaluation of the entire colon in young patients with hematochezia.
..
~
Q (,)
1
550 500 450
C 400 :l
H
D
A
B
Q
.M Cl
C E
F
G
350 300 22.99
23
23.01
23.02
23.03
Discounted Life Expectency (yeefs)
A - No Evab..tio" B - Am.copy+ FS C - Am.copy+ BE
D - A_copy+ Colom.oopy
G-BE
E - Am.copy+ FSIBE F-FS
1- Colom.oopy
H -FSIBE
GASTROENTEROLOGY Vol. 118, No.4
5038
5040
THE PREVALENCE OF FUNCTIONNAL DIGESTIVE SYMPTOMS (FDS) IN A PRECARIOUSNESS FRENCH POPULATION. Jean-Louis Legoux, Hubert Allemand, Frederic Los, Catherine Pecout, Martine De1herme, Jacques Frexinos, CHU de Bordeaux, Pessac, France; Public Health, Besancon, France; Sofres, Montrouge, France; Parke-Davis, Courbevoie, France; Occupational Health, Paris, France; CHU de Toulouse, Toulouse, France.
RELATIONSHIPS BETWEEN SYMPTOM SUBGROUPS AND MANAGEMENT STRATEGY OUTCOME IN PRIMARY CARE DYSPEPSIA. Nicoline T. Lewin-van de Broek, Erik Buskens, Theo J. Verheij, Niek J. de Wit, Andre 1. Smout, Mattijs E. Numans, Julius Ctr, Univ Med Ctr, Utrecht, Netherlands; Dept Gastroenterology, Univ Med Ctr, Utrecht, Netherlands. Background: The first step in the management of uncomplicated dyspepsia in primary care often consists of prescribing empirical therapy. Such therapy is usually based on the patient s symptoms and the presumed underlying pathology that causes these symptoms. Questions have arisen about the value of subgrouping when choosing a management strategy for primary care dyspepsia. Methods: We performed a randomized trial to compare the results of four management strategies in dyspeptic primary care patients and to estimate the value of subgrouping. Patients were allocated to either (I) empirical treatment in which therapy was based on the presented symptoms, or empirical treatment with (2) omeprazole or (3) cisapride regardless of the presented symptoms, or (4) prompt endoscopy followed by the appropriate treatment. Patients were classified into refluxlike, ulcer-like, and non-specific subgroups per strategy by using baseline data registered by the general practitioner. Yield was measured as the number of strategy failures. Findings: Of 349 included patients, 326 were analysed. No statistically significant difference was found between the strategies or between the symptom subgroups. However, patients in the reflux-like subgroup showed a trend towards a better outcome in all strategies. Ulcer-like dyspepsia seemed to benefit from omeprazole. The non-specific subgroup seemed to benefit from cisapride, but also had the highest proportion of strategy failure. Prompt endoscopy did not appear useful in any SUbgroup. Interpretation: The use of symptom subgroups seems to be a sensible approach when choosing empirical therapy. Patients with reflux-like symptoms appear to respond well to empirical therapy.
A previous survey of 4817 subjects representative of the general French population (GFP) aged 15 years and over demonstrated a high prevalence of FDS : 65 % of the population (28 millions) and 45 % (12,5 millions) of whom declared discomfort from the condition. At the same time, the same questionnaire was proposed to precariousness people (PP). This study compare the results of the both surveys. Methods: 907 consecutive precariousness persons (on income support, on an unemployed training scheme for 16-25 year olds or unemployed for more than 6 months), covered by the French social security system, attending 10 free health-care centers during the period of the survey (26/10 - 5/12/1996), and able to read French, were included in the study and completed the questionnaire used for the GFP (describing sociodemographic data and their gastrointestinal disorders : symptoms, duration, frequency, experience, discomfort and health-care consequences). Patients presenting with symptoms presumed to be organic in origin were excluded. Results: 52% PP reported FDS vs 65% in the GFP (p < 0.01). The sex ratio was 0.55. Pain was more frequent than in the GFP (60 vs 51 %, p
5039 COMPARISON OF THE KNOWLEDGE AND PRACTICES OF INTERNAL MEDICINE (1M) TRAINEES IN GREECE AND THE US CONCERNING H. PYLORI (HP) INFECTION. Grigoris I. Leontiadis, Virender K. Sharma, Colin W. Howden, George E. Kitis, Dept of Gastroenterology, G Papanikolaou Hosp, Thessaloniki, Greece; Univ of Arkansas for Med Sci, Little Rock, AR; Northwestern Univ, Chicago, IL. Background: The practices of US 1M residents concerning Hp infection have recently been reported (Am J Gastroenterol 1999; 94: 2618). The prevalence of Hp infection is higher in Greece than the US and national guidelines for the management of Hp infection are in place. Objectives: To assess the level of understanding of Greek 1M trainees surrounding Hp infection and to compare these with US 1M residents. Methods: We applied a slight modification of a questionnaire developed for US 1M residents to 116 1M trainees in Greece. Results: 78 were men; 71 planned careers in primary care; all were within 5 years of the start of postgraduate training. 38% used office-based tests for Hp (cf 64% in US; P
5041 EVALUATION OF YOUNG PATIENTS WITH RECTAL BLEEDING: A MARKOV MODEL. James D. Lewis, Alphonso Brown, J. S. Schwartz, Univ of Pennsylvania, Philadelphia, PA. Background: The optimal diagnostic strategy for young patients with rectal bleeding is unknown. Our model examines the relative cost-effectiveness of alternative diagnostic strategies. Methods: A Markov model was used to simulate the natural history of patients with rectal bleeding from benign diseases and/or colonic neoplasms. The base case is a 35 year old with otherwise asymptomatic hematochezia. The model assumes that persons with anal disease (hemorrhoids or fissure) are less likely to have a colonic neoplasm present at the time of bleeding. Diagnostic strategies included no evaluation, colonoscopy (COL), flexible sigmoidoscopy (FS), barium enema (BE), anoscopy, and all feasible combinations of these modalities. Estimates for variables in the model were obtained from the medical literature. Direct costs associated with performance of diagnostic procedures were based on Medicare reimbursement rates. Results: No evaluation yields the lowest life expectancy (figure). Strategies using anoscopy to triage persons with anal disease to no further evaluation yield lower life expectancies than a strategy of FS in all patients, at comparable costs. A strategy of FS plus BE yields the greatest life expectancy at a cost of $20,175 per year of life gained versus BE alone. In the base case, a strategy of FS plus BE yields greater life expectancy at reduced cost compared to COL. However, the incremental cost-effectiveness ratio comparing FS plus BE to COL is sensitive to estimates of the sensitivity of the tests. Using the maximum estimate of sensitivity of COL and the minimum estimate of the sensitivity of BE, a strategy of COL yields greater life expectancy at a cost of $18,812 per year of life gained. Conclusion: Evaluation of the colon of young patients with rectal bleeding yields an increase in life expectancy at cost comparable to screening for colon cancer. Based on our model, we recommend evaluation of the entire colon in young patients with hematochezia.
..
~
Q (,)
1
550 500 450
C 400 :l
H
D
A
B
Q
.M Cl
C E
F
G
350 300 22.99
23
23.01
23.02
23.03
Discounted Life Expectency (yeefs)
A - No Evab..tio" B - Am.copy+ FS C - Am.copy+ BE
D - A_copy+ Colom.oopy
G-BE
E - Am.copy+ FSIBE F-FS
1- Colom.oopy
H -FSIBE