Wednesday, September 02, 2009

Guideline adherence in the treatment of dyspepsia

I’m fascinated by studies of this type. Why is adherence to evidence so low? According to this survey published in Alimentary Pharmacology and Therapeutics regarding to adherence to best practice in dyspepsia treatment:

Results The expert, community gastroenterologist and PCP groups endorsed 75%, 73% and 57% of best practices respectively. Gastroenterologists were more likely to adhere with guidelines than PCPs (P less than 0.0001). PCPs were more likely to define dyspepsia incorrectly, overuse radiographic testing, delay endoscopy, treat empirically for Helciobacter pylori without confirmatory testing and avoid first-line proton pump inhibitors (PPIs). PCPs had more concerns about adverse events with PPIs [e.g. osteoporosis (P = 0.04), community-acquired pneumonia (P = 0.01)] and higher level of concern predicted lower guideline adherence (P = 0.04).

Conclusions Gastroenterologists are more likely than PCPs to comply with best practices in dyspepsia, although compliance remains incomplete in both groups. PCPs harbour more concerns regarding long-term PPI use and these concerns may affect therapeutic decision making. This suggests that best practices have not been uniformly adopted and persistent guideline-practice disconnects should be addressed.

As revealed by the study, one of the causes of guideline-practice disconnects is concern over adverse effects. What may be less clear is whether this is appropriate concern or over reaction to hype. Of course PPIs have long term adverse effects but what does the best evidence say about the benefits in comparison to the risks when used appropriately? Put another way: If use of PPIs was more evidence based appropriate use would increase and inappropriate use would decrease. Then wouldn’t patients be better off?

The media put adverse effects in the public spotlight, but not the benefits of guideline based use. Your gramma probably knows about the hip fracture risks of PPIs but how many people, even physicians, are familiar with the guidelines?

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