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Valori and colleagues (Gut 2001;49:495–501) assessed the effectiveness of an educational programme to reduce dyspepsia costs in the community.
Given one of the hypotheses was that quality of care would be improved because of “a more active stepdown approach for reflux symptoms and a switch from ranitidine to generic cimetidine” an analysis of changes in the type and volume of specific drugs would appear warranted to support the authors conclusions. It would also provide much needed data on the effectiveness of the “stepdown” approach recommended for the management of gastro-oesophageal reflux disease.1
The authors also report a subsequent fall in admissions to the gastrointestinal bleed unit in West Gloucestershire. Data are needed to assess whether this is due to their intervention or to natural variation. Of particular interest is the proportion of admissions for Helicobacter pylori related peptic ulcer bleeds in west compared with east Gloucestershire.
The high prevalence of non-definitively treated H pylori associated peptic ulcer disease in primary care has been demonstrated in a number of studies and remains a difficult management issue.2,3 In Australia, in 1999, only 1.3% of all antiulcerant prescriptions were for H pylori eradication therapy.4
Analysis of the volume of prescriptions for eradication therapies in each region during the study period would allow assessment of the impact of their strategy on the prevalence of H pylori associated peptic ulcer disease.
Details of individual drug usage were not available for the entire study period and therefore it was not possible to analyse changes for particular drugs.
The purpose of providing the gastrointestinal bleed unit and other data was to give an indication of whether the intervention might have adverse effects on other health outcomes related to dyspepsia. We were particularly concerned that the intervention might increase demand for endoscopy or increase morbidity from peptic ulcer complications. We acknowledge that during the study period it is possible that there may have been a natural decline in referral for endoscopy and gastrointestinal bleeding. Thus without a control group for these outcomes it is possible that the stable levels demonstrated in the study represent a real increase. However, we believe that this is exceedingly unlikely given the continued strong demand for endoscopy elsewhere and the steady rise in emergency medical admissions in the UK. We do not have sufficiently accurate data to make comment on whether the intervention reduced Helicobacter pylori related peptic ulcer bleeds.
It was not possible in this study to identify individual H pylori prescriptions. A more relevant outcome might have been the number of patients who, following eradication therapy (for whatever reason), no longer needed long term acid suppressing medication. Feedback from general practitioners suggests that there were many patients who responded in this way. Unfortunately, we have no hard data to support the anecdotal reports of the impact of H pylori eradication on drug costs.