NSAIDs increase risk of gastrointestinal bleeding in primary care patients with dyspepsia.

BACKGROUND: A 1-year prospective study of 545 patients with dyspepsia examined the natural history of dyspepsia in a primary care population. Predictors of gastrointestinal bleeding and other related utilization-of-service indicators were identified. METHODS: Subjects were adult primary care patients seen at a southern California county medical center. Data were collected by means of a patient questionnaire as well as from medical charts and a computerized hospital billing system. Chi-square, t test, and stepwise multiple logistic regression analyses were used to analyze the data. Outcome events were follow-up visits for any gastrointestinal event and follow-up visits for gastrointestinal bleeding specifically. RESULTS: Prior exposure to nonsteroidal anti-inflammatory drugs doubled the odds for any follow-up gastrointestinal event (odds ratio = 1.9; 95% CI = 1.4 to 2.8). Nonsteroidal anti-inflammatory drugs increased the risk for gastrointestinal bleeding by a factor of 7 (odds ratio = 7.1; 95% CI = 1.3 to 50.0). CONCLUSIONS: In a cohort of primary care patients with dyspepsia, use of nonsteroidal anti-inflammatory drugs was the most important predictor of a follow-up gastrointestinal event, both for any gastrointestinal event and gastrointestinal bleeding specifically.

Dyspepsia in primary care: perceived causes, reasons for improvement, and satisfaction with care.

BACKGROUND: While dyspepsia is a common problem in primary care populations, very little is known about patient perceptions of medical care for this disease. The present study of patients with dyspepsia treated by primary care physicians looks at causes, procedures, and reasons for improvement from the patient's viewpoint and relates these factors to patient satisfaction with family physicians' medical care. METHODS: Medical chart and billing data were collected for 545 adult patients who visited five family health centers for digestive complaints during a 6-month period in 1993. A questionnaire was completed by 288 patients 6 to 8 weeks after patient's index visit. Baseline findings are reported. RESULTS: The two most common causes of gastrointestinal problems were attributed to stress or anxiety (58%) and diet (46%). Between the time of the index visit and the baseline survey, 48% reported that they had recovered or improved. Of those who recovered or improved, most (75%) credited "taking GI medicine" followed by change in diet (44%). Patients who reported recovery or improvement of their gastrointestinal complaints (P < .001) and older patients (P = .032) were the most satisfied with overall medical care. Satisfaction with medical care was not associated with insurance coverage, procedures done, race, antiulcer medication treatment, diagnosis, general health status, or sex. CONCLUSIONS: Specific health status, ie, improvement of gastrointestinal (GI) problems, predicted patient satisfaction for 70% of cases in this study. Most patients who improved credited GI medicines for their improvement, and those who improved were more satisfied with their medical care.

Meta-analysis of risk factors for peptic ulcer. Nonsteroidal antiinflammatory drugs, Helicobacter pylori, and smoking.

Attributable risk models describe the role of three risk factors for peptic ulcer and related serious upper gastrointestinal (GI) events. The factors-nonsteroidal antiinflammatory drugs (NSAIDs), Helicobacter pylori, and cigarette smoking-have been identified as major risk factors for peptic ulcer in numerous clinical and epidemiologic studies. Overall risk ratios for each risk factor were based on meta-analyses of English-language studies of risk for peptic ulcer-related GI events. Exposure estimates for factors used data from North American populations. Summary risk and exposure values were computed for the general population, males and females separately, and the elderly. Hypothetical models of multiple factor attributable risks were developed using population attributable risk percent calculated from these summary values. General population attributable risk percent were as follows: 24%, NSAIDs; 48%, H. pylori; and 23%, cigarette smoking. Based on these numbers, the "no interaction" attributable risk model estimates that 95% of total peptic ulcer related risk is attributable to these factors in the general population. The "interaction" model attributes 89% of cases to these risk factors: 24%, NSAIDs alone; 31%, H. pylori alone; 34%, H. pylori/smoking combined. Between 89% and 95% of peptic ulcer-related serious upper GI events may be attributed to NSAID use, H. pylori infection, and cigarette smoking.

Patient and provider satisfaction with medical care.

BACKGROUND: This study compares patient and provider satisfaction with medical care and waiting time in a large family medicine residency program. Few published studies have dealt with both patient and provider perceptions. METHODS: Telephone interviews were conducted with 156 adult, English-speaking patients who were randomly selected from daily appointment schedules. The patients were asked to rate their satisfaction with 10 aspects of medical care and to estimate the length of time they waited to see their physicians. Sixty-five family health care providers responded to the same survey items through a self-administered questionnaire. RESULTS: In general, 97% of patients and 89% of providers were satisfied with the overall medical care provided at the family health center. Approximately 8% of patients and 22% of providers were dissatisfied with waiting time, and 11% of patients and nearly 60% of providers were dissatisfied with appointment scheduling. Patients' estimates of waiting time for care (mean = 16.1 minutes) were significantly shorter than providers' estimates (mean = 27.5 minutes). Patients who were dissatisfied with the length of waiting time estimated waiting 41.8 minutes, while satisfied patients estimated waiting 13.3 minutes (P less than .001). CONCLUSIONS: Family medicine patients reported higher levels of satisfaction with medical care than did providers. Both groups were the least satisfied with access to care.

A prospective study of risk for peptic ulcer disease in Seventh-Day Adventists.

Cross-sectional and prospective data were collected and analyzed to identify risk factors for the development of peptic ulcer disease in a population of 34,198 white, non-Hispanic Seventh-Day Adventists. On a life-style questionnaire administered in 1976, 3853 subjects reported ever having had a physician-diagnosed peptic ulcer for a lifetime prevalence of 13.5% for men and 11.0% for women. Odds ratios of greater than 2.0 (P less than 0.0001) were observed for use of "stronger pain relievers," current cigarette smoking, and history of rheumatism or other arthritis and coronary disease. For both sexes, lower but statistically significant odds ratios (P less than 0.05) were found for eating white bread, "snacking," ever having smoked cigarettes, low church involvement, poor dietary adherence, high blood pressure, rheumatoid arthritis, aspirin use, job frustration and dissatisfaction, having a "blue collar household," and having less education. During 3 years of follow-up, 154 incident cases of ulcer were identified. The average annual incidence was 1.7 per 1000. Multivariate adjusted relative risks were statistically significant for using stronger pain relievers (P less than 0.001), having rheumatic conditions (P = 0.006), and using aspirin (P = 0.013). These findings suggest that rheumatic disease and use of aspirin and stronger pain relievers are more important risk factors for development of peptic ulcer disease in certain populations than diet, life-style, or psychological or socioeconomic characteristics.

Comparison of ranitidine and cimetidine ulcer maintenance therapy.

We used published results from clinical trials to evaluate the efficacy of ranitidine and cimetidine as maintenance therapy following healing of acute duodenal ulcers. Only studies in which patients were treated with an evening-meal or bedtime dose of ranitidine (150 mg) or cimetidine (400 mg) over a 12-month period were used. The results from the analysis of seven clinical trials where ranitidine was directly compared to cimetidine indicated that 8.4% fewer patients experienced an ulcer recurrence on ranitidine (p less than 0.01). The estimate of the common odds ratio was 1.63, which indicated higher odds of recurrence versus nonrecurrence for cimetidine than ranitidine patients. The 95% confidence interval for the odds ratio ranged from 1.21 to 2.21. When data from placebo trials were included in the analysis, ulcer recurrence was 6.8% lower for ranitidine than for cimetidine (p less than 0.01).

Sex and smoking differences in duodenal ulcer mortality.

Data from the US Census Bureau and the National Center for Health Statistics suggest that differences in male and female smoking habits between 1920 and 1980 may have contributed to changes in duodenal ulcer mortality sex ratios. An attributable risk analysis suggests that between 43 per cent and 63 per cent of duodenal ulcer mortality for males results from smoking; the comparable figures for females being between 25 per cent and 50 per cent.