Background
Gastrointestinal complaints of the upper digestive tract such as abdominal pain, heartburn, nausea and vomiting are common in the primary care setting, while the differential diagnosis might vary from functional disorders to malignancy [
1‐
4].
The diagnosis and management of gastroesophageal reflux disease (GERD) and peptic ulcer disease are of particular interest.
Helicobacter pylori (
H. pylori) infection is the main cause of peptic ulcer disease and of gastric cancer [
5]. According to the Maastricht V/Florence Consensus Report on the management of
H. pylori infection, in young patients with uninvestigated dyspepsia the ‘test-and-treat’ strategy with non-invasive test, usually urea breath test (UBT) is recommended. In older adults and in patients with alarm symptoms such as weight loss, gastrointestinal bleeding, it is recommended to perform oesophago-gastro-duodenoscopy. If
H. pylori is identified, a-14 day treatment is recommended, using proton pump inhibitors (PPIs) with clarithromycin, amoxicillin or metronidazole, with or without bismuth. At least four weeks after completing therapy, a non-invasive test is recommended to confirm eradication of the infection [
6].
The prevalence of GERD has increased over the past few years [
7,
8]. GERD causes substantial burden to the health care system. In patients with typical GERD symptoms (e.g., heartburn and regurgitation), empiric PPI therapy is a reasonable approach to confirm GERD diagnosis, while in patients with alarm symptoms, endoscopy should be performed [
9].
Primary care physicians (PCPs) play a pivotal role in the management of GERD and
H. pylori infection. Deviations from guidelines for managing
H. pylori infection and GERD were reported, including in indications for testing, choosing diagnostic tests, treatment and follow-up [
10‐
21]. Studies from Israel demonstrated gaps in the adherence to guidelines for the management of
H. pylori [
22,
23] and GERD [
24] especially among PCPs. In a large database analysis of Maccabi Health Services (MHS) we identified variations in the use of diagnostic tests of GERD compared to the guidelines [
25].
The current period is characterized by high accessibility to online resources, and by the repercussions of the “choosing wisely” initiative [
26]. This warrants an updated assessment of adherence of PCPs to the guidelines on management of
H. pylori infection compared to GERD. The aim of this study was to assess the adherence of PCPs to guidelines on the management of
H. pylori infection and GERD in adults.
Methods
Study design and population
We conducted a cross-sectional study between March and July 2017 using the survey platform of MHS, the second largest health maintenance organization (HMO) in Israel. In Israel, access to care is universal to all citizens, according to the National Health Insurance Law, implemented since 1995. Most services are given at no cost at point of care. Citizens should be insured in one of the four HMOs [
27,
28]. MHS currently has over two million members, comprising about 25% of Israel’s population.
Data collection
The study team constructed the study questionnaire (see Additional file
1). The questions accessed information on the management of
H. pylori infection and GERD, and physicians’ referral to diagnostic tests, prescriptions for treatment of these conditions. In several questions, we asked the physicians to rank the frequency that selected clinical scenarios occurred at their practices. The replies were according to a Likert scale: always, usually yes, usually no and never. In analysis of the data, the replies “always and usually yes” were combined as “yes” and the replies “usually no” and “never” were combined as “no”.
The 2012 Maastricht IV/Florence guidelines on the management of
H. pylori infection [
29] and the 2013 American College of Gastroenterology (ACG) guidelines on the management of GERD [
9] were considered as references in this study, since they were the most updated guidelines during the study period.
Information accessed from the MHS database included characteristics of the physicians, such as age (in years), sex, the year they began working at MHS and their type of work relationship with MHS (self-employed vs. employee). Information on the number of years since the board certification was obtained via the questionnaire. The survey questionnaire was distributed to physicians through the electronic mail system of MHS. The message was sent on two occasions, three to four weeks apart, to increase the response rate. Additionally, the study team contacted by telephone physicians who did not open the survey link, and interviewed those who agreed to participate in the study. Overall, 610 PCPs were randomly selected. Of these, 183 physicians responded; three physicians, who started the questionnaire, did not complete it. Thus 180 physicians were included in the study (i.e. a response rate of 30%).
Statistical analysis
Differences between responders and non-responders in background characteristics were compared using the chi-square test for categorical variables and the Student’s
t test for continuous variables. The study sample was described using frequencies and percentages for categorical variables, and means and standard deviation (SD) for continuous variables. We performed unweighted and weighted analyses. The weights were determined using the inverse probability weighting method [
30], The probability to participate in the study was obtained from a multivariable logistic regression model in which the dependent variable was participation in the study (coded as 1 = yes and 0 = no) and the independent variables were age, sex and the year of starting work at MHS.
Differences in the characteristics of participants who did and did not follow recommendations regarding referral for
H. pylori testing were examined using the Student’s
t test for continuous variables and the chi square test and Fisher Exact test for categorical variables. Statistical significance was determined as
p < 0.05. The Benjamini and Hochberg false discovery rate method was used to adjust for multiple comparisons [
31]. We analysed the data using SPSS version 25 (IBM, New York, United States).
Discussion
The main finding of this survey was the limited adherence of Israeli PCPs to the guidelines on the management of H. pylori infection, and their relatively high adherence to the guidelines on the management of GERD.
Referral to
H. pylori testing was reported by 85% of the study participants in their investigations of peptic ulcer, despite strong recommendation to test and treat
H. pylori infection in patients with this condition [
6,
29]. About half of the participants reported referring first-degree relatives of gastric cancer patients to
H. pylori testing. Current evidence suggests that eradication of
H. pylori might reduce the risk of gastric cancer [
34].
H. pylori is transmitted between family members during childhood [
32,
35]. Concurrent
H. pylori infection and a family history showed a synergetic additive effect on the risk of gastric cancer [
36]. This accentuates the importance of
H. pylori testing for individuals with a family member who had gastric cancer.
Testing and treating
H. pylori infection are recommended for patients with unexplained IDA [
6,
29]. However, this recommendation was shown to be only partially followed in the current study. This concurs with findings observed even among specialists in gastroenterology in the United States [
19]. The low adherence to this recommendation might be explained by physicians’ skepticism regarding extra-gastric effects of
H. pylori infection.
Most participants in our study reportedly prescribed triple therapy. This is despite the increase in clarithromycin resistance in
H. pylori strains in Israel [
37] and the low success rates in
H. pylori eradication [
38].
Collectively, our updated evidence reinforces findings from previous studies [
10,
11,
13‐
15,
17] regarding gaps between clinical guidelines and practices of PCPs in the management of
H. pylori infection in adults. Physicians who followed the recommendations in our study were younger; less time elapsed since their board certification and they started working at MHS more recently than did those who did not follow recommendations. These findings corroborate with previous evaluations that indicated reduced quality of care performance among physicians with increasing years in practice [
39]. Various barriers of adherence to guidelines among physicians were shown. These included low awareness, familiarity and agreement with the guidelines; difficulty in overcoming the inertia of previous practices; and external barriers that inhibit the ability to perform the recommendations [
40]. These factors should be taken into account when planning educational interventions aiming to increasing adherence with the guidelines.
In contrast to the findings regarding
H. pylori management, the guidelines for GERD management were found to be well adopted by the participants, and consistent with the recommendation of the ACG guidelines [
9]. Similar observations were reported from Eastern Asian countries [
41] and Germany [
42], while others [
20,
21,
24] reported some gaps.
Our study has limitations. The response rate to participate was low, despite our efforts to increase compliance via repeated messages and phone calls. Nonetheless, responders and non-responders had similar demographic profiles.
Conclusions
Adherence of PCPs to guidelines on the management of H. pylori infection in adults was sub-optimal, while adherence to the guidelines on GERD management was relatively satisfactory. Simplification of the guidelines and exploring barriers towards their implementation by PCPs is warranted.
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