Aim: To define the characteristics of patients consulting with active dyspeptic symptoms in urban general practice, and to consider the implications of applying the British Society of Gastroenterology Dyspepsia management guidelines. Design: Prospective observational study over a period of 12 months. Setting: Two multipartner, two‐centre general practices in the City of Leeds (UK) with a combined target population of 11 011 registered patients. Subjects: A total of 340 patients consulting with active dyspeptic symptoms (52% male; mean age 53 years, range 16–89 years). Results: Of the practice population, 3% consulted with dyspepsia (first‐time consulter: 19%; previous consulter not yet investigated: 30%; previously investigated: 51%). Of 168 undiagnosed patients, 43% had upper abdominal pain (dysmotility‐like symptoms in 42%), 35% had reflux symptoms, 22% had mixed symptoms, 12% had ‘alarm’ symptoms and 18% had a history of NSAID use. Patients < 45 years old with simple dyspepsia accounted for 32% of undiagnosed cases. A fifth of the workload was in dealing with undiagnosed dyspeptics over 45 years old. One per cent of the population would require endoscopy if all undiagnosed cases either > 45 years or with complicated dyspepsia were investigated. Of 172 previously investigated patients, 29% had negative tests, 25% had ‘minor’ findings, and 45% had evidence of acid‐peptic disease. Patients with duodenal ulcer disease accounted for 12% of the total workload. Conclusions: A knowledge of the characteristics of patients consulting with dyspepsia in primary care should allow the adaptation of guidelines, to ensure advice is relevant to local case mix and compatible with local resources.
Background Atrial fibrillation (AF) is the most common sustained atrial arrhythmia. AF significantly affects patients' quality of life and increase morbidity and mortality. Patients with AF need to be appropriately anticoagulated to reduce the risk of stroke. Approximately every fifth stroke is due to AF and average costs for both health and social care is £44,000 over the first five years. Recent updated guidelines on the management of AF have recommended that all patients over the age of 65 be offered screening in the community using either short term ECG or manual pulse palpation. Purpose To determine the feasibility of an innovative community pharmacy led AF detection service incorporating referral for review and treatment to a specialist arrhythmia centre. Method Community pharmacists received intensive training on AF, how to record an ECG using a Kardia monitor and documenting the consultation on a referral form hosted on a national pharmacy database called PharmOutcomes. Targeted opportunistic detection was undertaken by the pharmacists for anyone over the age of 65 years with risk factors for AF. Patients were referred by the pharmacist to the specialist team via PharmOutcomes if they had possible new AF, previous AF and not anticoagulated, anticoagulated but experiencing side effects or adherence issues or a high AF symptom burden. Patients initated on anticoagulation by the specialist team were referred back to the community pharmacist via the New Medicines Service (NMS) for adherence monitoring. Results During a proof of concept phase (May to October 2016) and an upscale phase (May 2018-May 2019) 28 pharmacies were recruited and 1737 participants were enrolled in the study. 891 (51.3%) were male, 851 (41%) were aged over 75 years. 299 patients were referred by the pharmacists and 99 of these were seen by the specialist team in clinic. 28 patients (1.6%) were diagnosed with AF. 20 out of 28 (71.0%) were initiated on anticoagulation. 29 out of 146 patients (19.9%) had previous AF with either a high symptom burden (11) or a heart rate below 50 or above 100 beats per minutes (18). 7 patients (4.3%) with previous AF were started on anticoagulation. 48 out of 99 patients (48.4%) had their medication optimised. This included rate control titration and adjustment of anticoagulation doses. 31 out of 99 patients (31.3%) required further interventions such as holter monitors, echocardiograms or referral to other specialists. Conclusions The results demonstrate that the this service is a robust multidisciplinary process for the detection, protection and perfection of AF. The direct referral pathway ensures that patients are reviewed by a specialist team and receive optimal treatment and management. Referral back to the community pharmacist via the NMS enhances concordance with anticoagulation. Further analysis is being undertaken to assess the cost-effectiveness and health impact of this service. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The Health Foundation; ASHN in collaboration with BMS Pfizer
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