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Survey of Primary Care Physicians' Approach to Gastroesophageal Reflux Disease in Elderly Patients

^a Departments of Medicine (Divisions of Gastroenterology and General Internal Medicine), University of Alabama at Birmingham
^b Psychology, University of Alabama at Birmingham

C. Mel Wilcox, Division of Gastroenterology & Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294-0007 E-mail: mel_wilcox{at}gihep.uab.edu.

Decision Editor: John E. Morley, MB, BCh

	Abstract

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Background. Although gastroesophageal reflux disease (GERD) is a common condition, little is known regarding physicians' approach to the diagnosis and management of GERD in elderly patients.

Methods. We surveyed by facsimile a random sample of 14,000 practicing primary care physicians throughout the United States. Physicians were questioned using a case-based format about the approach to a symptomatic patient with GERD including the use of empiric therapy, the role of diagnostic testing, and the drugs of choice to treat GERD.

Results. A total of 2241 surveys (16%) was returned and tabulated. Most respondents were either internists (37%) or family practice physicians (56%) in solo or group practice, and 74% had been in practice for 11 or more years. There were 1980 (90%) respondents who evaluated more than 6 patients per week with GERD. Empiric therapy was commonly recommended for the symptomatic patient, most often in a step-up approach beginning with H₂-receptor blockers. Diagnostic testing, usually endoscopy, was recommended appropriately in patients with alarm symptoms. Proton-pump inhibitors were most often recommended for patients failing to respond to over-the-counter H₂-receptor blockers and for those with endoscopic esophagitis; the use of cisapride in combination with H₂-receptor blockers was also commonly recommended in these scenarios.

Conclusions. The management of symptomatic GERD in elderly patients appears similar to the management of GERD in other patients. Empiric therapy was frequently recommended in a step-up approach, and diagnostic testing was appropriate. Combination therapy with cisapride and an acid-reducing agent was commonly recommended.

GASTROESOPHAGEAL reflux disease (GERD) is a common disorder. It has been estimated that approximately 40% of the adult population in the United States has heartburn at least once per month, and up to 10% experience heartburn daily ⁽¹⁾. When compared with other chronic medical conditions, such as heart failure, patients with GERD experience a similar reduction in quality of life ⁽²⁾. Although symptomatic GERD usually becomes manifest by age 60 years, some patients present with symptomatic reflux disease or a GERD-related complication later in life ⁽³⁾. In addition, as life expectancy increases, physicians will increasingly manage patients who have had reflux disease for many years in whom alterations in medical therapy will be necessary. However, to our knowledge, surveys that assess the management of GERD in elderly patients have not been performed. Because most patients with symptomatic GERD are evaluated initially by primary care physicians, we surveyed a large random sample of generalists throughout the United States to determine the current approach to the diagnosis and management of GERD focusing on patients older than 55 years of age. From our study, we hoped to learn where knowledge gaps exist regarding the approach to the diagnosis and management of GERD in this unique group of patients.

	Methods

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On the basis of two recently published guidelines on the diagnosis and treatment of GERD ⁽⁴⁾⁽⁵⁾, we developed seven brief case studies to assess primary care physicians' knowledge and understanding of each key element of the diagnosis and treatment of GERD in elderly patients. The cases were developed using a series of multiple-choice questions. On the basis of guideline recommendations, an ideal answer for each question was identified. The seven brief case studies and accompanying multiple-choice questions were then incorporated into a survey format. Demographic questions were added, including type of practice, primary specialty, number of years in practice, gender, and questions concerning the characteristics of each respondent's experience with the volume and characteristics of GERD patients in their practices.

The survey was piloted by primary care physicians and revised on the basis of their suggestions. The survey was developed for administration by facsimile to primary care physicians who manage the care of adults in the United States. Primary care physicians included general internists, general practitioners, and family practitioners. In October 1998, 131,470 physicians within these categories with available facsimile numbers were identified. Power calculation indicated that 2240 responses were necessary to generalize to the broader physician population with a 4% rate of error and a 95% level of confidence; a random sample of 14,000 physicians was identified to receive the survey. As an incentive to participate, physicians were informed that they would receive the results of the survey as well as an educational activity by facsimile that focused on the diagnosis and management of GERD and that was certified for Category 1 CME credit. These materials were sent after the survey was completed. The study was approved by our institutional review board.

	Results

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Of the 14,000 faxed surveys, 2241 (16%) were received and entered for data analysis. The demographics of the respondents are shown in Table 1 . The majority of the respondents were men and had been in practice for more than 5 years. Gastroesophageal reflux disease was a common condition evaluated by the responding physicians, with approximately 50% of respondents evaluating more than 16 patients with GERD monthly (Table 2 ). Most of the patients diagnosed with GERD were 30 to 59 years of age; only 148 (7%) of patients diagnosed with GERD were older than 60 years of age.

For a patient with chronic heartburn who is otherwise healthy, H₂–receptor blockers (H2B) were the initial drug of choice, with 1078 respondents (49%) prescribing prescription doses and 261 (12%) recommending an over-the-counter (OTC) agent. Proton-pump inhibitors (PPI) were recommended by 739 respondents (34%). Only 71 (3%) initially used the prokinetic agent cisapride. Combination therapy of these regimens was recommended in <1%. For a similar type of patient without alarm symptoms who failed to respond to an OTC H2B, 1342 respondents (62%) initiated PPI therapy, whereas 564 (26%) increased the dose of H2B, and 239 (11%) added cisapride to the medical regimen.

For a patient with persistent heartburn despite PPI therapy, 1345 respondents (60%) added cisapride to the regimen, whereas only 39% (870) increased the dose of PPI to twice daily. One hundred fourteen respondents (5%) referred the patient for laparoscopic anti-reflux surgery. Overall, anti-reflux surgery was generally recommended when symptoms did not resolve with PPI therapy (61%), although 223 respondents (10%) considered surgery when H2B failed. The cost of lifetime therapy was a consideration for surgery for 419 respondents (19%).

Two questions, made on the basis of endoscopic examination, were posed to determine the choice of therapy. In a symptomatic patient with a normal endoscopic examination, respondents were much more likely to prescribe H2B (45%) or a PPI (24%) than a prokinetic agent (12%), and combination therapy of a PPI and a prokinetic was recommended by 221 respondents (10%). In contrast, PPI were the initial treatment of choice when endoscopic esophagitis was diagnosed. A combination therapy of a PPI and a prokinetic was also commonly used as the initial therapy for a patient with endoscopic esophagitis. As noted above, even in the setting of endoscopic esophagitis, lifestyle modifications were typically recommended.

	Discussion

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To our knowledge, this is the first survey to evaluate the management practices of primary care physicians focusing on GERD in older patients. Importantly, the demographics of the respondents suggested that the appropriate physicians were sampled: Over 90% were internists and family practitioners. In addition, the responding physicians were experienced: Over 70% had been in practice for at least a decade. Furthermore, GERD was a commonly encountered problem as evidenced by the fact that almost 50% of respondents evaluated 16 or more patients per month with this condition. Therefore, the survey results are likely to be representative of the management practices of GERD in a general practice setting.

The responses to questions related to diagnostic testing suggest that the use of endoscopy and barium studies in older patients with GERD was appropriate. Upper endoscopy was most commonly ordered in a patient who had a long history of heartburn with alarm symptoms, including weight loss and dysphagia. These results are reassuring given the widespread agreement that patients with these symptoms should undergo endoscopic evaluation to exclude complications of reflux disease, such as stricture or even neoplasm ⁽⁵⁾ (Fig. 1). In addition, endoscopy was ordered for patients with long standing heartburn even when uncomplicated, suggesting a heightened awareness by primary care physicians of the association of GERD with Barrett's esophagus and adenocarcinoma.

View larger version (36K): [in this window] [in a new window]   Figure 1. Algorithm for heartburn/GERD in adults: primary care approach. Endoscopy should be considered if proton pump inhibitor (PPI) use is required beyond 6 weeks. Upper endoscopy and/or ambulatory esophageal pH monitoring where appropriate. H2RA = histamine H2-receptor antagonist; LSM = lifestyle modifications; OTC = over the counter (nonprescription). Modified from Castell and colleagues (1) with permission.

As noted above, patients with heartburn that was perceived as mild by history or patients in whom endoscopic examination was normal most often received H2B therapy first, and life-style modifications were also very commonly recommended. The use of OTC H2B was also frequently prescribed in such patients. Interestingly, for patients failing to respond to OTC H2B, a prescription dose of a H2B, rather than a PPI, was recommended a third of the time. These results suggest that a "step-up" philosophy in treatment is commonly employed in the primary care setting. In contrast, we believe that gastroenterologists would more likely use PPI but in a step-down approach; that is, initiating PPI therapy, gaining control of symptoms, and then decreasing the dose if possible.

The prokinetic agent cisapride was frequently used in combination with H2B or PPI for patients with persistent symptoms. In addition, for patients who had persistent symptoms while on once-daily PPI, only 39% of the respondents would have increased the dose of the PPI, in contrast to the 60% who would have added cisapride. These treatment recommendations are at odds with recent guidelines ⁽⁵⁾ that suggest that if a response to a PPI is suboptimal, the dose should be doubled. Recent studies of symptomatic patients with GERD suggest that up to 30% require an increased dose of PPI therapy to control symptoms ⁽⁸⁾. Nevertheless, our survey did find that PPI were commonly employed as first-line agents for patients who had daily heartburn or endoscopic esophagitis when GERD was perceived as more severe by history and when OTC H₂RA failed to resolve symptoms. Patients with more severe endoscopic disease have more acid exposure requiring more aggressive therapy ⁽⁸⁾⁽⁹⁾. Cost appeared to be a major driving force against the use of initial PPI therapy for patients with perceived mild heartburn.

Several aspects of our study deserve comment. First, since our survey was completed, cisapride has been withdrawn from the market due to safety issues. Whether these warnings have affected the apparent common practice of combination therapy for GERD remains speculative. Because cisapride will no longer be utilized, the selection for drug therapy would be interesting to evaluate. Second, our survey intentionally asked questions about patients older than 55 years of age. We did not pose questions about patients older than 75 years of age because the vast majority of patients with heartburn present before age 60. Whether the management of very elderly patients with symptomatic GERD would be different from our results is unknown. Nevertheless, we believe that our questions address the issues germane to older patients typically evaluated in a general practice setting. Although we did not pose questions to evaluate differences between the management of young or very old patients, the responses suggest that there were no striking differences in the management of elderly GERD patients as compared with what might be anticipated in patients who are older than 55 years of age. Finally, our survey is subject to the bias inherent in any large survey. Although the percentage of respondents was low, our overall large sample size should permit valid conclusions.

On the basis of our survey results, it appears that GERD is a common medical condition evaluated in clinical practice. The approach to the diagnosis of the symptomatic patient is appropriate with empiric therapy given first in the otherwise healthy patient, with diagnostic testing reserved for those with alarm symptoms. Despite the efficacy of PPI, H2B appear to be the drugs of choice for empiric therapy and for treating patients with mild esophagitis, and these agents are usually prescribed in a step-up fashion. For patients perceived to have more severe disease, combination therapy with cisapride is frequently recommended, but this recommendation is not evidenced based. Our findings can be used to further focus educational efforts on the treatment of GERD in the older patient.

	Acknowledgments

 
This study was sponsored by a grant from The American Digestive Health Foundation.

Received June 19, 2000

Accepted June 26, 2000

	References

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