In this PhD project, the intervention and subsequent quality measurement focused on four diagnostic groups, i.e., patients referred within four common diagnostic scenarios in the hospital ambulatory care setting. The scenarios were chosen to represent several specialties across the medical spectrum. In addition, they represent clinical situations with some diagnostic difficulty in primary care, encompass symptoms with which patients commonly present in GP practice, and are adept for relatively simple referral guidelines.
They are also scenarios in which differential diagnoses are potentially very serious, but where many patients have more mundane explanations for their symptoms.
2.5.1 Dyspepsia
Dyspepsia usually refers to recurrent pain or discomfort in the upper abdomen[74].
In the Roma III classification of functional gastrointestinal disorders, functional dyspepsia includes one or more of the following symptoms: (a) bothersome postprandial fullness, (b) early satiation, (c) epigastric pain, and (d) epigastric burning. For the Roma III criteria to be fulfilled there also has to be no evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms[75]. However, dyspepsia is a term which has had many interpretations by different physicians[75], and the diagnosis of functional dyspepsia can only be applied after investigation. In the primary care setting, the term ‘uninvestigated dyspepsia’ is often used[74], as it is difficult to clinically differentiate between dyspepsia
20
and, for instance, gastroesophageal reflux disease[76]. The current PhD project considered referrals from primary care, and as such a wider definition of dyspepsia was used: all patients referred with uninvestigated upper gastrointestinal symptoms were included. This included patients with upper abdominal pain/discomfort, upper abdominal burning, reflux symptoms, early satiety and so forth.
Approximately 20-30% of people in Western societies report dyspeptic symptoms[77,78]. Dyspepsia represents about 2-5% of all medical consultations, in
European populations[79]. Of these, approximately 25% have an underlying organic cause at gastroscopy[80]. In the United Kingdom, the cost of dyspepsia from a health services
perspective was estimated at £500 million in 2002[81]. This figure is probably lower today, in light of cheaper medication, but dyspepsia still represents major financial burden, in addition to the burden of symptoms borne by patients.
Others have tried to use symptoms to differentiate significant from more mundane underlying disease[82], and to prioritise between patients with upper gastrointestinal symptoms[83]. There is an internationally accepted set of ‘alarm features’ (Table 1) specifically aimed at identifying underlying malignancy[84]. In this PhD project, these
features were included in the construction of the referral template, although not all of them were prioritised in the final version.
Table 1 – Alarm features in a patient with dyspepsia Age >55 years with new-onset dyspepsia
Family history of upper gastrointestinal cancer Unintended weight loss
Gastrointestinal bleeding Progressive dysphagia Odynophagia
Unexplained iron deficiency anaemia Persistent vomiting
Palpable mass or lymphadenopathy Jaundice
21 2.5.2 Suspected colorectal malignancy
Colorectal cancer is a major malignancy. In 2012, the age-standardised incidence rate of colon cancer in Norway was 24.1/100,000 for women and 26.7/100,000 for men, making it the second most common cancer amongst women and third most common amongst men[85]. Colon cancer ranked third in terms of cancer mortality in Norway 2012 for both men and women[85]. Cancers of the rectum and anus are also potentially serious
conditions.
Common symptoms of colorectal cancer include occult blood in stool, rectal bleeding, change in bowel habits, abdominal pain, weight loss, fatigue, and diarrhoea[86]. However, no single, clear symptom can currently identify patients with colorectal cancer in primary care, although a combination of symptoms can alert a GP as to the possible diagnosis[87-89].
Referral prioritisation systems, like the 2-week wait in the United Kingdom, have struggled to improve diagnostic certainty[90]. Some countries have screening programmes in place for colorectal cancer, but the Norwegian programme is still in a pilot phase[91]. Hence, the early identification of patients with this potentially serious disease remains difficult.
2.5.3 Chest pain
Coronary artery disease remains an important, albeit decreasing, cause of mortality;
ischaemic heart disease was responsible for 11.6% of deaths in Norway in 2012[92]. Chest pain is the symptom most classically associated with coronary artery disease, but non-life-threatening aetiologies are much more common explanations for chest pain in general practice[93]. Causes of chest pain other than coronary artery disease include acute diseases such as pulmonary embolus, aortic dissection, and perforated gastric ulcer, together with more benign, less acute diseases, such as musculoskeletal chest pain, gastroesophageal reflux disease, pneumonia, pleuritis, stress, panic disorder, and other psychogenic diseases[94].
Earlier epidemiological work in the United Kingdom suggests that 14% of men report chest pain suggestive of coronary artery disease and a further 24% report atypical chest pain[95]. Patients with chest pain represent approximately 1% of the GP caseload[96,97].
However, only about 10% of patients end up with a diagnosis of stable coronary artery disease, and about 1-4% with acute coronary syndrome[97,98]. Much of the diagnostic
22
work-up and consideration is focused on the identification of those 10% of patients with coronary artery disease. The patients referred by the GP to the hospital for chest pain evaluation represent an important, and sometimes challenging, proportion of medical out-patients. Hence, the current project included patients referred for chest pain evaluation or evaluation of suspected coronary artery disease.
2.5.4 Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) is an airway disease with persistent, and usually progressive, airflow limitation, coupled with an enhanced chronic inflammatory response[99]. It is often associated with acute exacerbations and comorbidities[99]. In many countries, the prevalence of COPD is directly related to tobacco smoking; however indoor and outdoor pollution may also be contributing factors, especially in developing
countries[100].
It has been estimated that between 250,000 and 300,000 suffer from COPD in
Norway[101], with a yearly incidence of about 1% of the population[102]. For approximately 1% of the population, the disease is serious enough to warrant regular review by primary and/or secondary care[101]. In 2009, almost 1% of the Norwegian health expenditure was estimated to be attributable to COPD[103]. More than 2000 people die from COPD every year in Norway, which is almost equal to the number of people who die from lung
cancer[92]. It is also clear that many of those affected are unaware that they have the disease, as only 43% of incident cases in a Norwegian population study had a prior diagnosis of asthma, bronchitis, emphysema, and/or COPD[102], suggesting a clear phenomenon of underdiagnosis.