Management of dyspepsia across the primary-secondary healthcare interface

Primary care remains at the frontline of care for most patients and the need to contain healthcare costs has led to a re-evaluation of the divide between primary and secondary care. Dyspepsia has a community prevalence of 25-50%, and forms 5% of the primary care physician's workload, 10% of whom are referred to a specialist. Problems presenting in primary care tend to be undifferentiated; those who do not have alarm symptoms and are under the age of 55 years are unlikely to have serious pathology. Management is largely symptom driven, on an empirical basis rather than on a diagnostic model as in secondary care where investigation rates are higher. The predictive value of symptoms for a specific diagnosis is small; primary care physicians include gastro-oesophageal reflux disease as part of the dyspepsia complex and the overall expenditure on acid suppression therapy is relatively large. The availability of open-access investigations such as endoscopy has influenced specialist referral rates and the ability to diagnose and treat patients with Helicobacter pylori-related problems has opened further opportunities. However, variations in the availability of the recommended diagnostic tests and the implications to primary care clinical practice of some of the new management recommendations (Maastricht II) in some national settings illustrate the divide with secondary care. The gap between primary and secondary care is narrowing in gastroenterology and the two groups need to continue collaboration to attain effective and cost-effective management for their patients.