H. Pylori related diseases:Where are we at & where are we going?
There is no controversy that H. Pylori (HP) causes gastritis. However, to date, there is no direct evidence that HP causes any ulcers. There is good statistical correlation between ulcer diseases and HP yet statistical correlation does not imply causality. HP induced gastritis is associated with hypochlorohydria and increased bicarbonate secretion seen with gastric ulcer (GU). Low acid and high bicarbonate secretion associated with HP has been found to be protective against the development of reflux oesophagitis (GORD). This is believed to be the reason why GORD develops for the first time after eradication of HP for duodenal ulcers (DU)(1).Despite greater than 90% correlation of HP and DU, paradoxically acid secretion is increased and bicarbonate secretion is decreased in DU. Yet HP eradication reduces relapse of DU although not to the extent it was believed in the past. Recent meta-analysis of randomized trials indicate a relapse rate of 20% of DU 6 months after HP eradication(2).So what shall we do? The following are my suggestions:
GU and DU: Eradicate HP if positive in CLO test or antral histology. Please re- member 27% of all ulcers are non-HP and non-NSAID/Aspirin(3).
GORD: Do not eradicate HP .There is Good evidence that you could aggravate GORD by removing HP(1).
NSAID/ASPIRIN ULCERS: Do not eradicate HP. Some studies even suggest slow healing of these ulcers after HP eradication(4).
Dyspepsia: Large multiple good studies demonstrate no advantage in eradication of HP(5). Empirical treatment with PPI helps 20% of patients.
Gastric Cancer Prevention: Jury is still out on this .There is some statistical correlation with HP. Good controlled animal studies are contradictory: Mongolian Gerbils develop gastric Ca with HP where as Monkeys do not. Large prospective Japanese studies are awaited. Suggest eradicate HP if there is family history or patient has specific concerns.
Accreditation:What does it mean or do for patient care?
We have recently achieved accreditation in Dec 2003 at the Southcoast Digestive Diseases Centre. After countless hours over 18 months and after having created a mountain of paper work, I learnt that accreditation does very little to enhance core patient care. Accreditation has no means of measuring the level of training, commitment, attitude or complication rates of doctors or nurses,the very attributes which affect the outcome of what we do for our patients day after day. However, accreditation audits and certifies the management structure and processes peripheral to core patient care. I can see that certification, audit and standardization of processes will have some relevance for large hospital groups and businesses such as Qantas. However, I fail to see what overbearing relevance accreditation could have for single speciality day theatres who have a dozen employees or so particularly since the large health funds are only prepared to pay lip service to accreditation. On the other hand , accreditation may be acceptable to general practices if this is tied to greater remuneration in acknowledgement of their efforts.
I have had the opportunity to have informal discussions with a number of colleagues in QLD who own and operate single speciality day theatres and equally frustrated by the pointless bureaucracy of accreditation. Bureaucracy’s obsession with accreditation takes precious time away from management who would other- wise invest their time in continuing enhancement of patient care. Time and again our patient surveys have demonstrated dissatisfaction with the amount of paper work they have to deal with prior to hospitalization. Most of this paper work is the requirement of bureaucracy, legislation and accreditation.
I believe that accreditation is yet another poorly thought out imposition of bureaucracy on health facilities achieving nothing in terms of quality of real care for the patient.
I would love to receive any feed back on this matter from members of Gold Coast Medical profession. As always , I am available at 07 5531 7809 for discussion regarding any of your patients.
Bhaskar Chakravarty
REFERENCES:
1.Labenz J et al Gastroenterology,1997,112:1442-1447.
2.Laine L et al Am. J. Gastroenterol. 1998,93:1409-1415. 3.Ciociolla AA et al Am .J. Gastroenterol. 1999,94:1834-1840. 4.Hawkey CJ et al Gut 2002,51:336-343.
5.Schubert ML Current Opinion Gastroenterology 2003,19:517-518.