Aliment Pharmacol Ther 2000; 14: 1581±1588.
Factors associated with consulting medical or non-medical practitioners for dyspepsia: an Australian population-based study J. I. W ESTBROOK*, J. M CINTOSH & N. J. TA LLEYà *School of Health Information Management, and School of Health Information Management, Faculty of Health Sciences, University of Sydney, Australia; and àDepartment of Medicine, Nepean Hospital, University of Sydney, Australia Accepted for publication 14 August 2000
SUMMARY
Background: Little is known about how many dyspeptics in the population consult medical and non-medical practitioners, or the factors associated with various consulting patterns. Methods: A cross-sectional survey of 748 Australians with dyspepsia investigated their age, sex, dyspepsia symptoms, medical and non-medical consultations, and health status on the SF-12. Results: Overall, 56% had ever consulted a medical practitioner for dyspepsia. Of these, 54% consulted within 6 months of ®rst symptoms. Non-medical practitioners were consulted by 29%. Compared to dyspeptics in all, or most, other consulting groups, subjects who did not consult (37%, group NO) were characterized by fewer symptoms, better physical health, and younger age. Those who only consulted doctors (34%, group M) were older and had better
INTRODUCTION
Despite the high prevalence of dyspepsia in the community, the majority of dyspeptics do not consult a medical practitioner about their symptoms.1±13 British surveys revealed that only 22±25% of people with dyspepsia had consulted a doctor for symptoms within the previous 6 or 12 months and only 42% ever sought medical advice.6±9 In the United States, only 22±29% of dyspeptics consulted Correspondence to: Dr J. I. Westbrook, School of Health Information Management, Faculty of Health Sciences, University of Sydney, PO Box 170, Lidcombe 1825, Australia. E-mail:
[email protected] Ó 2000 Blackwell Science Ltd
mental, but poorer physical health. Those who only consulted non-medical practitioners (7%, group N) were younger and had better physical, but poorer mental health. Dyspeptics consulting both medical and non-medical practitioners (22%, group M + N), were older, more dissatis®ed with medical care, had more symptoms and poorer physical and mental health. Timing of medical consultations was similar in groups M and M + N. Group M + N dyspeptics consulted similar types, but more non-medical practitioners than group N. No sex differences were found in consulting behaviour. Conclusions: Many dyspeptics do not consult; they have fewer symptoms than consulters. Consultation with nonmedical practitioners is common and is associated with poor mental health. Dyspeptics seeking advice from both medical and non-medical practitioners are less satis®ed with their medical management than those who only consult doctors for their dyspepsia.
a doctor in the previous year.12 Reasons given by patients for consulting a medical practitioner about dyspepsia include: severity of symptoms; anxiety about symptoms; and fear of serious disease.8, 13±15 Factors found to be associated with consulting a doctor about dyspepsia include: increasing age; duration of dyspepsia; severity of symptoms; frequent dyspepsia; lower socioeconomic status; and experience of stressful life events.6, 7, 9, 13, 15, 16, 17 An important question, not yet answered, is whether people with dyspepsia consult at a similar stage in their illness. Little is known about the extent to which people with dyspepsia seek the advice of other non-medical health 1581
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practitioners, such as allied or alternative health practitioners. One possible hypothesis explaining why patients seek care from non-medical practitioners is dissatisfaction with medical care. Verhoef et al. found that a sample of Canadian patients with upper gastrointestinal problems, who sought alternative health care in addition to medical care, were less satis®ed with, and more sceptical about, conventional medicine.18 In a further study, patients' dissatisfaction with their gastroenterologists was identi®ed as a reason for seeking a second opinion.19 There is a scarcity of data about dyspepsia patients' satisfaction with medical care. Ascertaining the proportions and pro®les of people who do or do not consult various health practitioners for dyspepsia provides important information about factors precipitating consultation and assists in understanding the extent to which consulters represent the population of people with dyspepsia. As part of a crosssectional survey to determine the prevalence of dyspepsia in an Australian population, the proportions ®tting into each of four different consulting patterns were identi®ed. These were: dyspeptics who only consult medical practitioners; those who only consult non-medical health practitioners; those who consult both; and those who do not consult. The ®rst null hypothesis was that the four consulting groups do not differ signi®cantly in age, sex, duration, number and severity of symptoms, and overall physical and mental health status. Furthermore, it was hypothesized that dyspeptics who consult medical practitioners and those who consult both medical and non-medical practitioners do not differ signi®cantly in the timing of their ®rst presentation to a doctor or in their satisfaction with medical care. Additionally, it was hypothesized that dyspeptics who only consult non-medical practitioners and those who consult both medical and non-medical practitioners consult similar numbers and types of nonmedical practitioners. MATERIALS AND METHODS
Subjects The sample consisted of 748 people with dyspepsia, collected in a random telephone survey of households which established the prevalence of dyspepsia in the state of New South Wales (NSW). NSW has a population of 6.2 million, approximately one third of the Australian population. Overall, 2300 people were
interviewed, achieving a response rate of 69%. Respondents did not differ signi®cantly from nonrespondents in age or sex. Households were selected using an electronic version of residential telephone numbers. The household member to be interviewed was randomly selected according to the number of people in the household aged 18 years or over. Pregnant women were excluded. A minimum of 10 call attempts was made to each household in order to make initial contact. Once contacted, a minimum of ®ve call-backs was made to contact the correct respondent. Data were weighted by household size and the age and sex of the NSW population. Subjects' dyspepsia status during the last 3 months was established using the Rome I de®nition, namely the presence of epigastric pain or discomfort.20 Discomfort was de®ned as one of the following nine symptoms experienced more frequently than a one-off episode: epigastric pain; early satiety; postprandial fullness; nausea; vomiting; retching; bloating; belching/burping; or anorexia. In compliance with the Rome I de®nition, experience of gastro-oesophageal re¯ux symptoms (heartburn, acid regurgitation and food regurgitation) alone did not qualify as evidence of dyspepsia. However, people who reported dyspepsia with gastro-oesophageal re¯ux symptoms were included in the sample. Materials A structured questionnaire was developed and pilottested on four samples of 25 subjects. After each pilot it was revised where necessary. The questions pertinent to the present report established age, sex and the presence of dyspepsia. Subjects were asked which of the following symptoms they had experienced in the past 3 months: the nine dyspepsia symptoms (listed above); three gastro-oesophageal re¯ux symptoms (heartburn, acid regurgitation and food regurgitation); and dysphagia. They also rated the severity of each symptom on a validated four-point severity scale (1, very severe; 4, mild).21, 22 The total number of symptoms (possible range 1±13), and an average severity score (the subject's severity scores were added and divided by the number of their symptoms) for each subject was calculated. Medical consultation history for dyspepsia was explored in terms of whether consultation had ever occurred, duration of symptoms at ®rst medical consultation, whether there Ó 2000 Blackwell Science Ltd, Aliment Pharmacol Ther 14, 1581±1588
PATTERNS OF CONSULTING BEHAVIOUR FOR DYSPEPSIA
had been recent consultation (in the previous 3 months) and satisfaction with medical management (using a four-point scale from 1, very dissatis®ed to 4, very satis®ed). Respondents were asked if they had consulted any of the following non-medical health practitioners concerning their dyspepsia: naturopath; chiropractor/osteopath; dietitian/nutritionist; pharmacist; community nurse; homeopath; iridologist; acupuncturist; or any other non-medical practitioners. The above data enabled subjects to be classi®ed into the four consulting groups. Subjects' health status was measured by the validated SF-12 which produces two sub-scores:23 a physical (physical component score [PCS] 12) and a mental (mental component score [MCS] 12) health score. Procedure Experienced interviewers, all of whom underwent prior training, undertook the interviews. A CATI (computerized aided telephone interviewing) system was used to guard against problems such as missed questions and out-of-range values. Questions were randomized to avoid bias. Techniques were adopted to assist accurate recall. In order to report how long they waited before consulting a doctor, respondents needed to recall information over differing periods of time. Research on long-term recall shows that while some recall of detailed information, such as dietary history, may be poor recall of other information of importance for epidemiological studies is more reliable.24±30 This is particularly so if the information has been reinforced over time and techniques are used to assist recall.31 Subjects' recall would have been assisted by the fact that symptom experience had been reinforced over time, as all were current dyspepsia sufferers. Those required to recall over the longest periods had suffered repeated exposure to symptoms. If subjects had dif®culty in recalling ®rst presentation to a doctor for dyspepsia, the interviewer used questions relating to landmark events as a prompt, for example: `Did it occur before or after you were married?', a technique shown to improve recall of information.30, 32, 33 To examine differences between the four consulting groups, ANOVAS were performed. When the result was signi®cant a Duncan's range test was applied to determine which group means differed signi®cantly. When it was only appropriate to compare two groups, t-tests or v2-analyses were used.
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RESULTS
Prevalence of dyspepsia The prevalence of dyspepsia in NSW was 32.5% (95% CI: 30.6±34.4, n 748). No signi®cant difference was found between prevalence rates for men and women. Consultation patterns and rates Information regarding health consultations for dyspepsia enabled respondents to be categorized into four consulting groups. The largest group, group NO (No consultation), consisted of those who had not consulted any health practitioners for their dyspepsia (37%, n 277). Just over a third of respondents only consulted medical practitioners, group M (medical only) (34%, n 254). Members of the smallest group, group N (non-medical only), only consulted non-medical practitioners (7%, n 49). Group M + N consisted of the 22% (n 168) of subjects who had consulted both medical and nonmedical practitioners for dyspepsia. Overall, a total of 56% of respondents (n 422) (95% CI: 52.8±60.0) had `ever' consulted a medical practitioner for dyspepsia. The majority (54%) of `ever' consulters had consulted within 6 months of ®rst experiencing symptoms and 78% had consulted within 3 years. Only 10% waited longer than 10 years before seeking care (Figure 1). The variable `time before ®rst consultation' was subdivided into four (< 1 week±1 month, > 1 month±1 year, > 1 year±3 years, > 3 years). Patients in groups M and M + N consulted a doctor at similar times of symptom duration (v2 2.67, d.f. 3, P > 0.05). A total of 20% (n 150) (95% CI: 17.1± 22.9) of dyspeptics had consulted a medical practitioner about their dyspepsia in the last 3 months. Recent medical consultation rates for groups M and M + N did not differ signi®cantly (v2 1.22, d.f. 1, P > 0.05). Twenty-nine percent (n 217; 95% CI: 25.7±32.3) of all dyspepsia cases had consulted non-medical practitioners from one or more professions. Pharmacists were the non-medical practitioners most frequently consulted (15%, n 110), followed by naturopaths (13%, n 94), dietitians/nutritionists (6%, n 45), chiropractors/osteopaths (4%, n 29), iridologists (3%, n 24), acupuncturists (3%, n 22), homoeopaths (2%, n 16) and community nurses (2%, n 16). For people who consulted a non-medical practitioner, the average number of practitioner groups consulted was 1.6. Members of group M + N consulted non-medical
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Figure 1. Duration of dyspepsia at ®rst medical consultation (n 394).
with the four consulting patterns indicated that these differed signi®cantly, as shown in Table 1. Dyspeptics who consulted doctors, groups M and M + N, were signi®cantly older than those in groups NO and N. The latter two groups did not differ signi®cantly in age from each other. There were no signi®cant differences in the gender composition of the four consulting groups (v2 0.63, d.f. 3, P > 0.05).
practitioners from a signi®cantly greater number of professions (mean 1.7) than did members of group N (mean 1.4, t 2.01, d.f. 215, P < 0.01). v2-analyses were performed to examine whether dyspeptics in group N or Group M + N were more likely to consult non-medical practitioners from particular professions. Subjects from both groups were as likely to consult pharmacists (v2 0.04, d.f. 1, P > 0.05), naturopaths (v2 0.26, d.f. 1, P > 0.05), chiropractors/ osteopaths (v2 2.87, d.f. 1, P > 0.05), iridologists (v2 1.34, d.f. 1, P > 0.05), dieticians/nutritionists (v2 1.60, d.f. 1, P > 0.05) and acupuncturists (v2 0.05, d.f. 2, P > 0.05) about their dyspepsia. The numbers consulting the other non-medical groups were too small to carry out valid comparisons.
Satisfaction with medical care Of dyspeptics who had `ever' consulted a medical practitioner for dyspepsia, 27% reported that they were very satis®ed with the management of their condition; 58% were satis®ed, 11% were dissatis®ed and 3% were very dissatis®ed with their care. People in group M + N were signi®cantly less satis®ed with their medical care compared to those in group M, who consulted only medical practitioners (21% dissatis®ed vs. 10%, v2 9.37, d.f. 1, P < 0.01).
Age and sex The mean age of the total sample was 43.7 years (s.d. 17.8). The ANOVA comparing the ages of people Characteristics
F (d.f. 3, 743) P
Age
Number of symptoms
Physical health score (PCS)
Mental health score (MCS)
35.0 < 0.001
22.3 < 0.001
13.8 < 0.001
5.13 < 0.01
NO 2.8 M 3.5 g N 3.6 M + N 4.6
M + N 44.3 g M 45.5 NO 49.6 g N 50.1
M + N 44.1o N 44.4 NO 45.9 g M 48.0
Means of consultation groups N 34.3 g NO 37.2 M+N 46.7 g M 50.5
Table 1. ANOVAs and Duncan range tests for characteristics on which the four consulting groups differed signi®cantly
N no consultation; NO Non-medical consultation only; M medical consultation only; M + N medical and non-medical consultation. }Indicates group means that do not differ signi®cantly. Ó 2000 Blackwell Science Ltd, Aliment Pharmacol Ther 14, 1581±1588
PATTERNS OF CONSULTING BEHAVIOUR FOR DYSPEPSIA
Dyspepsia symptoms The average number of symptoms reported by the total sample of dyspeptics was 1.6 (s.d. 1.0). When the four consulting groups were compared using ANOVA, dyspeptics in group M + N reported signi®cantly more symptoms than any other group. Dyspeptics in group NO had signi®cantly fewer symptoms than all other groups (Table 1). Those who consulted only medical or only non-medical practitioners reported a similar number of symptoms. The average symptom severity score of the total sample was 3.2 (s.d. 0.76). The mean symptom severity of the four groups revealed no signi®cant differences (F 1.15, d.f. 3, 743, P > 0.05). Health status The mean PCS score for the total sample was 47.1 (s.d. 10.2), indicating that people with dyspepsia had signi®cantly poorer physical health than the norm (PCS 50). Dyspeptics who did not consult or who only consulted non-medical practitioners had signi®cantly better physical health status than those in groups M and M + N (Table 1). The mean MCS score for the total sample was 46.1 (s.d. 10.9), which was also signi®cantly below the norm (MCS 50). Comparison of the MCS scores of the four consulting groups revealed that dyspeptics in group M had signi®cantly better mental health than those who consulted both medical and non-medical practitioners (group M + N), or only non-medical practitioners (group N). The MCS scores of dyspeptics who did not consult (NO) did not differ signi®cantly from those of the other three consulting groups (Table 1). DISCUSSION
The results provide a pro®le of the characteristics and consulting behaviour of dyspeptics in Australia. The majority (56%) consulted a medical practitioner at some time for their dyspepsia. This result is in keeping with a general trend of high medical consultation rates by Australians for gastrointestinal conditions, overall.34, 35 Population studies in Britain and Sweden, which were similar in design to the present study, found lower `ever' dyspepsia consulting rates of 42% and 45%, respectively.8, 36 Three UK population studies found that 25% of dyspeptics had consulted a medical practitioner in the previous 6 months.6, 7, 9 This is similar to our 3-month Ó 2000 Blackwell Science Ltd, Aliment Pharmacol Ther 14, 1581±1588
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`recent' consulting rate of 20%. Penston et al. reported that 22% of their British sample had consulted for dyspepsia in the previous year.8 `Ever' consulting rates provide an indication of the incidence of consulting for dyspepsia. Thus the present results show that Australians are more likely than Swedish and British dyspeptics to consult at least once for dyspepsia. `Recent' consulting rates provide a measure of the prevalence of consulting for dyspepsia as both ®rst time and repeat consulters are included. Therefore, British dyspeptics appear slightly more likely than Australians to consult repeatedly for dyspepsia.6, 7, 9 Swedish dyspeptics with a reported recent consulting rate of only 5%, appear considerably less likely to repeatedly consult compared to Australians with dyspepsia.36 A key issue in relation to consulting behaviour is how long people with dyspepsia wait before consulting a medical practitioner. The majority (78%) of the current sample consulted within 3 years of ®rst experiencing symptoms, most (54%) within 6 months. In a Finnish sample, 60% of dyspeptics who consulted a general practitioner did so within 4 weeks of experiencing symptoms, a considerably greater percentage than the 26% of dyspeptics in the current study who consulted within 1 month of symptom onset.37 Nearly one in three Australian dyspeptics sought advice from non-medical practitioners. No known research has examined the extent to which people with dyspepsia consult such practitioners. Around 8% of patients attending a Canadian gastroenterology outpatient clinic reported attending an alternative practitioner within the previous 2 years.18, 19 Only 2% of a British sample with organic upper gastrointestinal disorders had consulted an alternative health provider.38 It has been shown that consultations with alternative practitioners often occur in association with medical consultation.39, 40 Over one third of British people who consulted alternative practitioners in 1980/ 81 were simultaneously seeking advice from medical practitioners for the same problem.39 In the present study, the majority of dyspeptics who consulted a nonmedical health practitioner also consulted a medical practitioner about their dyspepsia. It is likely that many doctors are unaware that patients are consulting other practitioners as patients are reluctant to divulge such information to their doctor.41 Few dyspeptics in this study sought care only from a non-medical practitioner. The results identi®ed the characteristics of dyspeptics who had adopted the four patterns of consulting
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behaviours. The most common patterns were not to consult (37%) or only to consult medical practitioners (34%). Compared to dyspeptics in all, or most other consulting groups, those who had only consulted doctors tended to be older, have a moderate number of symptoms, have poorer overall physical health but better mental health and be more satis®ed with their medical care. Subjects who had consulted both types of practitioners were similar to those who had consulted only doctors, in their poor physical health. They had the highest number of symptoms of any group, poorer mental health than group M and were more dissatis®ed with their medical care. These last three factors probably contributed to their decision to seek nonmedical care, although it is impossible to say which were causes or effects and for which subjects. The dissatisfaction which group M + N members expressed about their medical management was not re¯ected in the timing of either their initial or recent medical consultations, which were no different than those of group M. Consultation with the two types of practitioners seems to have occurred concurrently, although further investigation is needed as to the inter-relationships of multiple consultations. Overall, poor physical health as measured by the SF12 and number of dyspepsia symptoms, is associated with consultation with a medical practitioner, although the average severity of symptoms, an imprecise measure of total discomfort which a dyspeptic is experiencing, does not. Dyspeptics who only sought non-medical care tended to be younger and have better overall physical health than groups M and M + N. They had fewer symptoms than group M + N, but more than those who did not consult. Non-medical consulters' mental health was poorer than those in group M. Their overall physical health, which was better than that of groups M and M + N, may have contributed to their not seeking medical care. However, their psychological symptoms (as suggested by their poorer mental health) may have led them to regard non-medical care as more appropriate. People in group M + N consulted more types of non-medical health practitioner than did those in group N. There was no evidence that group N favoured more alternative type practitioners, such as naturopaths, or that group M + N preferred practitioners from professions more allied to medicine, such as pharmacists. Those who did not consult resembled those who consulted non-medical practitioners only in their younger age and better physical health. Their mental
health status did not differ signi®cantly from that of any of the other groups and they had fewer dyspepsia symptoms than all other groups. Their failure to consult may be largely due to the fact that they did not have as many dyspepsia symptoms as groups M and M + N and that they had better physical health than was the case in groups M and M + N. Both groups N and NO may change their consulting behaviour over time. A prospective study of people with dyspepsia could examine the history of their consulting behaviour. The results of a 1981 British survey of alternative health practitioners supported the stereotype of young people and women as those who seek alternative health care.39 In that survey, alternative practitioners reported that two-thirds of their patients were young or middleaged women.39 In the current study, dyspeptics who consulted both medical and non-medical practitioners (group M + N) were of similar age and sex to those who only consulted doctors. However, the small group N comprised the youngest group in our study. Verhoef et al., in their study of gastrointestinal out-patients, found no signi®cant differences in socio-demographic factors or health status in those who had consulted alternative practitioners and those who had not done so.18 That study did not separate alternative consulters into those who consulted these practitioners alone and those who also consulted a medical practitioner, which may explain their failure to observe differences apparent in the present study. Little is known about the effectiveness or otherwise of alternative therapies in treating dyspepsia symptoms. There is randomized controlled trial evidence that acupuncture produces a signi®cant decrease in sham feeding stimulated acid output.42 Yet such evidence of the effectiveness of acupuncture to accelerate ulcer healing is not available.43 As more and more patients seek out alternative health care, investigation into the potential bene®ts of such treatments is warranted. There also needs to be investigation into why dyspeptics decide to consult practitioners of all types. What help do they consider they receive from non-medical practitioners? How satis®ed are they with the help they receive? Will they have ongoing consultations with these practitioners? It may be that while alternative practitioners are not able to offer more effective treatments for patients' symptoms, their holistic approach, including listening to, validating and addressing patients' concerns about their symptoms and the impact that these have on patients' quality of life, is of therapeutic value. Ó 2000 Blackwell Science Ltd, Aliment Pharmacol Ther 14, 1581±1588
PATTERNS OF CONSULTING BEHAVIOUR FOR DYSPEPSIA ACKNOWLEDGEMENTS
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