Thursday, July 14, 2011

Do Family Physicians Take Abdominal Pain Seriously?

From Medscape Medical News

Jim Kling

July 13, 2011 — Complaints of nonspecific abdominal pain (NSAP) in children rarely prompt additional testing or referrals from family physicians, who commonly prescribe medications for the conditions despite a lack of evidence of their effectiveness, according to a study published in the July/August issue of the Annals of Family Medicine.

NSAP, defined as pain for which the physician believes there is no organic pathologic cause, is a common complaint that can lead to school absences and affect a child's well-being.
It is often a complex and time-consuming problem for specialists.

There may be psychological comorbidity or other nonspecific somatic symptoms, and the symptoms can be long-lasting. However, there is a general belief that family physicians consider NSAP to be benign and that parents and children are in need of little more than reassurance.

To better understand the discrepant view between specialists and family physicians regarding NSAP, Marieke J. Gieteling, MD, from the Department of General Practice, Erasmus MC–University Medical Center, Rotterdam, the Netherlands, and colleagues set out to evaluate the primary care view of this condition. Most studies to date on NSAP have been conducted on patients under the care of specialists. Instead, Dr. Gieteling and colleagues used data from the Second Dutch National Survey of General Practice (2001) to calculate incidence and to identify factors associated with childhood NSAP treated in primary care settings. The study focused on children between the ages of 4 and 17 years who had NSAP.

NSAP incidence was 25.0 (95% confidence interval [CI], 23.7 - 26.3) per 1000 person years.
Of children with newly diagnosed NSAP, 92.7% saw their physician once or twice.
Several factors were independently associated with NSAP: female sex (odds ratio [OR], 1.4; 95% CI, 1.3 - 1.5), nongastrointestinal-nonspecific somatic symptoms (OR, 1.3; 95% CI, 1.1 - 1.5), and a higher frequency of healthcare visits (OR, 1.04; 95% CI, 1.03 - 1.05).

The authors determined that on average, family physicians prescribe medication in 45.3% of all healthcare visits; yet, they prescribed medication (laxatives and antispasmodics being the most common) in only 21.3% of visits in which NSAP was diagnosed, which was a significantly lower rate (P < .001).
Three percent of patients with an NSAP diagnosis received referrals to a specialist, and 1% received further testing.
The researchers note that it is quite surprising that patients only visit once or twice for NSAP, because specialists report that NSAP tends to be chronic, and parents and children can be difficult to reassure. It is possible that family physicians are successfully managing NSAP by reassuring parents that there is no underlying disorder and teaching them methods to cope with the problem.
However, it is unknown whether patients who did not revisit the physician continued to experience pain and simply endured it, or were treated with alternative medicine.
The researchers call for further studies into the prognosis of NSAP in family practice settings and the effectiveness of family physician management.
The authors have disclosed no relevant financial relationships.
Ann Fam Med. 2011;9:337-343. Full text

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