Researchers: Khitam Muhsen¹, Gabriel Chodick^1,2, Tomer Ziv¹, Amir Ben Tov²

Background: Health care utilization patterns of patients with digestive tract diseases are not clear.

Objectives: To describe:
1. Patterns and correlates of health service utilization among patients with gastroesophageal reflux (GERD), H. pylori infection and celiac;
2. physicians' behavior regarding management of these illnesses.

Method: Demographic and clinical data were extracted from the Maccabi Healthcare Services database on patients with celiac (N=1628) and GERD (N=75,219), and those who performed an H. pylori (N=84,826) urea breath test (UBT). A survey of 180 family physicians and 108 pediatricians was performed (response ~30-35%).

Findings: Celiac patients: 58% and 75% performed endoscopy and visited a specialist in gastroenterology, respectively. Underutilization of endoscopy was related to serum transglutaminase IgA antibody level, age and residential district. GERD patients: 81%, 43%, and 92% visited a specialist in gastroenterology, performed gastroscopy and purchased proton pump inhibitors, respectively. Gastroscopy overuse (≥2 [N=11,261] increased with age (p<0.001), in Jerusalem and the south districts, and among former Soviet Union (FSU) immigrants (p<0.001). Among patients who underwent UBT, 33% performed gastroscopy; this was positively related to age, peptic ulcer diagnosis and birth in the FSU. About 45% of H. pylori positives purchased treatment.

Conclusions: Health-care utilization differs between diseases, towards underutilization and overuse in celiac and GERD patients, respectively. Correlates of healthcare utilization were related to patients' rather than physicians' characteristics. Gaps in managing H. pylori infection versus the guidelines were evident.
Survey: Referral to H. pylori testing was reported by 85%, 46% and 60% of family physicians in investigating peptic ulcer, unexplained iron deficiency anemia and relatives of gastric cancer patients, respectively. Gaps in managing H. pylori infection were also observed among pediatricians. For GERD and celiac 90%< of physicians follow the recommendations.

Recommendations: The Maccabi database is a valuable, accessible and efficient resource in health service research. Interventions are needed to improve H. pylori infection management among community physicians. Interventions to improve treatment outcomes in celiac patients should focus on the peripheral and underprivileged towns. Overuse of gastroscopy in FSU immigrants might reflect high prevalence of gastrointestinal disease in this sub-population and warrant further investigation.

Research end date: 07/2018