Introduction

This quality standard covers the investigation and management of dyspepsia and gastro‑oesophageal reflux disease (GORD) symptoms in adults 18 and older. It includes the investigation of dyspepsia and GORD symptoms as a risk factor for oesophagogastric cancer but it does not include the diagnosis and management of oesophagogastric cancer because this will be covered by a separate quality standard. For more information see the topic overview.

NICE quality standards focus on aspects of health and social care that are commissioned locally. Areas of national policy, such as surveillance of Helicobacter pylori (H pylori), or public health campaigns to highlight cancer risk, are therefore not covered by this quality standard.

Why this quality standard is needed

Dyspepsia describes a range of symptoms arising from the upper gastrointestinal (GI) tract. Symptoms, which typically are present for 4 weeks or more, include upper abdominal pain or discomfort, heartburn, gastric reflux, and nausea or vomiting. The causes of dyspepsia symptoms include gastric and duodenal ulcers (strongly associated with the bacterium H pylori), GORD, oesophagitis and oesophageal or gastric cancers. In many cases, the cause is unknown (functional dyspepsia). In addition, certain foods and medicines (such as non‑steroidal anti‑inflammatory drugs) are believed to contribute to the symptoms and underlying causes.

GORD is a chronic condition in which gastric juices from the stomach (usually acidic) flow up into the oesophagus. It can lead to an abnormality of the cells in the lining of the oesophagus (Barrett's oesophagus), which is itself considered the most important risk factor for oesophageal adenocarcinoma. There are several risk factors for GORD, including hiatus hernia, certain foods, heavy alcohol use, smoking, and pregnancy, but there is also a genetic component. There is some evidence to suggest that GORD is more likely to occur in socially disadvantaged people, and its prevalence increases with age.

The prevalence of dyspepsia depends on the definition used and is estimated to be between 12 and 41% of the general population.

Almost all causes of dyspepsia are recurrent and intermittent in nature. The only definitive treatments for dyspepsia symptoms are H pylori eradication therapy if the person has peptic ulcer disease and H pylori, and surgery if the person has GORD. Other treatments such as proton pump inhibitors (PPI) do not address underlying reasons for dyspepsia; once treatment stops, symptoms may return.

Dyspepsia accounts for between 1.2 and 4% of all consultations in primary care in the UK. Half of these are for functional dyspepsia, in which the cause cannot be determined. There has been an upward trend in prescribing for dyspepsia and GORD, particularly proton pump inhibitors. The use of endoscopy has also increased considerably over the past decade, as awareness of its value in diagnosing dyspepsia and GORD has grown. Some of the costs associated with treating dyspepsia and GORD are decreasing, but the overall use of treatments is increasing. As a result, the management of dyspepsia and GORD continues to have potentially significant costs to the NHS.

This quality standard focuses on improving the overall care of adults with dyspepsia and GORD and the management of their condition, to promote self‑management, support people with persistent and unexplained symptoms, improve consistency of referral for endoscopy and the quality of testing for H pylori.

The quality standard is expected to contribute to improvements in the following outcomes:

  • incidence of oesophagogastric cancer

  • oesophagogastric cancer mortality rates

  • oesophagogastric cancer survival rates

  • H pylori antimicrobial resistance rates

  • self‑management of dyspepsia

  • health‑related quality of life

  • patient experience of primary care.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

i Adults

1b Life expectancy at 75

i Males ii Females

Improvement area

Reducing premature mortality from the major causes of death

1.4 Under 75 mortality rate from cancer (PHOF 4.5*)

i One and ii Five‑year survival from all cancers

v One and vi Five‑year survival from cancers diagnosed at stage 1&2 (PHOF 2.19**)

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions (ASCOF1A**)

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Improving functional ability in people with long‑term conditions

2.2 Employment of people with long‑term conditions (PHOF 1.8*, ASCOF 1E**)

3 Helping people to recover from episodes of ill health or following injury

Overarching indicator

3a Emergency admissions for acute conditions that should not require hospital admission

Improvement area

Improving outcomes from planned treatments

3.1 Total health gain as assessed by patients for elective procedures

i Physical health‑related procedures

4 Ensuring that people have a positive experience of care

Overarching indicator

4a Patient experience of primary care

i GP services

4b Patient experience of hospital care

4c Friends and family test

4d Patient experience characterised as poor or worse

i Primary care

ii Hospital care

Improvement area

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Improvement area

Reducing the incidence of avoidable harm

5.2 Incidence of healthcare‑associated infection (HCAI)

ii C. difficile

Alignment across the health and care system

* Indicator is shared

** Indicator is complementary

Indicators in italics are in development

Table 2 Public health outcomes framework for England, 2013–16

Domain

Objectives and indicators

Vision: To improve and protect the nation's health and wellbeing and improve the health of the poorest fastest

Outcome measure

Outcome 1) Increased healthy life expectancy, i.e. taking account of the health quality as well as the length of life

Outcome 2) Reduced differences in life expectancy and healthy life expectancy between communities (through greater improvements in more disadvantaged communities)

1 Improving the wider determinants of health

Objective

Improvements against wider factors that affect health and wellbeing and health inequalities

Indicators

1.8 Employment for those with long‑term health conditions including adults with a learning disability or who are in contact with secondary mental health services (NHSOF 2.2*, ASCOF 1E**)

1.9 Sickness absence rate

2 Health improvement

Objective

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

Indicators

2.11 Diet

2.12 Excess weight in adults

2.14 Smoking prevalence – adults (over 18s)

2.19 Cancer diagnosed at stage 1 and 2

2.23 Self‑reported well‑being

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicators

4.3 Mortality rate from causes considered preventable (NHSOF 1a**)

4.5 Under 75 mortality rate from cancer (NHSOF 1.4*)

4.13 Health‑related quality of life for older people

Alignment across the health and care system

* Indicator is shared

** Indicator is complementary

Patient experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to dyspepsia and GORD.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that affect patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for dyspepsia and GORD specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole dyspepsia and GORD care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to adults with dyspepsia and GORD.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality dyspepsia and GORD service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating adults with dyspepsia and GORD should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults with dyspepsia and GORD. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.