Management of dyspepsia among Asians by general practitioners in East London

BMJ 1995; 310 doi: (Published 08 April 1995) Cite this as: BMJ 1995;310:910
  1. Paul N Malcolm, registrara,
  2. Thomas Y K Chan, senior registrara,
  3. Pui-Ling Li, registrarb,
  4. Jean Richards, consultantb,
  5. William Hately, consultanta
  1. a Department of Radiology, Royal London Trust, Whitechapel, London E1 1BB
  2. b Department of Public Health Medicine, East London and City Health Authority, Tredegar House, London E3 2AN
  1. Correspondence to: Dr P N Malcolm, Department of Radiology, St Thomas's Hospital, London SE1 7EH.
  • Accepted 19 August 1994

The London Borough of Tower Hamlets has a large Asian community. The largest ethnic groups in the borough are white (64.4%) and south Asian (25.7%)—comprising Bangladeshi (22.9%), Indian, Pakistani, and other Asian subgroups.1 Use of health services varies between ethnic groups. Asian patients, for example, consult their general practitioners more often than white patients do.2 Debate continues about whether this can be explained solely by a higher prevalence of illness.3 We used ethnic data from the 1991 census to study whether the number of referrals from general practitioners for investigation of dyspepsia was disproportionately great for the size of the Asian population in Tower Hamlets and, if so, whether this was because of increased dyspeptic disease.

Patients, methods, and results

We reviewed 834 barium meal and swallow examinations requested by general practitioners from October 1991 to September 1992 at the Royal London and Mile End Hospitals. We also reviewed the results of 417 endoscopies requested by general practitioners over the same time, which followed the introduction of an open access upper gastrointestinal endoscopy service in October 1991. The ethnic group of patients was classified as Asian or other according to name, and the populations were analysed by age as under 45 years or 45 years and over. Outcome was subdivided into suspected malignancies, major abnormalities (suspected malignancies, gastric and duodenal ulcer and scarring, oesophagitis, and gastric erosions); and minor abnormalities (gastritis, duodenitis, hiatus hernia, reflux, etc).4 We also related endoscopic appearance to the result of urease tests for Helicobacter pylori.

The table shows a significantly higher referral rate for barium studies in Asian patients, with fewer abnormal results, suspected malignancies, and major and minor abnormalities among them than might be expected from the size of the population. The proportion of patients with disease at barium examination per 1000 population was, however, similar in the two groups. Significantly more Asians under 45 than others under 45 were referred, but they had significantly fewer abnormal results.

Comparison of referral rates for and outcome of barium meal examination and endoscopy in Asian and other populations in Tower Hamlets, October 1991-September 1992. Values are proportions (with percentages in parentheses) unless stated otherwise

View this table:

The referral rate for endoscopy was significantly higher among Asians than the other group. The pattern of abnormalities was similar to that found in the barium studies, and the proportion of the population with abnormal results in the two groups was similar.


Our findings suggest disproportionate referral for investigation in Asians that is not explained by the extent of dyspeptic disease. The proportion of abnormal results from barium studies in the whole population (57%) is similar to that in the study of Conry et al (58%),4 suggesting that high referral is led by factors at presentation rather than by a low threshold for referral. The available evidence suggests that census underenumeration is unlikely to be an important factor.5

There was no evidence for different prevalence of H pylori in Asian and other populations from our study. The greater proportion of investigations in younger Asians—who generally speak more fluent English—is evidence against language difficulties being an important factor.

Somatisation, or expression of psychological distress in somatic terms, seems to be commoner in Asians than other racial groups,2 though further study is required to determine whether it is a factor. Our study does not control for greater socioeconomic deprivation as reflected in unemployment among Asian men,1 which may also be relevant.

Our findings have practical implications, raising concerns about radiation dose in young Asians. They indicate that the reasons for presentation with dyspeptic symptoms in Asian patients may be more complex than in other patients and that this should influence investigation. In wider terms there is a need for caution in how quality of health care for ethnic minorities is compared. Greater use of hospital services such as radiology or endoscopy may not necessarily indicate improved health care.

We thank Mr N A Taub for help with the statistical analysis.


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