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Background. Prompt endoscopy is not a cost-effective strategy for the initial management of dyspepsiaUnacceptable delay in diagnosing problems such as oesophageal and gastric cancer occurs. National Institute of Clinical Excellence (NICE) in 2004. In the investigation of dyspepsia, NHS guidelines advised measures other than initial endoscopy such as testing and eradication for H pylori..
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1. MEND StudyUse of Assessors for Managing Upper GI Endoscopy Referrals Dr Paul Duane
Celtic Workshop 2008
2. Background Prompt endoscopy is not a cost-effective strategy for the initial management of dyspepsia
Unacceptable delay in diagnosing problems such as oesophageal and gastric cancer occurs
3. National Institute of Clinical Excellence (NICE) in 2004 In the investigation of dyspepsia, NHS guidelines advised measures other than initial endoscopy such as testing and eradication for H pylori.
4. The NHS Improvement Plan (June 2004) New overall goal for the NHS – that by March 2007, all scans and diagnostic procedures would have been accomplished within 13 weeks of GP referral
5. MEND Project Demand Management Reviewing the appropriateness of GP referrals for upper GI endoscopy
Primary Care Group, Swansea University
Department of General Practice, Cardiff University
Endoscopy Units at Morriston & Singleton Hospitals, Swansea and Neath Port Talbot Hospital
6. All Wales Dyspepsia Management Guidelines Closely modelled on the NICE and SIGN guidelines had been circulated to all clinicians in NHS Wales two weeks before the start of the intervention.
9. Study Location Swansea Neath Port Talbot Population = 227,100
Morriston Hospital , 850 beds
Singleton Hospital, 600 beds
Population = 139,650
Neath Port Talbot Hospital, 270 beds
10. October 2004 A letter was sent to all 215 general practitioners in the catchment area of the three endoscopy units.
The same letter was also sent to the 359 hospital consultants and post holders at junior grades based at the three hospitals.
11. Methods used to assess problems Uncontrolled before and after study (intervention date 1/11/2004)
Two general practitioners were employed on a part-time basis to judge whether the requests for gastroscopy adhered to the NICE referral guidelines
The interval, between the date on the referral letter and the date of the endoscopy was calculated in days in order to assess the interval between request and procedure.
12. Key measures for improvement Adherence to All Wales Dyspepsia Management Guideline for the referral of patients with dyspepsia, by general practitioners and by doctors working in the hospitals.
The number of referrals received for gastroscopy.
The referral-to-procedure interval (in days) for gastroscopy at the three endoscopy units.
13. Adherence of gastroscopy referrals to guidance: weekly proportions (%)
14. Adherence to Guidelines General Practitioners GPs increased their adherence rates from a mean 55% before intervention to 75% during intervention (p<0.001)
This change was observed in all three endoscopy units
Singleton, 52% to 71%,
Morriston, 66% to 80%
Neath Port Talbot, 52% to 71%
15. Adherence to Guidelines Hospital Doctors Mean adherence rate was 70% and this was higher than for GPs
There appeared to be no step-change corresponding to the period change
There appears to be a trend upwards after the intervention
16. Referrals requesting gastroscopy: weekly totals
17. Number of Referrals Dyspepsia referrals
Reduction in GP referrals of 3.2 per week was not significant
Reduction in hospital referrals of 10 per week was very significant (p<0.001)
This represented drop from 26.6 to 18.4 referrals per week (decrease of 31%)
18. Quality of referrals improved Greater proportion meeting the guidelines
More “urgent & soon” category
Fewer “simple dyspeptics” being referred
19. The referral-to-procedure intervals Significant reduction in the referral-to-procedure interval for gastroscopy.
The mean interval in the pre-intervention period was 52.1 (sample size 1188, SD 67.9) days
The mean interval of 39.4 (sample size 612, SD 46.2) days in the post-intervention period.
Difference in the means is 4.14, p-value <0.001. (95% C.I. 6.6 - 18.6 days )
20. Feedback from Referrers The intervention provoked resistance from some clinicians.
22 letters received,
21 from specialists (14 letters from 7 surgeons and 7 from 5 physicians) and one from a general practitioner.
These letters were critical of the referral assessment strategy.
21. Letters from Consultants What about diagnosing early gastric cancer?
I am not in the habit of requesting unnecessary investigations …...I find it insulting my clinical acumen
I had no idea that the MEND study was in operation
Who will bear the legal responsibility if it turns out there was significant pathology
Irrespective of NICE or MEND recommendations I will continue to gastroscope patients I assess
Danger of introducing restrictive practices
Inappropriate referrals to radiology for Barium meals
Patients are being diverted to gastroenterology outpatients
22. Criticisms of the referral assessment The strongest concern was a perceived erosion of clinical freedom
This view was also commonly associated with an outright disagreement with the NICE guidelines!
“Mechanisms to ‘ration’ services”
The guidance used in the study was developed for primary care, and not for dyspepsia occurring in hospital settings.
23. Currrent position in 2008 Have the dyspepsia guidelines stood the test of time?
Has there been change in approach to managing dyspepsia in primary care?
Has there been a switch of emphasis?
Helicobacter pylori testing (UBT or faecal antigen)
Gastroenterology outpatient referrals
Barium studies
Will some patients with cancer be missed?
24. Have the dyspepsia guidelines stood the test of time?
The guidelines were based on best evidence available from studies in the appropriate population – primary care
The guidelines have not been super-ceded since their introduction in 2004
25. Change in managing dyspepsia in primary care?
Increasing proportion of referrals are for alarm symptoms
GPs are using the “Test & Treat” strategy before referring patients
26. Has there been a switch of emphasis?
Helicobacter pylori testing
Gastroenterology outpatient referrals
Barium studies
27. Helicobacter pylori testing Serology still the preferred method of testing in primary care
Some GPs are referring more directly for Urea Breath Test
Faecal antigen testing has not taken over in spite of evidence of its cost effectiveness
28. Gastroenterology outpatient referrals
Not over-burdened with dyspeptics being referred
Many patients can be reassured and don’t need OGD
GORD symptoms seem to predominate
29. Barium studies No increase in the number of referrals
Personal communication from Dr D Richards, Consultant Radiologist
Radiologists more confident in advising GPs against using Barium studies for simple dyspepsia
30. Will some patients with cancer be missed?
The guidelines were not designed to pick up cancer
Majority still present as advanced disease
Majority have alarm symptoms and so are diagnosed quickly
31. Key learning points Referral assessment can be successfully introduced.
Providing feedback shows promise as a way to both improve the quality of referrals from primary care and to reduce demand in general.
Hospital clinicians are more resistant than general practitioners to referral assessment
32. Key learning points (continued) There is a greater demand for gastroscopy in hospitals than in primary care.
Demand management systems need to consider the work generated by secondary care and not just referrals from primary care.
33. Thanks and acknowledgments Professor Glyn Elwyn, Professor of Primary Care, Cardiff University
Dr Diane Owen and Dr Llinos Roberts, Primary Care Group, Swansea University
K. Wareham and team, Clinical Research Unit, Swansea
Dr Miles Allison, Endoscopy Programme Lead, NLIAH
34. Any Questions?