Dr Paul DuaneCeltic Workshop 2008

BackgroundPrompt 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

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.

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

MEND Project Demand Management

Reviewing the appropriateness of GP referrals for upper GI endoscopyPrimary Care Group, Swansea UniversityDepartment of General Practice, Cardiff

UniversityEndoscopy Units at Morriston & Singleton

Hospitals, Swansea and Neath Port Talbot Hospital

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.

Study LocationSwansea Neath Port Talbot

Population = 227,100Morriston Hospital , 850

bedsSingleton Hospital, 600

beds

Population = 139,650Neath Port Talbot Hospital,

270 beds

October 2004A 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.

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.

Key measures for improvement1. Adherence to All Wales Dyspepsia Management

Guideline for the referral of patients with dyspepsia, by general practitioners and by doctors working in the hospitals.

2. The number of referrals received for gastroscopy.

3. The referral-to-procedure interval (in days) for gastroscopy at the three endoscopy units.

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Adherence of referrals for endoscopy to dyspepsia guidance:-Observed weekly percentages and fitted models

Interv ention start: 1/11/2004 Interv ention end: 30/04/05

General practitioners Hospital Doctors

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 unitsSingleton, 52% to 71%,Morriston, 66% to 80%Neath Port Talbot, 52% to 71%

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

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Referrals requesting endoscopy:Weekly totals and 12-week moving averages

Interv ention start: 1/11/2004

Interv ention end: 30/04/05

Dyspepsia referrals (general practitioner)Dyspepsia referrals (hospital doctors)All referrals (general practioners)All referrals (hospital doctors)

Dyspepsi referrals (general practitioners)Dyspepsia referrals (hospital doctors)

All referrals (general practitioners)All referrals (hospital doctors)

Number of ReferralsDyspepsia 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%)

Quality of referrals improvedGreater proportion meeting the guidelinesMore “urgent & soon” categoryFewer “simple dyspeptics” being referred

The referral-to-procedure intervalsSignificant 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 )

Feedback from ReferrersThe 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.

Letters from ConsultantsWhat 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 operationWho 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 assessDanger of introducing restrictive practices Inappropriate referrals to radiology for Barium mealsPatients are being diverted to gastroenterology

outpatients

Criticisms of the referral assessment

The strongest concern was a perceived erosion of clinical freedomThis 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.

Currrent position in 2008Have 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 referralsBarium studies

Will some patients with cancer be missed?

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

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

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GP Open Access Referrals

Neath

Morriston

Has there been a switch of emphasis?Helicobacter pylori testing

Gastroenterology outpatient referrals

Barium studies

Helicobacter pylori testingSerology 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

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

Barium studiesNo 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

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

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% of OGD with new cancer diagnosis in Morriston

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

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.

Thanks and acknowledgmentsProfessor Glyn Elwyn, Professor of Primary Care, Cardiff

UniversityDr Diane Owen and Dr Llinos Roberts, Primary Care Group,

Swansea UniversityK. Wareham and team, Clinical Research Unit, SwanseaDr Miles Allison, Endoscopy Programme Lead, NLIAH

Any Questions?