Final celtic workshop 2008.ppt

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  • 1. 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.
  • 7.  
  • 8.  
  • 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.  
  • 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.  
  • 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?