Final celtic workshop 2008.ppt


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Final celtic workshop 2008.ppt

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