MEND Study Use of Assessors for Managing Upper GI Endoscopy Referrals

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?