Innovative Ideas Register

Improved Primary Care Management of Dyspepsia

Development of the Initiative

The management of dyspepsia over the past couple of decades has been revolutionised by the combination of the discovery of Helicobacter pylori and the advancement of endoscopic skills. Endoscopy is, however, a relatively invasive procedure, occasionally requiring sedation and not without operative complications. In the management of dyspepsia, a high proportion of gastroscopies are negative. Furthermore, in the age group 18–45, the risk of gastric cancer is very low. The improved quality of serological testing for H. pylori has resulted in suggestions that management of the condition might more appropriately occur in primary care.

This project was jointly developed by ADHB and ProCare to focus on patients aged 18–45 who present to their GPs with dyspepsia or heartburn, and are referred for gastroscopy.

Our preliminary studies identified that 25% of GPs unnecessarily referred patients from this group to gastroscopy and 25% of GPs mistakenly did NOT refer the subgroup of patients in this age group who did require gastroscopy. Our study also indicated other areas of variation from evidence based practice.

We believe that the outcome of training GPs in the correct approach to management of dyspepsia would not only be better management of patients but also a cost saving to the DHB.

The successful completion of the project allows for an advertising campaign for patients to attend their GPs for correct management of a common problem that patients often do not raise with their GP.

Implementation of the Initiative

The project was implemented in 158 Central Auckland GPs. Implementation was multifaceted, comprising small group, intensive, interactive CME, and ongoing audit and feedback (which continues). Support material included the evidence-based guideline with explicit secondary care referral criteria, a one-page summary and algorithm and patient information brochures.

We have evaluated 232 referral letters to Gastroenterology OPD, 6 months’ laboratory and pharmaceutical data. We have also evaluated 1490 case studies of various clinical scenarios — 158 doctors completed a set of five cases pre-implementation, and 140 completed the set again post-implementation.

Results

The outcome of the project was that there has been a 10% reduction in referrals for gastroscopy from the target group of GPs and a large absolute increase in appropriateness of evidence-based treatment.

The effect is as follows:

• Patients get a higher level of correct and appropriate care in the primary care setting.
• There is a reduction in unnecessary gastroscopies and barium meals in the secondary sector.
• There is a shorter waiting time for those who genuinely need gastroscopy.
• Resources previously used for gastroscopy in the secondary sector are now diverted to colonoscopy, thus reducing the waiting time for colonoscopy as well.

The projected saving of the programme is $1.5 million and these savings are being used to provide other outpatient services in gastro-enterology. ADHB and ProCare are using some of their from the 2003 Health Innovation Awards winnings to pay for the project leaders to spend time with other DHBs/PHOs that wish to set up the project in their area.

Gastroscopies at ADHB currently cost $420 dollars. In order to effectively match the innovation for cost, they would have to cost $24! Most of the avoided gastroscopies would be negative and none are urgent.

A summary of the clinical outcomes and economic evaluation are outlined below. Detailed data are available upon request.

ADHB/ProCare Dyspepsia Project Final Report (November 2002)

(Economic Evaluation added on 7 April 2003)

One evaluable aim of the project was to treat the majority of dyspeptic sufferers in primary care with non-invasive, affordable, cost-effective measures and thus to decrease the number of potentially avoidable gastroscopies.

Achieved:

• Referral letters in the target group showed an absolute decrease in potentially avoidable gastroscopies from 41% to 20% of all referrals.
• The target group’s percentage of total referrals to the Gastroenterology Department decreased from 53% to 31%.
• Case studies showed 71% relative decrease (29.25% absolute decrease) in potentially avoidable gastroscopies. (There were four4 cases evaluating approach to a wide variety of clinical scenarios — relative decreases were 65%, 72%, 77% and 70% — absolute decreases were 34%, 34.5%, 23% and 25%.)
• Case studies showed a corresponding 63% relative increase (31% absolute increase) in primary care management of the range of clinical scenarios.

A second evaluable aim of the project was to increase awareness of Helicobacter pylori infection and improve rates of non-invasive testing for this (the so-called “test and treat” strategy).

Achieved:

• Laboratory data of the target group showed 35% increase in non-invasive testing for Helicobacter pylori infection in the group as a whole, and 65% in the group less one doctor.
• Case studies showed a 103% relative increase (37% absolute increase) in the application of the “test and treat” strategy (36% to 73%).

A third evaluable aim of the project was to treat Helicobacter pylori infection with appropriate antibiotics.

Achieved:

• Pharmaceutical data of the target group showed an actual decrease in use of inappropriate antibiotics from six scripts in a three-month period to only one. The control group showed no change.
• The total number of prescriptions for H. pylori eradication therapy increased by 18.514%.
• Case studies showed an intention to cease use of inappropriate antibiotics.

A fourth evaluable aim of the project was to be aware of alarm features in those patients at risk of an acute bleed and thus avoid acute high risk (high morbidity and mortality) admission by referral for elective gastroscopy, ie, appropriate referral to secondary services.

Achieved:

• Case studies showed an increase from 70% to 92% in recognition of those at risk of an acute upper GI bleed, which translates to a 73% decrease in non-recognition and non-referral of a patient with multiple alarm features and high risk of an acute GI bleed.
• Increase in “appropriate” referral letters from 59% to 80%.

A fifth evaluable aim of the project was to assess the economic viability of this project in ADHB and potential for implementation in other DHBs.

Achieved:

• Economic modelling indicates a potential net saving of $2.5 million for Auckland DHB. Even if only 50% implementation occurs, the saving would be $1.1 million.
• Gastroscopy costs $422 per person. The management pathway reduces effective cost to $42 per person.
• When the outcomes of this project are projected to the smallest DHB population ($40,000) in New Zealand, there would still be savings of over $100,000 to a DHB employing this approach for the management of dyspepsia.

Primary Contact

Allan Pelkowitz, Andrea Steinberg and Peter Didsbury
Auckland DHB and ProCare
Level 8, Building 13
Green Lane Hospital, Private Bag 92 189
AUCKLAND

Tel. (09) 630 9943 ext 4098
email: allanp@adhb.govt.nz