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Type and Title of Submission


Title:

Primary Care Dyspepsia Management Programme

Description:

A dyspepsia management programme developed to implement the standards set by NICE clinical guideline 17: Dyspepsia: Managing Dyspepsia in Adults in Primary Care 2004 (updated 2005). A primary care based clinical service, developed with support of local Gastroenterologists to improve the care of patients suffering with dyspepsia and empower patients to improve self-care through enhanced patient knowledge and education. The project has so far reviewed over 15,000 patient records and seen over 3000 patients with a face-to-face review.

Category:

Clinical

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG17 - Dyspepsia: Managing dyspepsia in adults in primary care

Category(s) that most closely reflects the nature of the submission:

Implementation policy

Is the submission industry-sponsored in any way?

Yes
The programme was supported by Wyeth Pharmaceuticals for two years to allow sustained investment in the development and evaluation of the service.


Description of submission


Aim

The aims of the project were: - To improve the care of patients suffering from dyspepsia and related upper gastro-intestinal disorders. - To empower patients to improve self-care through enhanced patient knowledge and education. - To implement the standards set by NICE clinical guideline 17: Dyspepsia managing dyspepsia in adults in primary care 2004 (updated 2005). - To develop the role of pharmacists and other health care professionals in the management of dyspeptic patients. - Reduce GP workload associated with dyspepsia through improved access to primary care based services. - Improved working between primary and secondary care. - Aid the management of ulcer healing drug cost.

Objectives

1. To enhance services for patients by improving access to dyspepsia management clinics, allowing detailed review of disease and treatment through a skilled health care professional. 2. To develop a consistent approach with secondary care colleagues to implement NICE guidance and move the management of dyspepsia patients to primary care where appropriate, freeing time with secondary care for those patients who need specialist care. 3. To ensure effectiveness and value for money of ulcer healing drugs by reducing the frequency of prescribing in appropriate patients in line with NICE guidance and implementing formulary choices.

Context

It was recognised that ulcer healing drugs represented a significant prescribing pressure to the PCT and 85% of the cost was due to proton pump inhibitors. Reviews had already been conducted to ensure patients received the most cost effective PPI available and where possible prescribed the lowest effective doses. This highlighted that the majority of patients were prescribed a PPI for uncomplicated dyspepsia; also the work had to be repeated regularly to maintain the changes. It was felt to achieve lasting improvements in patient care and cost-effectiveness, there was a need to conduct detailed clinical audit and improve patient knowledge through face to face clinical contact. The goals of the initiative were supported by the publication of NICE guideline 17 which established standards for the treatment of dyspepsia in primary care. It recognised the role of pharmacist's and GP's in filtering patients prior to secondary care referral and educating patients to be responsible for their own care. A project group was developed and a toolkit produced alongside a training programme run by local gastroenterologists.

Methods

1. Upper GI registers have been completed in 31 out of 54 practices. 2. Clinics have been completed or in the process of being completed in 11 practices. 3. Over 50% of patients reviewed through the project have been eligible for a change in medication, delivering the NICE requirement for patient medication review. 4. There was a smaller increase in PPI prescribing in the practices that received patient clinic reviews. 5. Patient feedback has highlighted that 100% of the patients attending clinic felt that the appointment was of benefit. 6. The project has improved access to dyspepsia services with over 4500 patients offered appointments, 3000 patients attending for review and over 15000 audits of patient medical records. 7. Over 100 referrals to secondary care were prevented for H pylori breath tests as patients were tested in primary care and more were given serology tests. With overall support from local gastroenterologists who provided training and regular contact, a toolkit was produced to provide a reference when running the clinics. Patients were very supportive of the service with specific comments received such as "the clinic changed my life" and "it is useful to see somebody who knows about my condition and has time to talk". The main barrier has been getting patients to attend and getting the support of the practices in terms of if a patient cancels and appointment, offering them a new appointment. GP's can also refer into the service and this has taken time for them to build up trust in the service, although the latest results show that in a 6 month period, 53 new GP referrals were received.

Results and evaluation

Progress was monitored by developing a clinic spreadsheet to record who was seen and any actions taken to record monthly the progress of the service. An impact evaluation report was produced in February 2008 to provide the PCT with feedback on progress so far. As a result of this, the toolkit was updated and a new spreadsheet developed to record specific information to improve data quality. The project was submitted to the pharmaceutical care awards 2007 and reached the semi-finals. An article has also been published in the Journal of Clinical Pharmacy in May 2009. A follow up of two practices where all patients had been seen in a clinic was completed which demonstrated the usefulness of the service but that continued support is essential. An extension was applied for to continue the service which has now been completed and a business case put in to the PCT to develop the service across the whole PCT.

Key learning points

Initial organisation and a clear plan of the start and end points is necessary. We had difficulty knowing whether some of the changes in prescribing costs were due to the service or price changes with ulcer healing drugs. It has been difficult to follow patients journeys through the service as patients don't seem to only be seen within the service but see their GP also who may change their medication so a more universal service is necessary. This was partly because the service was run half to one day per week in most practices so if the patient arrived a different day or if on holidays, there was a gap between when they could next be seen. The gastroenterologists have expressed a wish to see an intermediate service available to refer patients back to after a secondary care appointment e.g. to re-do an H pylori breath test or provide life-style advice and education, thus saving secondary care time and referrals. No other service is available to regularly review dyspeptic patients who are often given medication and their condition not fully explained. It helps practices meet NICE requirements and provides patients' access to a specialist primary care pharmacist or nurse to help them help themselves.

View the supporting material

Contact Details

Name:Megan Blythe
Job Title:Primary Care Pharmacist
Organisation:IntraHealth
Address:1st Floor, William Brown Centre, Manor Way
Town:Peterlee
County:Durham
Postcode:SR8 5TW
Phone:07799643542
Email:megan.blythe@intrahealth.co.uk
Fax:0191 5181656

 

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This page was last updated: 04 August 2009

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.