Quality standard
Quality statement 4: Discussion about referral for non‑urgent endoscopy
Quality statement 4: Discussion about referral for non‑urgent endoscopy
Quality statement
Adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment have a discussion with their GP about referral for non‑urgent direct access endoscopy.
Rationale
There is currently wide geographical variation in referral rates for endoscopy for adults with dyspepsia or reflux symptoms. Although many adults with dyspepsia or reflux symptoms will not need an endoscopy, it is important that those with an increased risk of oesophagogastric cancer have a discussion with their GP about referral for endoscopy to investigate the cause.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment have a discussion with their GP about referral for non‑urgent direct access endoscopy.
Data source: Local data collection.
Process
Proportion of adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment who have a recorded discussion with their GP about referral for non‑urgent direct access endoscopy.
Numerator – the number in the denominator who have a recorded discussion with their GP about referral for non‑urgent direct access endoscopy.
Denominator – the number of adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment.
Data source: Local data collection.
Outcome
a) Incidence of oesophagogastric cancer.
Data source: Local data collection. Office for National Statistics Cancer Registration Statistics collect data on the incidence of cancer.
b) Oesophagogastric cancer survival rate.
Data source: Local data collection. Office for National Statistics Geographic patterns of cancer survival in England provide data on 1‑ and 5‑year survival rates.
c) Patient satisfaction with investigation of dyspepsia and reflux symptoms.
Data source: Local data collection.
What the quality statement means for different audiences
Service providers (general practices) ensure that processes are in place so that adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment have a discussion with their GP about referral for non‑urgent direct access endoscopy.
Healthcare professionals (GPs) discuss referral for non‑urgent direct access endoscopy with adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment.
Commissioners (NHS England area teams) commission services that ensure adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment have a discussion with their GP about referral for non‑urgent direct access endoscopy.
Adults with indigestion or heartburn whose symptoms do not respond to treatment should have a discussion with their GP about referral for an endoscopy. An endoscopy is a procedure that is sometimes carried out to investigate indigestion symptoms and find out what is causing them. It involves using an endoscope (a narrow, flexible tube with a camera at its tip), to see inside the oesophagus and stomach. The person may be offered sedation before the procedure or given a local anaesthetic to numb the throat. The endoscope is then guided down the person's throat and into their stomach. Not everyone with indigestion or heartburn will need an endoscopy.
Source guidance
Suspected cancer: recognition and referral. NICE guideline NG12 (2015, updated 2021), recommendations 1.2.3 and 1.2.9
Definitions of terms used in this quality statement
Not responded to treatment
Adults with uninvestigated dyspepsia or reflux symptoms should try a full dose proton pump inhibitor (PPI) for a month and, if there is an inadequate response, H2 receptor antagonist (H2RA) therapy for a month, in order to manage their symptoms. If there is no improvement in symptoms after 8 weeks of treatment and testing for Helicobacter pylori is negative, it should be concluded that the condition has not responded to treatment. [Adapted from NICE's guideline on gastro-oesophageal reflux disease and dyspepsia in adults, recommendations 1.4.3, 1.4.4 and 1.4.6]
Discussion about referral for endoscopy
Endoscopy should not routinely be offered to diagnose Barrett's oesophagus. If endoscopy is considered, the discussion should focus on the person's preferences and their individual risk factors (long duration of symptoms, increased frequency of symptoms, previous oesophagitis, previous hiatus hernia, oesophageal stricture or oesophageal ulcers, or male gender; Bennett et al. BOB CAT: a large-scale review and Delphi consensus for management of Barrett's esophagus with no dysplasia, indefinite for, or low-grade dysplasia). If people have had a previous endoscopy and there is no change in symptoms, discuss continuing management according to previous endoscopic findings. [NICE's guideline on gastro-oesophageal reflux disease and dyspepsia in adults, recommendations 1.3.4 and 1.6.11]
Non‑urgent direct access endoscopy
Primary care arranges for a non‑urgent endoscopy to be carried out and retains clinical responsibility throughout, including acting on the result. [NICE's guideline on suspected cancer]
Equality and diversity considerations
Healthcare professionals should take into account cultural and communication needs when discussing a referral for non‑urgent direct access endoscopy.
Healthcare professionals should respect a person's choice to refuse an endoscopy if they consider themselves to be too frail due to age.