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Improving the quality of GI care in GP surgeries



Gastroenterology does not appear in the QOF but GP Dr Jamie Dalrymple describes how a project he was involved with set out to introduce quality criteria for four common conditions

GI disorders account for about 10% of the clinical work of the NHS and there is evidence that they are not always well managed in general practice. Few quality criteria are available to guide their management and there are no GI quality criteria in the QOF.

The Improving Management in Gastroenterology study (IMAGE), funded by the Health Foundation, attempted to plug this gap by examining four index gastroenterological conditions – IBS, GORD, coeliac disease and IBD – at eight study centres throughout England.

Developing the quality criteria

41270001First, we produced a set of quality criteria for each by synthesising the views of patients about diagnosis and management with recommendations from clinical practice guidelines.

Patients were invited to take part in focus groups in each of the eight regions to generate common and disease-specific themes. At the same time, recommendations relevant to clinical care were summarised from current guidelines.

These two elements were combined by consensus to produce the four sets of quality criteria.

Are they useful in practice?

41270002The next stage of the study was to attempt to apply the quality criteria in clinical practice and ask:

• Were the criteria applicable in practice?

• Did applying them improve patient care?

A number of standards were evaluated at baseline – including symptom scores, quality of life, measures of psychopathology and patient enablement. The quality criteria were then used during consultations with patients recruited from 39 general practices in England.

A clinical decision support software package was developed to help implement the criteria during a consultation. Patients’ symptoms and quality of life were re-evaluated at one year. Data showed that for IBS mean symptom severity scores had fallen and mean quality-of–life scores had improved. Use of the software was associated with increased appropriate prescribing of antispasmodics and low-dose antidepressants. For GORD, the software use was associated with a reduction in anxiety and depression scores and there was a significant fall in anxiety scores in IBD patients.

How patients are faring

41270003The IMAGE study has produced an enormous amount of data. In terms of symptoms, most patients with colitis and Crohn’s disease were symptom free. Most patients with coeliac disease and GORD had either no symptoms or mild symptoms. In contrast, nearly two-thirds of patients with IBS had moderate or severe symptoms.

But for both the generic and condition-specific measures, the mean quality of life scores were no lower than 70% of the maximum possible, indicating that most patients reported a fairly good quality of life.

Just over 20% of our sample scored high enough on the anxiety subscale to indicate definite anxiety. This is far higher than the national average of around 5% as reported in a National Psychiatric Morbidity survey.

There is a wide variation in prevalence with only 18% of patients with GORD being anxious as opposed to 27% of IBS patients. Some 7% of the sample had definite depression. Again, this is higher than the prevalence reported in the National Psychiatric Morbidity survey, where around 3% of responders were classified as being depressed. Just over 8% of patients with coeliac disease and IBD were depressed. GORD patients again had the lowest rate with just over 5% classified as depressed.

41270004The data relating to patient enablement and satisfaction showed that the mean patient enablement score for all patients is fairly low.

GORD patients felt slightly more enabled than patients with other conditions while those with coeliac disease felt the least enabled. While the lower score could indicate that patients were dissatisfied with the care they receive, it could be that they already felt well equipped to deal with their condition.

The mean patient satisfaction score with their consultation is 72, which is only slightly lower than the national benchmark of 76. But, within conditions, IBS patients are less satisfied with their consultations than patients with other conditions, scoring only a mean of 67. GORD patients are the most satisfied, scoring a mean of 75.

The most striking finding was that patients not only wanted more information from authoritative sources such as their GP but also from patient organisations and other patients. This might account for some of the low scores for patient enablement.

Surprisingly, IBS patients suffered the worst symptoms and were the most anxious, closely followed by those with coeliac disease in terms of the symptom scores and depression. I believe the management of these ‘less serious’ illnesses needs to be re-evaluated to tackle these issues.

Despite the fact that there was a high rate of residual symptoms particularly reported for patients with coeliac disease, GORD and IBS, reported quality of life was fairly high.

Also, despite the fact that patients reported low levels of enablement, there were fairly good levels of satisfaction with their most recent GP consultation.

This study provides evidence that care of patients with GI disorders can be improved by targeting aspects of their care and that this care may be supported by validated clinical decision support software.

Dr Jamie Dalrymple is chair of the Primary Care Society for Gastroenterology, a GPSI in gastroenterology in Norwich and hospital practitioner in gastroenterology at the Norfolk and Norwich University Hospital

Useful websites

Patient support groups

Coeliac UK

Crohns and Colitis UK

The Gut Trust

Patient information

CORE

GORD IBS Coeliac disease IBD Gastro-oesophageal reflux disease Gastro-oesophageal reflux disease