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Problems with implementing guidelines: a randomised controlled trial of consensus management of dyspepsia
R H Jones1, S Lydeard, J Dunleavey
1Department of Primary Medical Care, University of Southampton.
Objective:
To determine the feasibility and benefit of developing guidelines for managing dyspepsia by consensus between general practitioners (GPs) and specialists and to evaluate their introduction on GPs' prescribing, use of investigations, and referrals.
Design:
Randomised controlled trial of effect of consensus guidelines agreed between GPs and specialists on GPs' behaviour.
Setting:
Southampton and South West Hampshire Health District, United Kingdom.
Subjects:
179 GPs working in 45 practices in Southampton district out of 254 eligible GPs, 107 in the control group and 78 in the study group.
Main Measures:
Rates of referral and investigation and costs of prescribing for dyspepsia in the six months before and after introduction of the guidelines.
Results:
Consensus guidelines were produced relatively easily. After their introduction referral rates for upper gastrointestinal symptoms fell significantly in both study and control groups, but no significant change occurred in either group in the use of endoscopy or radiology, either in terms of referral rates, patient selection, or findings on investigation. No difference was observed between the control and study group in the number of items prescribed, but prescribing costs rose by 25% (from 2634 pounds to 3215 pounds per GP) in the study group, almost entirely due to an increased rate of prescription of ulcer-healing agents.
Conclusion:
Developing district guidelines for managing dyspepsia by consensus between GPs and specialists was feasible. However, their acceptance and adoption was variable and their measured effects on some aspects of clinical behaviour were relatively weak and not necessarily associated with either decreased costs or improved quality of care.