Clinical trial: evaluation of a clinical decision-support model for upper abdominal complaints in primary-care practice

Interventions to improve the performance of upper GI endoscopy quality indicators

The promotion of quality and best practices in gastroenterology and endoscopy is an ongoing effort. For upper GI endoscopy, quality indicators derived from clinical studies and expert consensus have been long established but remain variably obtained. To date, data on interventions aimed to improve these indicators are scarce. We systematically reviewed the literature to identify interventions and measures demonstrated to improve the performance of previously established upper endoscopy quality indicators. We also identified evidence gaps and opportunities for improvement in this area.

Prevention of overuse: A view on upper gastrointestinal endoscopy

Many upper gastrointestinal (GI) endoscopies worldwide are performed for inappropriate indications. This overuse of healthcare negatively affects healthcare quality and puts pressure on endoscopy services. Dyspepsia is one of the most common inappropriate indications for upper GI endoscopy as diagnostic yield is low. Reasons for untimely referral are: unfamiliarity with dyspepsia guidelines, uncertainty about etiology of symptoms, and therapy failure. Unfiltered open-access referrals feed upper GI endoscopy overuse. This review highlights strategies applied to diminish use of upper GI endoscopies for dyspepsia. First, we describe the impact of active guideline implementation. We found improved guideline adherence, but resistance was encountered in the process. Secondly, we show several forms of clinical assessment. While algorithm use reduced upper GI endoscopy volume, effects of referral assessment of individual patients were minor. A third strategy proposed Helicobacter pylori test and treat for all dyspeptic patients. Many upper GI endoscopies can be avoided using this strategy, but outcomes may be prevalence dependent. Lastly, empirical treatment with Proton pump inhibitors achieved symptom relief for dyspepsia and avoided upper GI endoscopies in about two thirds of patients. Changing referral behavior is complex as contributing factors are manifold. A collaboration of multiple strategies is most likely to succeed.

Clinical measurement of gastrointestinal motility and function: who, when and which test?

Symptoms related to abnormal gastrointestinal motility and function are common. Oropharyngeal and oesophageal dysphagia, heartburn, bloating, abdominal pain and alterations in bowel habits are among the most frequent reasons for seeking medical attention from internists or general practitioners and are also common reasons for referral to gastroenterologists and colorectal surgeons. However, the nonspecific nature of gastrointestinal symptoms, the absence of a definitive diagnosis on routine investigations (such as endoscopy, radiology or blood tests) and the lack of specific treatments make disease management challenging. Advances in technology have driven progress in the understanding of many of these conditions. This Review serves as an introduction to a series of Consensus Statements on the clinical measurements of gastrointestinal motility, function and sensitivity. A structured, evidence-based approach to the initial assessment and empirical treatment of patients presenting with gastrointestinal symptoms is discussed, followed by an outline of the contribution of modern physiological measurement on the management of patients in whom the cause of symptoms has not been identified with other tests. Discussions include the indications for and utility of high-resolution manometry, ambulatory pH-impedance monitoring, gastric emptying studies, breath tests and investigations of anorectal structure and function in day-to-day practice and clinical management.

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a gastrointestinal motility disorder that results from the reflux of stomach contents into the esophagus or oral cavity resulting in symptoms or complications. The typical symptoms of GERD are heartburn and regurgitation of gastric contents into the oropharynx. GERD affects quality of life and may cause erosive esophagitis, esophageal strictures, and Barrett esophagus, a precursor to esophageal adenocarcinoma. GERD is a clinical diagnosis and is most effectively treated with proton-pump inhibitors (PPIs). Long-term use of PPIs is associated with bone fractures, chronic renal disease, acute renal disease, community-acquired pneumonia, and Clostridium difficile intestinal infection.

Systematic review of the effects of care provided with and without diagnostic clinical prediction rules

BACKGROUND

Diagnostic clinical prediction rules (CPRs) are worthwhile if they improve patient outcomes or provide benefits such as reduced resource use, without harming patients. We conducted a systematic review to assess the effects of diagnostic CPRs on patient and process of care outcomes.

METHODS

We searched electronic databases and a trial registry and performed citation and reference checks, for randomised trials comparing a diagnostic strategy with and without a CPR. Included studies were assessed for risk of bias and similar studies meta-analysed.

RESULTS

Twenty-seven studies evaluating diagnostic CPRs for 14 conditions were included. A clinical management decision was the primary outcome in the majority of studies. Most studies were judged to be at high or uncertain risk of bias on ≥3 of 6 domains. Details of study interventions and implementation were infrequently reported.For suspected Group A Streptococcus throat infection, diagnostic CPRs reduced symptoms (1 study) and antibiotic prescriptions (5 studies, RR 0.86, 95% CI 0.75 to 0.99). For suspected cardiac chest pain, diagnostic strategies incorporating a CPR improved early discharge rates (1 study), decreased objective cardiac testing (1 study) and decreased hospitalisations (1 study). For ankle injuries, Ottawa Ankle Rules reduced radiography when used with clinical examination (1 study) but had no effect on length of stay as a triage test (1 study). For suspected acute appendicitis, CPRs had no effect on rates of perforated appendix (1 study) or the number of non-therapeutic operations (5 studies, RR 0.68, 95% CI 0.43 to 1.08). For suspected pneumonia, CPRs reduced antibiotic prescribing without unfavourable outcomes (3 studies). For children with possible serious bacterial infection, diagnostic CPRs did not improve process of care outcomes (3 studies).

CONCLUSION

There are few randomised trials of diagnostic CPRs, and patient outcomes are infrequently reported. Diagnostic CPRs had a positive effect on process outcomes in some clinical conditions; however, many studies were at unclear or high risk of bias and the results may be context specific. Future studies should seek to detail how the CPR might alter the diagnostic pathway, report effects on both patient and process outcomes, and improve reporting of the study interventions and implementation.

TRIAL REGISTRATION

The protocol for this review was not registered with PROSPERO, the international prospective register of systematic review protocols. The review was conceived and protocol prepared prior to the launch of PROSPERO in February 2011.

The Use of Evidence-Based, Problem-Oriented Templates as a Clinical Decision Support in an Inpatient Electronic Health Record System

BACKGROUND

The integration of clinical decision support (CDS) in documentation practices remains limited due to obstacles in provider workflows and design restrictions in electronic health records (EHRs). The use of electronic problem-oriented templates (POTs) as a CDS has been previously discussed but not widely studied.

OBJECTIVE

We evaluated the voluntary use of evidence-based POTs as a CDS on documentation practices.

METHODS

This was a randomized cohort (before and after) study of Hospitalist Attendings in an Academic Medical Center using EPIC EHRs. Primary Outcome measurement was note quality, assessed by the 9-item Physician Documentation Quality Instrument (PDQI-9). Secondary Outcome measurement was physician efficiency, assessed by the total charting time per note.

RESULTS

Use of POTs increased the quality of note documentation [score 37.5 vs. 39.0, P = 0.0020]. The benefits of POTs scaled with use; the greatest improvement in note quality was found in notes using three or more POTs [score 40.2, P = 0.0262]. There was no significant difference in total charting time [30 minutes vs. 27 minutes, P = 0.42].

CONCLUSION

Use of evidence-based and problem-oriented templates is associated with improved note quality without significant change in total charting time. It can be used as an effective CDS during note documentation.