Dyspeptic complaints are common. Patients may suffer from a disturbing feeling or pain in the stomach or early saturation, while a cause can rarely be seen.
If there are no alarm symptoms, the initial treatment by the General Practitioner (GP) according to the guideline is firstly lifestyle advice and, secondly, antiacids (H2RA / antacidum / PPI). In case of persistent or recurrent complaints an Hp test and, if positive, Hp eradication should be performed. A gastric endoscopy is not indicated for patients younger than 55 and without alarming symptoms, because this rarely has consequences for treatment. In the Netherlands, many patients are inappropriately referred for a gastric endoscopy.
This project aims to develop an educational e-learning for patients and to test it as a strategy to reduce inappropriate gastric endoscopies in patients with dyspeptic complaints.
The e-learning was developed using literature, guidelines, focus groups with GP’s and patients and interviews with patients and paramedics.
Subsequently, a multi-center randomized study was set up in four peripheral centers. Patients referred by the GP for gastric endoscopy due to uncomplicated dyspeptic symptoms (without alarming symptoms), were classified ‘at random’ in an intervention group (e-learning instead of gastric endoscopy) of control group (standard care: gastric endoscopy). We compared the number of gastric endoscopies performed in both groups after 12 weeks. In addition, the severity of complaints, disease-related quality of life and fear of illness were measured at the moment of inclusion and after 12 weeks.
Regional GPs received information about the study and were approached when we wanted to include a patient that they referred for gastric endoscopy. After 12 weeks they were informed about the effect of the study on their own patients.
The most important barriers for de-implementation are the need for certainty for patients and GP’s, the accessibility of gastric endoscopy without the intervention of a specialist, and the lack of knowledge among GP’s and patients, including the apparent lack of alternatives to a gastric endoscopy. The trend that GP’s want to commit themselves to provide sensible care facilitates de-implementation. Patients are interested in alternatives for gastric endoscopy to avoid this invasive test.
The data collection is still ongoing, but to date, 27 participants were randomized in the intervention group and 23 in the control group. Eight (24%) patients underwent a gastric endoscopy in the intervention group and 25 (89%) in the control group (p <0.001).
The severity of symptoms and quality of life was not different between the intervention and control group, at baseline and follow-up. Quality of life improved in the intervention group, but not in the control group. Fear of disease improved in the intervention and control group.
At the moment, this project is being completed. In the following years, this de-implementation strategy will be scaled up to other hospitals in the Netherlands.
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