title: Influencing referral practice using feedback of adherence to NICE guidelines: a quality improvement report for dyspepsia.
abstract: OBJECTIVE
  Rising demand and increasing waiting times for upper gastrointestinal endoscopy (gastroscopy).
  
  
  METHODS
  Quality improvement study with pre- and post-intervention data collection.
  
  
  METHODS
  Three endoscopy units in two hospital trusts (Singleton, Morriston and Baglan Hospitals endoscopy units), UK.
  
  
  METHODS
  Number of gastroscopy requests from general practitioners (GPs) and hospital doctors; their adherence to dyspepsia referral guidelines and the referral-to-procedure interval for upper gastroscopy. Data collected for six months before and for five months after the intervention.
  
  
  METHODS
  Referrals were assessed against the National Institute for Health and Clinical Excellence (NICE) guidelines for the management of dyspepsia by two part-time GPs and feedback sent to clinicians where requests did not adhere to the referrals criteria
  
  
  RESULTS
  Adherence to guideline criteria increased significantly among GPs after the intervention (from 55% to 75%). There was no similar effect for hospital doctors, although their adherence rate (70%) was at a higher level than that of GPs before the intervention. The number of gastroscopy referrals for dyspepsia declined after the intervention, particularly from hospital doctors where a drop of 31% was observed, from 26.6 to 18.4 referrals per week. With the inclusion of seasonal effects, an estimated drop of 3.2 referrals per week from general practice was not significant (p = 0.065) while an estimated drop of 10.0 referrals per week for hospital doctors was very significant (p<0.001).
  
  
  CONCLUSIONS
  Referral assessment can be successfully introduced and shows promise as a way of improving the quality of referrals and reducing demand. Hospital clinicians are more resistant than GPs to referral assessment but nevertheless responded to the feedback by reducing their endoscopy gastroscopy requests. Most such referrals are generated in hospitals rather than in primary care: this finding has important implications for demand management.
authors.affiliation: Department of General Practice, Centre for Health Sciences Research, Cardiff University, Cardiff, UK. elwyng@cardiff.ac.uk
authors.forename: Glyn
authors.initials: G
authors.lastname: Elwyn
authors.forename: Diane
authors.initials: D
authors.lastname: Owen
authors.forename: Llinos
authors.initials: L
authors.lastname: Roberts
authors.forename: Kathie
authors.initials: K
authors.lastname: Wareham
authors.forename: Paul
authors.initials: P
authors.lastname: Duane
authors.forename: Miles
authors.initials: M
authors.lastname: Allison
authors.forename: Alan
authors.initials: A
authors.lastname: Sykes
mesh_terms: D004415:Dyspepsia / Q000175:diagnosis*; D005194:Family Practice / Q000193:education* / Q000592:standards; D005246:Feedback; D005260:Female; D005773:Gastroscopy / Q000706:statistics & numerical data*; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011785:Quality Assurance, Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D006113:United Kingdom