Table A.6 Cost effectiveness of GI services: summary of articles examined for primary care
| Authors | Research setting and year of study | Study design | Sample size | Topic of document | Key results and conclusions | Comments |
|---|---|---|---|---|---|---|
| Jones770 | UK (1996) | Review | NA | GI disease in primary care | Conclusions mainly in the form of a research agenda | Although only 1996, this report is already dated. Main conclusion is that the statement “there is little evidence on which guidelines can be based” is no longer true |
| Delaney582 | 1990s | Review | NA | This review aims to summarise the evidence on the role of H pylori in dyspepsia from the perspective of the primary care, to suggest a strategy for managing dyspepsia, including peptic ulcer disease | The two UK studies suggest that eradicating H pylori in patients with proven peptic ulceration who are receiving long term treatment (the entry criteria were conservative in defining “long term” treatment) might produce savings of up to £41 000 per 100 000 population a year, or save up to £20m a year in the UK spending of £90m a year on H2 antagonists, based on the figure for 1990 | The studies referred by the author have a small number and they do not seem to be proper cost effectiveness studies |
| Bloor and Maynard514 | UK (1994) | Review | NA | Prescribing of NSAIDs | NSAIDs accounted for about 1 in 20 prescriptions. Switching patients so that ibuprofen accounts for 50% of prescriptions and reducing all the other brands accordingly would reduce overall drug expenditure by £45m (26%). In addition, serious adverse reactions could be reduced by 12.5% (to 440 a year) and GI reactions by 16.5% (to 263 a year) | This is an excellent review. However, by the authors’ own admission, it has to be considered an exploratory work |
| Delaney et al751 | UK (1998) | RCT | 478 Patients aged under 50 and presenting with dyspepsia for longer than four weeks | To determine the cost effectiveness of near patient testing for H pylori and endoscopy for managing dyspepsia | Costs effectiveness was determined from the NHS perspective, and based on improvements in symptoms and use of resources at 12 months. Quality. Costs were higher in the intervention group (£368 v £253) per patient. The test and endoscopy strategy was less cost effective than usual management | It is unclear whether a policy to test for H pylori and then eradicate it is cost effective as an initial management strategy in primary care. Future trials should evaluate the cost effectiveness of this strategy compared with empirical prescribing |
| Banait et al580 | UK (north west England) (1997) | RCT | 114 GP practices (57 control, 57 intervention group) | To test the effectiveness of “educational outreach” as a strategy for facilitating the uptake of dyspepsia management guidelines in primary care | The proportion of appropriate referral was higher in the intervention group in the six month post-intervention period. In this study, the dissemination of clinical practice guidelines using educational outreach proved to be more effective than passive guideline dissemination alone. However, the intervention also produced unintended outcomes, notably an increase in prescribing expenditure | Before it is more widely used, this strategy requires further investigation to confirm that changes in GP behaviour do improve patient outcomes and to assess the overall cost effectiveness of this expensive intervention |
| Galloway et al519 | UK (2000) | Questionnaire based survey | 28 General practices performing endoscopy | To examine whether endoscopy in primary care can be considered a safe procedure | Endoscopy in primary care seems to be safe. This good safety record is probably attributable to careful case selection and minimal use of intravenous sedation | The economics of service provision have not been investigated within this survey, but data have been published showing that rigid sigmoidoscopy performed outside secondary care is not necessarily a cheaper option |
| Valori et al750 | UK (England) (1995) | Controlled trial | 123 GPs covering a population area of 325 000 and 250 000 for intervention and control group, respectively | To determine whether a multifaceted educational strategy for general practitioners aimed at improving quality of dyspepsia management can control dyspepsia costs without increasing demand for endoscopy | After the intervention, drug costs declined and then stabilised in the intervention group. The overall cost in the intervention group was reduced by 57.9 pence per head of population per half year in comparison with the control group. This difference was maintained for three consecutive years, resulting in a cumulative savings of £1.13m. The estimated cost of the intervention was £6600. If the intervention were carried out across the country the estimated national savings would be £25m a year | There are two limitations to this study: the study was not an RCT and important outcomes, such as symptoms and GP consultations, were not measured |
| Read et al771 | UK (England) (1995) | Before-and-after study | 487 GPs in Leicester HA and gastroenterology teams within the hospitals | To study whether the introduction of consensus guidelines would encourage a movement towards care in the community for patients with stable disease, and hence speed up new consultation rates | The guidelines did not reduce the period between initial referral and first consultation in outpatients | Response rate was quite low: 106 (21%) and a further 52 (total 32%) after a reminding letter.In an ideal world such guidelines should be evidence based, but when this is unavailable a consensus view on diagnosis and management can be valuable, although it may not produce the best answers |
| Kernick693 | UK (2002) | Review | NA | The economic perspective of intermediate care in GI | Although 16% of GPs are already providing specialist interest services,692 there is currently no evidence to support these changes for increased effectiveness or cost effectiveness | This article is a good review, but it does not include a proper economic evaluation. |
| Moody et al772 | UK (Leicestershire) (1991) | Postal questionnaire survey | 259 (41% response rate) | Care of chronic GI disorders and patients with IBD. What do GPs want from local GI units? | GPs desire a more specialist education (that is, regular bulletin on the management of both IBD and chronic GI disorders). 60% wanted a telephone hot line to senior GI personnel, with direct dialling for immediate advice. 80% wanted shared care with hospital consultants | The article includes no economics |
| Parry et al,564 | UK (2002) | Retrospective case series | 51, mean age 60 (range 31–84) | To determine the number of patients referred to a DGH, the indication, enteroscopy with or without histological diagnosis, and to compare findings with other series from tertiary referral centres or outside the UK | Indications (obscure GI bleeding), most common findings (small bowel AVMs), and “missed” lesions within reach of a gastroscope were in keeping with other series. The current need for push enteroscopy in a DGH is small (about 1 per 8000 population a year). Criteria for enteroscopy should be developed and refined. It may be that enteroscopy does have a place in the routine procedures carried out in selected DGHs, but this will have resource and training implications that need to be measured | The study does not include a proper economic evaluation |
| Hungin et al773 | UK (south Tees DHA) (1990) | Cohort study. Patient management in the year before open access was compared with the year after | 715 | To determine the impact of open access gastroscopy in general practice and in particular, the value of a normal result | Open access is associated with a rationalisation of drug treatment, reduced consultations, and a low hospital referral rate | The study did not include a proper economic evaluation of the resource consequences. The authors point out that one of the main limiting factors of the study design was the accuracy of the general practice records. However, although details of clinical symptoms were variable and only briefly recorded, recording of drug prescribing was consistently good |
| Parry et al578 | UK (northwest region of England) (1998) | GP survey | 177 | To describe how awareness of patient H pylori status changes the practice of GPs who do not currently use H pylori testing and/or eradication in their management of dyspepsia | Until the use of H pylori tests in primary care has been evaluated in appropriate RCTs, advocates of testing as a means to reduce endoscopy referrals should be cautious about its potential impact on service workload | This article is dated as more RCTs have been performed since. However, it did not include any economics |
| Parry et al774 | UK (1999) | RCT | 136 GP randomised to receive effectiveness matters and 126 who did not receive effectiveness matters (control group) | To investigate the impact of distribution of a printed summary of research findings on GPs’ self reported management of peptic ulcer disease and dyspepsia | Distribution of a single, printed summary of research findings in isolation from other interventions is unlikely to have an impact on patient management | The study did not include an economics component |
| Smith et al775 | UK (2004) | Cross sectional observational study | 486 Patients (recruited via an advert in the newspaper) | Frequency, duration, and severity of symptoms. HRQoL of patients managed in primary care compared with patients managed in secondary care | Patients managed solely in primary care do not have less “severe” IBS. Thus the overall impact of IBS on society may be much greater than currently estimated | There might have been problems of self selection. Further study to evaluate the effects of patients’ symptoms and HRoQL over time is also merited. The study did not include an economic component |