Commissioning pathways Indigestion (dyspepsia) Supplementary information to be read in conjunction with the pathway Reference Supplementary Information 1.1 Symptom Description Annual incidence 40%. Prevalence 34%. GP consultation in 5%, Endoscopy in 1% annually Patients who consult with dyspepsia have no more symptoms than those with dyspepsia who do not consult; but they do have more 'life events' and are more likely to fear that they have a life-threatening condition (Logan R, Delaney B. Implications of dyspepsia for the NHS. BMJ 2001; 323: 675-677) 1.3 Self Assessment & Self Care Support for patients in understanding their condition and choices available through NHS Direct and NHS Choices. For more information see the pathway web page 1.3 Self Assessment & Self Care - Support individuals to undertake and monitor their own healthcare - Provide expert advice - Obtain information from individuals to support assessment of their health status and needs (History Taking) 1.6 Escalation thresholds & decision aids -Receive and direct requests for health care assistance using protocols and guidelines -Prioritise treatment and care for individuals according to their health status and needs -Refer individuals to specialist services for treatment and care -Advise and support others pending the attendance of a healthcare practitioner 1.6 Escalation thresholds & decision aids Support for patients in understanding their condition and choices available through NHS Direct and NHS Choices (though more work needs to be done to dovetail the presenting symptoms). 1.7 Red Flags For 2 week Cancer referral. Progressive unintentional weight loss, progressive difficulty swallowing, persistent vomiting, iron deficiency anaemia, epigastric mass and any patient over age 55 years with unexplained and persistent recent-onset dyspepsia 2.0 Primary Assessment COMMISSIONING AND CONTRACTING Before starting commissioning consider existing primary care medical contracts. Are you already paying for this work? Is it more appropriate to commission this stage of the pathway from primary care contractors? Have your Practice Based Commissioning (PBC) groups considered this pathway for any service redesign? Have you considered the contractual options to commission the pathway at primary care level? Is the current primary care contract fully utilised? Is there capacity to commission additional activity under additional or enhanced service arrangements?
2.0 Primary Assessment 2.0 -Obtain information from individuals to support assessment of their health status and needs (History Taking) -Undertake routine clinical measurements -Determine an individuals state of physical health and fitness -Assess an individual with a suspected health condition 2.1 Thresholds & Decision Aids -Agree the nature and purpose of assessment and investigation into an individuals health status -Plan assessment and investigation into an individuals health status -Plan inter-disciplinary assessment and investigation into an individuals health status -Select assessment and investigative techniques/procedures for use -Assess an individual with a suspected health condition -Determine an individuals state of physical health and fitness -Agree courses of action following assessment 2.0 Primary Assessment History: Ask if first episode, long or short history, symptoms of GORD? Patients who consult with dyspepsia have no more symptoms than those with dyspepsia who do not consult; but they do have more 'life events' and are more likely to fear that they have a life-threatening condition (Logan R, Delaney B. Implications of dyspepsia for the NHS. BMJ 2001; 323: 675-677) Explore the patient's fears and reassure as far as is justified. Worry about the seriousness of symptoms is a significant factor in bringing patients with dyspepsia to their GP. The perspective of the patient and doctor may differ widely (Lydeard S, Jones R. Factors affecting the decision to consult with dyspepsia: comparison of consulters and non-consulters. J R Coll Gen Pract 1989; 39: 495-498) 2.2 Diagnostics (Dx) SERVICE IMPROVEMENT A summary of service improvement knowledge for UK Radiologists is available. See the hyperlink or website for information. 2.2 Diagnostics (Dx) COMMISSIONING AND CONTRACTING Generic Patient Reported Outcome Measures exist for this pathway (EQ5D). Currently clinical consensus has not been reached for a condition specific measure. 2.2 Diagnostics (Dx) 2.2 -Request investigations to provide information on an individuals health status and needs -Obtain specimens -Perform a specialist clinical measurement investigation -Assess system/organ function using specialised procedures -Excise underlying tissues and organs -Maintain fluid levels and balance in individuals -Administer contrast media to increase information provided by diagnostic imaging -Obtain images of organs and tissues using ultrasound 2.3 -Undertake a risk assessment in relation to a defined health need -Assess an individuals needs arising from their health status -Assess an individuals suitability to undergo planned actions -Assess the need for and provision of environmental and social support -Determine a diagnosis and prognosis for an individual -Refer individuals to specialist services for treatment and care 2.2 Diagnostics (Dx) Full Blood Count: Aged 55 or over with: a. a recent onset of dyspepsia, or with continuous symptoms or with a change in symptoms; b. other risk factors for cancer or anxiety about cancer. Of any age with: a. risk factors for peptic ulcer, e.g. family history or NSAID use; b. with severe symptoms; c. with a past history of gastric ulcer or previous gastric surgery;
d. with a family history of upper GI cancer in >two first-degree relatives; Helicobacter Pylori Detection: Preferred: 13C Urea breath Test. Stop PPI 2-weeks and antibiotics 4-weeks BEFORE test. Stop PPI 2-weeks and antibiotics 4-weeks BEFORE test. Faecal Antigen Test Lab-based serology. NB: High false +ves. Therefore, unnecessary treatment of larger group of people. Trial of PPI: Proton Pump Inhibitor Ultrasound: Indicated for symptoms of cholelithiasis, abnormal liver function (except mildly elevated Gamma GT), abdominal mass or organomegaly and pancretitis' (MBUR6, Framework for Primary Care Access to Imaging) Direct access gastroscopy WORKFORCE - Request investigations to provide information on an individuals health status and needs - Obtain specimens - Perform a specialist clinical measurement investigation - Assess system/organ function using specialised procedures - Excise underlying tissues and organs - Maintain fluid levels and balance in individuals - Administer contrast media to increase information provided by diagnostic imaging Obtain images of organs and tissues using ultrasound - 2.4 Treatments (Tx) Reassurance, Information & Self-Help: Advise p to avoid triggers they associate with dyspepsia, such as: smoking, alcohol, coffee, chocolate, fatty foods. Advise pt on weight reduction, being overweight may cause dyspepsia. Raising the head of the bed & not eating close to bedtime may reduce dyspepsia symptoms in some people. For many pats, self-tx with antacid &/or alginate therapy (either prescribed or purchased over-the-counter & taken as required) may continue to be appropriate for immediate symptom relief. However, additional therapy is appropriate to manage symptoms that persistently affect pts quality of life. Provide pts with access to educational materials to support the care they receive Physical/Psychological Treatment : Psychological therapies, such as cognitive behavioural therapy & psychotherapy, may reduce dyspeptic symptoms in the short term in individual pts. Given the intensive & relatively costly nature of such interventions, routine provision by primary care teams is not currently recommended WORKFORCE - Support individuals to prepare for, adapt to and manage change - Support individuals to undertake and monitor their own health care - Plan activities, interventions and treatments to achieve specified health goals 2.4 Treatments (Tx) 2.4.1 - Support individuals to prepare for, adapt to and manage change - Support individuals to undertake and monitor their own health care - Plan activities, interventions and treatments to achieve specified health goals 2.4.2 - Support individuals to access and use services and facilities 2.4.3 - Support individuals to maintain their spiritual well-being - Support individuals to access and use services and facilities - Support individuals to retain, regain and develop the skills to manage their lives and environment - Agree a plan to enable individuals to develop the knowledge and skills required to manage their condition - Encourage behavioural change in people and agencies to promote health and wellbeing 2.4.4 - Prescribe pharmaceuticals to achieve specified health goals - Provide expert advice - Manage an individuals medication to achieve optimum outcomes - Administer medication to individuals - Support individuals to self medicate 2.4.5
- Assess an individuals suitability to undergo planned actions - Agree courses of action following assessment 2.4 Treatments (Tx) SERVICE IMPROVEMENT 2.4.5 For good practice pre-operative assessment guidance, use the hyperlink above or see the website. 2.5 Rehabilitation & Review - Assess an individuals needs arising from their health status - Arrange access to resources needed to support planned health care/lifestyle programmes - Evaluate treatment plans with individuals and those involved in their care 2.6 Escalation thresholds, QOL meas., decision aids, remote advice - Receive and direct requests for health care assistance using protocols and guidelines - Prioritise treatment and care for individuals according to their health status and needs - Refer individuals to specialist services for treatment and care - Advise and support others pending the attendance of a healthcare practitioner 2.6 Escalation thresholds, QOL meas., decision aids, remote advice TECHNOLOGY Oldham Community PAS system for recording waiting time journeys through ICATs or other intermediate services. 2.6 Escalation thresholds, QOL meas., decision aids, remote advice 2.6 Decision Aids: Retrospective studies have found that cancer is rarely detected in patients under the age of 55 years without alarm symptoms, and, when found, the cancer is usually inoperable. In the UK, morbidity (non-trivial adverse events) and mortality rates for upper gastrointestinal endoscopy may be as high as 1 in 200 and 1 in 2000 respectively Support for patients in understanding their condition and choices available through NHS Direct and NHS Choices (though more work needs to be done to dovetail the presenting symptoms). 2.6 Escalation thresholds, QOL meas., decision aids, remote advice COMMISSIONING AND CONTRACTING Can the quality of primary care be improved to help referrals? 2.7 Red Flags Chronic gastrointestinal bleeding, progressive unintentional weight loss, progressive difficulty swallowing, persistent vomiting, iron deficiency anaemia, epigastric mass or suspicious barium meal 3.0 Specialist Assessment 3.0 - Obtain information from individuals to support assessment of their health status and needs (History Taking) - Undertake routine clinical measurements - Determine an individuals state of physical health and fitness - Assess an individual with a suspected health condition 3.1 - Agree the nature and purpose of assessment and investigation into an individuals health status - Plan assessment and investigation into an individuals health status - Plan inter-disciplinary assessment and investigation into an individuals health status
- Select assessment and investigative techniques/procedures for use - Assess an individual with a suspected health condition - Determine an individuals state of physical health and fitness - Agree courses of action following assessment 3.2 Diagnostics (Dx) 3.2 - Request investigations to provide information on an individuals health status and needs - Perform a specialist clinical measurement investigation - Assess system/organ function using specialised procedures - Excise underlying tissues and organs - Maintain fluid levels and balance in individuals - Administer contrast media to increase information provided by diagnostic imaging - Obtain images of organs and tissues using ultrasound 3.3 Thresholds & Decision Aids -Undertake a risk assessment in relation to a defined health need -Assess an individuals needs arising from their health status -Assess an individuals suitability to undergo planned actions -Assess the need for and provision of environmental and social support -Determine a diagnosis and prognosis for an individual -Refer individuals to specialist services for treatment and care 3.2 Diagnostics (Dx) SERVICE IMPROVEMENT A summary of service improvement knowledge for UK Radiologists is available. See the hyperlink or website for information. 3.2 Diagnostics (Dx) Upper GI Endoscopy: (Could be direct access from primary assessment if ensure appropriate application of thresholds) Chronic GI bleeding, progressive unintentional weight loss, progressive dysphagia, persistent vomiting, iron deficiency anaemia, epigastric mass, suspicious barium meal. Dyspepsia in > 55yr if ALL of: recent onset persistent symptoms in spite of treatment (most days > 4-6 wks) unexplained (by lifestyle changes, medication etc) Red Flags or >55 yrs + recent onset, unexplained, persistent symptoms (despite tx) Retrospective studies have found that cancer is rarely detected in patients under the age of 55 years without alarm symptoms, and, when found, the cancer is usually inoperable. In the UK, morbidity (non-trivial adverse events) and mortality rates for upper gastrointestinal endoscopy may be as high as 1 in 200 and 1 in 2000 respectively. No good evidence that beneficial to screen for Barretts oesophagus by UGIE in all cases of GORD 3.2.3 Double Contrast Barium Meal: Indications as per endoscopy, only when endoscopy is unavailable or cannot be tolerated by the patient, or rarely for persistent symptoms with negative endoscopy. DCBM has limited sensitivity in detecting early gastric cancer or duodenal inflammation, and oesophagitis. Furthermore biopsies cannot be taken (NICE) 3.2.4 Ultrasound: Indicated for symptoms of cholelithiasis, abnormal liver function (except mildly elevated Gamma GT), abdominal mass or organomegaly and pancreatitis (MBUR6, Framework for Primary Care Access to Imaging) 3.2 Diagnostics (Dx) COMMISSIONING AND CONTRACTING Commissioning a World Class Imaging Service tool has been developed to support commissioners of imaging services. It aims to bring together a number of valuable resources about diagnostic imaging in one easy and convenient reference tool. For more information see the web page. 3.4 Definitive Treatments (Tx) 3.4.1 - Support individuals to prepare for, adapt to and manage change - Support individuals to undertake and monitor their own health care - Plan activities, interventions and treatments to achieve specified health goals 3.4.2
- Support individuals to access and use services and facilities 3.4.3 - Support individuals to maintain their spiritual well-being - Support individuals to access and use services and facilities - Support individuals to retain, regain and develop the skills to manage their lives and environment - Agree a plan to enable individuals to develop the knowledge and skills required to manage their condition - Encourage behavioural change in people and agencies to promote health and wellbeing 3.4.4 - Prescribe pharmaceuticals to achieve specified health goals - Provide expert advice - Manage an individuals medication to achieve optimum outcomes - Administer medication to individuals - Support individuals to self medicate 3.4 Definitive Treatments (Tx) 3.4.1 Reassurance, Information & Self-Help: As 2.4.1 3.4.3 Physical/Psychological Treatment: As 2.4.3 3.4.4 Medication: As 2.4.4 3.5 Rehabilitation, Review & QOL measurement WORKFORCE - Assess an individuals needs arising from their health status - Arrange access to resources needed to support planned health care/lifestyle programmes - Evaluate treatment plans with individuals and those involved in their care 3.6 Escalation thresholds & decision aids - Receive and direct requests for health care assistance using protocols and guidelines - Prioritise treatment and care for individuals according to their health status and needs - Refer individuals to specialist services for treatment and care - Advise and support others pending the attendance of a healthcare practitioner 3.7 Red Flags Persistent symptoms, previous normal investigations, not responding to treatments, weight loss 4.0 Subspecialist Assessment 4.0 Subspecialist Assessment -Obtain information from individuals to support assessment of their health status and needs (History Taking) - Undertake routine clinical measurements - Determine an individuals state of physical health and fitness - Assess an individual with a suspected health condition 4.1 Thresholds & Decision Aids - Agree the nature and purpose of assessment and investigation into an individuals health status - Plan assessment and investigation into an individuals health status - Plan inter-disciplinary assessment and investigation into an individuals health status - Select assessment and investigative techniques/procedures for use - Assess an individual with a suspected health condition - Determine an individuals state of physical health and fitness - Agree courses of action following assessment 4.2 Diagnostics (Dx) Physiological Investigations Oesophagel manometry & ph recording (+ bile detection) Gastric emptying measurements & EGG, biliary manometry
4.2 Diagnostics (Dx) SERVICE IMPROVEMENT A summary of service improvement knowledge for UK Radiologists is available. See the hyperlink or website for information. 4.2 Diagnostics (Dx) 4.2 - Assess system/organ function using specialised procedures - Obtain images of organs and tissues using light sensitive film and digital imaging equipment - Acquire MR images for diagnostic purposes 4.3 Thresholds & Decision Aids -Undertake a risk assessment in relation to a defined health need -Assess an individuals needs arising from their health status -Assess an individuals suitability to undergo planned actions -Assess the need for and provision of environmental and social support -Determine a diagnosis and prognosis for an individual -Refer individuals to specialist services for treatment and care 4.2 Diagnostics (Dx) COMMISSIONING AND CONTRACTING Commissioning a World Class Imaging Service tool has been developed to support commissioners of imaging services. It aims to bring together a number of valuable resources about diagnostic imaging in one easy and convenient reference tool. For more information see the web page. 4.4 Definitive Treatments (Tx) SERVICE IMPROVEMENT 4.4.5 For good practice pre-operative assessment guidance, use the hyperlink above or see the website. 4.4 Definitive Treatments (Tx) 4.4.1 - Support individuals to prepare for, adapt to and manage change - Support individuals to undertake and monitor their own health care - Plan activities, interventions and treatments to achieve specified health goals 4.4.2 - Support individuals to access and use services and facilities 4.4.5 - Assess an individuals suitability to undergo planned actions - Agree courses of action following assessment 4.4.6 - All aspects of invasive surgery and surgical environment are relevant this area is still subject to development - Brief and prepare others for their role in health care actions - Maintain health and safety in a clinical/therapeutic environment - Prepare and dress for specified health care roles - Prepare individuals for health care actions - Prepare resources for use in health care actions - Communicate effectively - Move and position individuals to optimise health care actions - Support others in providing health care actions - Monitor and manage the environment and resources during and after health care actions - Measure and record body fluid output, blood loss and wound drainage - Receive and handle clinical specimens within the sterile field - Prepare, apply and attach post intervention materials to support healing - Support individuals during and after clinical/therapeutic activities - Sterilise and disinfect equipment used for the provision of health care
4.5 Rehabilitation, Review & QOL measurement - Assess an individuals needs arising from their health status - Arrange access to resources needed to support planned health care/lifestyle programmes - Evaluate treatment plans with individuals and those involved in their care