6.1 Local implementation

Implementation of national clinical guidelines is the responsibility of local NHS organisations and is an essential part of clinical governance. It is acknowledged that not every guideline can be implemented immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed. These discussions should involve both clinical staff and management. Local arrangements may then be made to implement the national guideline in individual hospitals, units and practices, and to monitor compliance. This may be done by a variety of means including patient-specific reminders, continuing education and training, and clinical audit.

6.2 Key points for audit

In order for the audit of this guideline to be efficient the information used should be derived from routinely collected data. It is recognised that due to gaps in the data available there may be difficulties doing this. It is recommended that the national systems currently in place, such as the Scottish Clinical Information Management Programme (http://www.ceppc.org/scimp/), be used to ensure appropriate diagnostic codes for functional dyspepsia, investigations and treatment. The use of stand-alone systems is discouraged, as they require double entry of data. Audit could take place on three levels: national, regional/local and practice level. The following are recommended areas for audit.

National level

• stage shift in presentation of upper GI cancer
• use of a national referral form

Regional or local level

• the % of patients undergoing H. pylori test and treat before referral
• the % of patients referred for GI endoscopy who are less than 55 years of age without alarm features
• the % of patients undergoing upper GI endoscopy who are less than 55 years of age with alarm features

Practice level

• prescribing of acid suppression therapy for functional dyspepsia
• success rate of primary H. pylori eradication
• the number of patients managed with a diagnostic code of functional dyspepsia.

6.3 Recommendations for research

The literature review integral to the SIGN guideline process enabled the guideline development group to highlight areas of research need based on the following principles:

• the issues should be related to the guideline and/or its implementation
• information gained should be of value in the management of dyspepsia
• the questions should be answerable

The following areas for further research are listed in order of priority:

• A comparative study of the pathological stage and presenting symptoms of upper GI cancers before and after the implementation of this guideline. This is required to demonstrate that early, treatable cancer is not missed by managing patients under 55 years of age presenting with uncomplicated recent onset dyspepsia without endoscopy. In any research studies the definition of ‘recent-onset’ should be defined.
• The efficacy and safety of the “test and treat” policy versus early upper GI endoscopy in the management of patients over 55 years of age presenting with recent onset uncomplicated dyspepsia.
• The management of functional dyspepsia with reference to lifestyle management, patient education, psychosocial interventions and pharmacological intervention.
• Definition of the age related risk of having upper GI cancer associated with a presentation of dyspepsia along with one of the commonly quoted alarm features
• A health economic study exploring whether short term increases in costs and work load related to tests of H. pylori status and drugs involved in H. pylori eradication are related to any possible medium to long term savings from reductions in endoscopic investigations and drugs to manage the symptoms of dyspepsia.
• A study to explore whether wider use of antibacterial therapy and eradication of H. pylori are associated with adverse effects.

6.4 Resource implications

The economic consequences of implementing this guideline are likely to include the following:

• an increase in the need for tests of H. pylori status
• an increase in the cost of drugs involved in H. pylori eradication regimes
• a reduction in the need for endoscopic investigation of the GI tract, especially in younger patients
• a reduction in the use of drugs to manage the symptoms of dyspepsia.

The economic consequences are difficult to quantify precisely at the local level. Impact will depend on the following factors:

• the age of the population
• the prevalence and incidence of GI problems
• the existing management practice
• the availability of different investigations.

The following points form the suggested background to local budget impact calculations:

• There are short-term work implications for GPs in taking breath test samples, starting treatment and reviewing progress but these should be offset by medium- to long-term savings as cases are resolved more quickly.
• Giving a CUBT sample is a straightforward procedure that can be done either at a brief hospital visit or by sending in a sample to the hospital for analysis. Analysis of the CUBT requires specialist equipment and staff however and the capacity of local hospitals to manage CUBT samples should be kept under review.