Effectiveness of disseminating consensus management recommendations for ulcer bleeding: a cluster randomized trial

Abstract

Background:International guidelines for the management of nonvariceal upper gastrointestinal bleeding have not been widely adopted in clinical practice. We sought to determine whether a national, multifaceted intervention could improve adherence to guidelines, especially for patients at high risk of nonvariceal upper gastrointestinal bleeding. Methods:In this randomized trial, we stratified hospitals by region and size and allocated sites to either the control or experimental group. Health care workers in the experimental group were given published guidelines, generic algorithms, stratification scoring systems and written reminders and attended multidisciplinary guideline education groups and case-based workshops. These interventions were implemented over a 12-month period after randomization, with performance feedback and benchmarking. The primary outcome of adherence rates to key guidelines in endoscopic and pharmacologic management, determined by chart review, was adjusted according to site characteristics and possible within-site dependencies. We also report the rates of adherence to other recommendations.Results: Forty-three sites were randomized to the experimental (n = 21) or control (n = 22) groups. In our primary analysis, we compared patients before (experimental group: n = 402 patients; control group: n = 424 patients) and after (experimental group: n = 361 patients; control group: n = 389 patients) intervention. Patient-level analysis revealed no significant difference in adherence rates to the guidelines after the intervention (experimental group: 9.8%; control group: 4.8%; p = 0.99) after adjustment for the rate of adherence before the intervention (experimental group: 13.2%; control group: 7.1%). The adherence rates to other guidelines were similar and decreased over time, varying between 5% and 93%.Interpretation: This national knowledge translation-based trial suggests poor adherence to guidelines on nonvariceal upper gastrointestinal bleeding. Adherence was not improved by an educational intervention, which highlights both the complexity and poor predictability of attempting to alter the behaviour of health care providers (Trial registration: ClinicalTrials .gov, no.

Upper gastrointestinal bleeding in Egyptian patients with cirrhosis: Post‐therapeutic outcome and prognostic indicators

“…This in part goes with the current recommendation to hospitalize patients with UGIB due to peptic ulcer disease for 72 h following endoscopic hemostasis or 48 h in other series. 21,22 On the other hand, postinterventional ulcers were more frequently followed by complications, so their early discharge carries a high risk.…”

Adherence to Guidelines: A National Audit of the Management of Acute upper Gastrointestinal Bleeding. The REASON Registry

“…Such data for NVUGIB are scarce, with some reports suggesting marked differences in practice across countries (13) and suboptimal uptake of national guidelines (14). Predictors of adherence are poorly defined in the literature, even though some have been suggested as a result of a multifaceted randomized educational intervention for guideline dissemination (15). Inferential testing performed as part of the REASON data analysis shed some light on possible discrepancies between observed practice and existing guidelines.…”

“…However, the impact of such educational efforts is often only modest. In fact, recent national data obtained from a 48-site cluster randomized clinical trial show that a multifaceted educational intervention over a 12-month period to disseminate UGIB guidelines did not improve adherence (15). The issue of low guideline adherence is longstanding and complex involving attitude, knowledge, contextual and behavioural barriers (26,27).…”

Editorial: how can we best promote the routine use of scores that are accurate at predicting outcomes in patients with upper gastrointestinal bleeding?

“…Almost three decades after the creation of the GBS, many risk stratification schemes have been published, although none of the existing scores has been widely accepted in clinical practice . As many of these are reasonably straightforward in their components, this poor uptake may reflect a lack of perceived clinical utility by clinicians in improving any of the relevant outcomes for patients with UGIB.…”