DISCUSSION
The GIRFT programme is funded by the United Kingdom Department of
Health. It aims to improve patient care through highlighting unwarranted
variations in clinical practice. Clinical outcome data are presented to
clinicians highlighting the performance of their trust relative to all
trusts in England. Where unwarranted variation in outcomes is
identified, clinicians and managers are engaged to identify ways in
which outcomes could be improved. Ultimately, the approach relies on
decision-makers within individual trusts recognising that their outcomes
may be sub-optimal and then working constructively to improve. The use
of data to benchmark performance and to identify subsequent improvements
is key to this approach. Our study investigates the impact of the GIRFT
programme on three specific recommendations from the GIRFT National
Report in urology.
Use of day-case surgery for TURBT was increasing steadily prior to GIRFT
visits, but the rate of increase more than doubled after the GIRFT
visits. Based on our analysis, the GIRFT programme has had a significant
impact, reducing use of hospitals beds for overnight stay. Our team have
previous reported outcomes for TURBT performed as day-case surgery to be
at least as good as those for TURBT performed with an overnight
stay.10 Whilst not all patients undergoing TURBT will
be suitable for day-case surgery, with some requiring an extended period
of monitoring due to co-morbidity, frailty or disease severity, the
increased use of day-case surgery for TURBT is encouraging.
Nevertheless, with a number of trusts performing over half of all TURBT
procedures as day-case, there appears to be significant scope for
greater use of day-case surgery for many trusts.
For stent use to manage ureteric stones, we identified a significant
temporal trend towards greater ureteric stent use prior to GIRFT visits
and a significant change in trend after visits. We recognise that use a
ureteric stent will be the best treatment option for some patients
presenting with urinary tract stones, notably those with associated
sepsis, and in these cases its use is clearly appropriate. However,
complications associated with stenting are relatively
common.11 Consequently, its use purely as a short-term
measure, where other evidence-based, definitive treatment options are
indicated and available, should be discouraged.12During the same period, use of ureteroscopy or ESWL increased
significantly after GIRFT visits. Such changes are likely to reduce the
need for return admissions and so represent an efficient use of
resources but are also likely to improve patient quality of life by
offering definite treatment at an earlier time point.
Although there was a significant trend towards longer waiting times for
male bladder outflow tract surgery after a presentation with urinary
retention prior to GIRFT visits, which was not apparent afterwards, this
change was not significant, suggesting any impact of GIRFT visits on
waiting times was limited. The reasons why this recommendation was not
implemented to the same extent as the other recommendations investigated
are likely to be multifactorial, complex and vary from trust to trust.
However, reducing surgery waiting times against a backdrop of increase
pressure on services, due to factors such as demographic ageing and
increasing morbidity of the background population, is likely to be
challenging.13 Indeed, the steady and significant
increase in outflow tract surgery waiting times during the baseline
period provides evidence of this. Compared to the other recommendations
investigated, reducing waiting times may be a more intractable problem
that the changes to practice and service organisation required to move
to a day-case model for TURBT or to reduce stent use for ureteric
stones. Moreover, these other recommendations have the potential to
either reduce costs, free-up beds or reduce human resource requirements.
Reducing waiting times may only be achievable though increasing bed
usage and staff numbers. Nevertheless, the GIRFT methodology is based on
engagement with key stakeholders at a local level to help understand how
recommendations can best be implemented within a given
setting.14 Ongoing support is offered to trusts to
help them implement recommendations. Further investigation of barriers
and facilitators to implementation of GIRFT recommendations is needed.
In other areas of healthcare, where barriers and facilitators to
implementation of guidance has been investigated, resource constraints
have been identified as a key barrier15, 16 and
engagement with clinicians locally, peer support and use of data to
change perceptions were found to be facilitators.17
ITSA is a potentially powerful technique for the analysis of the impact
of an intervention.18 It is particularly useful where
a randomised controlled trial is not practical, and this is often the
case when evaluating the impact of a new healthcare policy or quality
improvement programme.19 However, one of the major
threats to the validity of ITSA is that it is often not certain that it
was the intervention of interest that caused any observed change. In our
study this is less of an issue, since the visits to individual trusts
were spread over 20 months, with each trust having its own intervention
point. For the same reason the impact of seasonal factors is likely to
be small, and the lack of any significant autocorrelation supports this
view. A second threat to ITSA validity is changes in the way data are
recorded over time.19 In our case, this is also
unlikely to be a major problem since data are recorded by experienced
data coders and there have been no major changes in the codes used over
the time period covered. As such, our findings are likely to be
relatively robust.
One further limitation of the ITSA approach we used is that there is no
comparator group that received no intervention. We are unable to comment
on how stent use would have changed without our interventions.
In summary, we present evidence that GIRFT programme recommendations
around increasing rates of day-case surgery for TURBT and reducing stent
use and increasing use of ureteroscopy or ESWL for ureteric stones have
had an impact on clinical practice across England. The recommendation to
reduce waiting times for male bladder outflow surgery have, as yet, had
no significant impact on clinical practice. Further research should look
to investigate reasons for good and poor adoption of recommendations and
clinical guidelines within health services with a view to establishing
the most effective methods of influencing practice. Although the GIRFT
methodology may have helped to remove a number of barriers to effective
implementation of changes to clinical practice, better understanding how
the methodology can be adapted to address more intractable issues is
needed.