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Implementation Tips & Communication Tool
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IBS Guideline Resource Kit
 Introduction
 Guideline Resource Info & Algorithm
 Info for Patients & Clinicians
 The Science
Implementation Tips
 Impact Assessment
Delfini Evidence & Usability Scale
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Introduction [PDF]
Guideline Resource Information & Algorithm [PDF]
Information for Patients & Clinicians [PDF]
The Science: Treatment [PDF]
The Science: Diagnosis [PDF]
The Science: Communications [PDF]
Implementation Tips [PDF]
Impact Assessment Template [Excel]

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“EXPLICIT" EVIDENCE-BASED CLINICAL PRACTICE GUIDELINE RESOURCE KIT
Irritable Bowel Syndrome (IBS)

Original March 2003
Updates —

  • 07/06: Herbal Preparations
  • 04/07: Medication Withdrawal
  • 06/09: Rome III Diagnostic Criteria


IMPLEMENTATION TIPS & COMMUNICATION TOOL
How to Use this Information
Preparing For Implementation: Meeting-In-A-Box
IBS Implementation Strategy Suggestions
“IBS Case for Change and Need for Patient Choice” – Talking Points: IBS Summary of Gaps
Measurement Ideas

How to Use this Information

This information is designed to be used as a checklist to assist with communicating the IBS guideline content to target groups and to plan local implementation and measurement. The guideline includes evidence-based content formatted for health care professionals and patients. You may wish to reformat some of the content for various target groups and various implementation “vehicles.” There is good evidence that using a combination of implementation strategies is more effective than using single strategies.

For education and detailing you will want to use the all the Delfini IBS Guideline Resource Kit contents along with the implementation strategies described below, including “IBS Case for Change and Need for Patient Choice Talking Points” in this document.

Preparing For Implementation: Meeting-In-A-Box

1. Familiarize yourself with the IBS guideline and tools.

a. Be sure to use the ““IBS Case for Change and Need for Patient Choice” – Talking Points” below because it describes the gaps between current practice and improved care for patients with IBS.

b. Be sure to use the impact assessment information which you should complete to reflect your local conditions (e.g., size of population with IBS, estimates of current testing and referrals of patients with IBS from primary care to GI).

2. Select the strategies you plan to use from the list of implementation strategies below.

3. Prepare an information briefing for your decision leaders and health care professionals involved in QI work and in caring for IBS patients. Include the evidence, benefits, harms, risks and projections of costs and savings).

4. Prepare a measurement plan using your own gap analysis and impact assessment to project potential practice change.

5. Be prepared to do an “elevator talk” or “academic detailing” by knowing the key points of the guideline.

6. Schedule educational sessions utilizing existing and special forums you create for educating various target groups about IBS.

a. Present to each group the gaps, the guideline key points, the information and decision-aids.

b. Consider using case studies, e.g.:

i. A 42 year-old with new diagnosis of IBS—1st visit
ii. A 43 year-old woman—self-care has not controlled symptoms

7. Create appropriate information and decision aids and disseminate through various strategies.


IBS Implementation Strategy Suggestions

Decision Support Materials for:
Leaders
Clinicians
Other health care professionals
 1. Leaders need to know about the “gaps” between current and optimal care of IBS. Succinct text summaries and tables are useful information/decision-aids. The gaps are in the following areas:
Understanding the condition, quality-of-life issues and diagnostic testing
The importance of the physician-patient relationship in IBS
Relevant, valid information about self-care and physician-directed care
Costs associated with inappropriate diagnostic and management interventions
2. For clinicians, consider:
Text summaries including key guideline points and specific prescribing information
“1 or 2 pagers” – algorithm and algorithm key points
Leadership Buy-in & Support

 1. Pay attention to both structural leaders and opinion leaders. Personal sources (e.g., colleagues) are often preferred over impersonal (e.g., print) sources especially when there is medical uncertainty. However, obtaining buy-in is much easier to achieve when decision-support materials are used along with personal contact.
2. Multiple studies have reported success by using leaders to implement change: leaders can be used to teach, encourage, demonstrate, persuade and establish norms.
3. Take the guideline to leadership meetings, QI councils, etc. to have it “blessed” by leadership and oversight committees.
Information Dissemination & Training
CME and Other Events
Academic Detailing		 1. Educational activities which benefit clinicians & patients
Use information and decision aids to make presentations at CME events, lunch meetings, staff meetings, clinic meetings and other “standing” meetings.
Create special events, grand rounds programs, etc.
Target primary care providers and gastroenterologists
Present information at nursing in-services and standing meetings
Present information at pharmacist’s meeting
Present to P & T committee

2. Use the principles of Academic Detailing: Short, 1-on-1 “conversations” with educational & behavioral objectives –
Mutual participation (address driving/restraining forces)
Limited number of essential messages
Reinforcement & repetition
Can be used by pharmacists, leaders, interested “champions” of the IBS guideline
Systems and Administrative Changes
 Improvement through changes in –
Facilities, systems, roles (including staffing), methods (including procedures), equipment, supplies, other resources
Examples:
o Decision rules, decision-aids embedded into the electronic medical record
o Periodic reminders
o CME credit for self-study
o Messages in newsletters
o Registries
o Nursing roles (phone and in-person management)
Patient-centered Strategies
 Approaches or tools designed to influence patients’ decision-making
Examples of including information/decision-aids in various vehicles:
o Patient ed materials
o Pharmacy hand-outs
o Newsletters
Measurement & Feedback Information from measurement of clinical practice is systematically recycled to practitioners
Examples
o Performance reports: referral rates with targets and peer comparison

“IBS Case for Change and Need for Patient Choice” – Talking Points: IBS Summary of Gaps

In Irritable Bowel Syndrome, currently in our health care systems, there are gaps in –
1. Understanding the condition and diagnosis
2. The importance of good rapport physician-patient communications
3. Understanding of self-care and physician-directed treatment options
4. Quality of life for patients with IBS
5. Costs of diagnostic testing and referral

Gap 1. Understanding the condition and diagnosis — About Irritable Bowel Syndrome –

IBS is a chronic medical condition characterized by episodic abdominal discomfort associated with altered bowel habits

  • Episodes of diarrhea or constipation or both
  • Fecal Urgency
  • Prevalence is 10-15%

Cause is unknown but there is no evidence that IBS increases risk for other diseases (colitis, cancer, other)

There is insufficient evidence to conclude that, beyond history and PE, any diagnostic testing improves health outcomes

Benefits: perceived patient satisfaction, perceived risk management
Harms: Risk (e.g., bowel perforation), discomfort/pain, fear, cost, inconvenience, false +’s, time (e.g., missed work), potential increased risk of lawsuit since evidence does not support

These facts along with management information can be easily made available to patients who may choose self-care and/or physician-directed care

Gap 2. The importance of good rapport physician-patient communications

A good physician-patient relationship is important in caring for patients seeking treatment for IBS:

A good physician-patient relationship is based on –

Good information

Engagement between physician & patient

These are learnable skills consisting of the medical interview, showing support and empathy, positive talk, information-giving, avoiding negative talk

The strongest association for improved patient outcomes with physician behavior is for providing information to patients. Numerous studies have showed a statistically significant association between providing information and satisfaction, symptom improvement, trust, comprehension and adherence. Go to The Science for downloads.

  • Beck RS et al. JABFP 2002. 15:25-38
  • Hall JA et al. Medical Care 1988.26:657-675
  • Stewart MA. CMAJ 1995. 152:1423-1433

What patients want is information & engagement from their health care providers:

Accomplish this through a patient-centered care experience which supports the needs, values and preferences of individual patients

Do this by applying the best available evidence

Use that information to assist patients in making choices about the care they receive

Patients need help to –

Understand the issues they face
Gain enough information and support to help them make a decision
Obtain care

Gap 3. Understanding of self-care and physician-directed treatment options
Options for treating IBS patients include –

  • Self-Care
  • Understanding of the condition
  • Dietary Changes
  • OTC preparations (e.g., psyllium, loperamide, simethicone)
  • Physician-directed Care
  • Usually includes discussion of and frequently prescription of medications for discomfort, constipation, diarrhea

Gap 4. Quality of life for patients with IBS


Patient quotes about how IBS affects their quality of life:
“What it's like to have IBS is excruciating pain, bloating and severe constipation. It leaves you feeling very uncomfortable with no energy, having not much of a social life and not being able to do much. You're very debilitated in your means of life.“ JC


"IBS has had a profound affect on my life. It’s affected everything….IBS has affected my work performance.…I was staying home probably two or three days probably every 3 weeks because I had gotten so impacted that I had to take very drastic measures to relieve myself….That was also very draining so even when I went back to work I was very dragged out…which affects your thinking….You can’t react quickly. You don’t get as much done in a day. Your productivity is lower.” LB


“…I always had to worry about the discomfort of sitting on a plane for a long period of time or the changes in food....I ended up turning down a lot of dates because I didn’t feel well or I was in pain. I was irritable…during the end of the week when I’m at four/five days without a bowel movement or I didn’t want to go out and do things with [my daughter] that involved physical activity….IBS is very real…the pain and the discomfort…cause a lot of things – it causes lower back pain and it’s very real and the pain is very real.“ GS

Quality of life for patients with IBS can be improved:

  • Can be improved through better clinician and patient understanding of the condition and management options
  • Understanding what IBS is (and isn’t)
  • Attention to a positive working relationship between physician and patient
  • Understanding the issues around testing: blood tests, stool tests, radiological and endoscopic diagnostic interventions
  • Knowing (includes quantitative information where available) about ALL reasonable self-care and physician-directed management options

Gap 5. Costs of diagnostic testing and referral
Organizations can clarify current and projected health care and economic outcomes as well as improve care with an IBS clinical guideline and associated tools for clinicians and patients:

  • Improve quality of life for patients with IBS
  • Increase patient options where few alternatives provide benefit
  • Improve patient satisfaction
  • Improve provider satisfaction
  • Potential cost savings


Measurement Ideas

Options for measuring guideline implementation include –

1. Patient visits for IBS (including provider specialty)

2. Referrals to GI

3. Endoscopy procedure rates

4. Lab test rates

5. Prescribing rates for IBS

6. Patient satisfaction with management of IBS

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Help for Clinicians and Patients: Irritable Bowel Syndrome