Efforts to educate health care workers about following guidelines for the care of patients with nonvariceal upper gastrointestinal bleeding did not improve adherence at the patient or institutional level. The absence of significant differences in adherence rates among experimental and control groups underscores the difficulty in modifying the behaviour of practising professionals. Although elaborate in its design, the components of the experimental intervention were simple, enhancing feasibility and favouring generalizability in a real-world setting. However, 2 recent cluster-randomized trials in Canada have shown that the implementation of such simple, albeit multifaceted, measures does not necessarily translate into improved outcomes.17,18
Certain barriers may have prevented improvement, including lack of a champion at a given site to promote guideline uptake, variable uptake of the 6-facet intervention and staggered implementation in the timing of these interventions at different sites. It is possible that simultaneous implementation of these interventions could have had a greater impact on behaviour, while some effective facets may have lost benefit over time. Endoscopic hemostasis and intravenous PPI infusion were each associated with acceptable adherence rates (> 80%), but the combination of the 2 as recommended by guidelines was poorly followed. For example, physicians may have chosen to modify the duration of PPI infusion depending on local practicalities (for example, substantially shortening the infusion as some data now suggest is occurring;4
in our trial, between 29% and 54% received an infusion for 66 h or less). We found that a more relaxed interpretation of these guidelines (as part of preplanned sensitivity analyses, including the use of clips for endoscopic hemostasis and varying levels of flexibility with regards to the timing, dose and route of administration of PPI) improved the absolute values of adherence but did not result in statistically significant improvement following the educational intervention.
The influence of local practices on adherence, even if contradictory to national or international guidelines, is suggested by certain factors in our study having a higher intracluster correlation coefficient. Evolution in practice since the publication of the guidelines may have had an effect on our results; however, interventions have changed minimally over time (e.g., the use of clips has increased, but in keeping with evidence-based technological evolution, we also included the use of clips in our analysis).6
In recent years, since publication of the initial guidelines, a few non–North American placebo-controlled studies of oral or low-dose intravenous PPI have suggested benefit for gastrointestinal bleeding.19
However, the evidence base for low-dose and oral PPIs for upper gastrointestinal bleeding is less than that for high-dose PPI versus placebo. There have been few head-to-head studies of different PPI regimens.19
Nonetheless, awareness of these recent low-dose studies may have brought into question the optimal route and dose of PPI administration, and this might partly explain the observed lack of adherence.
The relatively lower cost of oral versus intravenous PPI in Canada may have also affected adherence to guidelines, with physicians altering practice to reduce treatment costs. In addition, drug shortages led to some reductions in intravenous pantoprazole use in Canada immediately before and during the study period, causing some institutions to forego intravenous PPI use or to switch to oral or disintegrating forms. There is a lack of evidence supporting shorter durations of intravenous PPI infusion, and perhaps this specific part of the guideline is less critical to the management of nonvariceal upper gastrointestinal bleeding and may deserve less weight (e.g., infusion for 60 h instead of 72 h).
Successful guideline implementation with professionals collaborating in an environment similar to that for patients with nonvariceal upper gastrointestinal bleeding has involved the use of many different tools targeting clinical decision support,20,21
and regular performance feedback.20
There have also been national efforts to improve the prevalent inappropriate prescribing of acid suppressants.22,23
The methods of interventions have, here too, been disparate with assessment of possible needs and barriers prior to their implementation performed only in very rare instances24–27
and have resulted in varying success in prescribing behaviour or cost savings.
When we compare the data from the present study to that from past pilot work originating from national registries,4,13
we noted significantly lower adherence rates than previously reported for the most important guidelines, presumably because of some of the reasons discussed above.
The needs and barriers analysis performed before the start of the trial identified relevant obstacles. This early analysis permitted a subsequent tailoring of the interventions to each site, even though all components of intervention were delivered to all experimental sites. Nonetheless, it is likely that the observed lack of behavioural modification was caused by poorly identified barriers. Although our study focused on 6 interventions, a recent systematic review did not find a relation between the number of interventions and treatment effect.28
The complexity of the interventions, even though it was designed to be broadly applicable, may have limited its adequate functional uptake. Others have found simple and cheap reminders to have the same effect as more elaborate tailored interventions.28,29