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Improvement in the implementation of Helicobacter pylori management guidelines among primary care physicians following a targeted educational intervention

Background Consensus guidelines recommend that in regions with a high rate of clarithromycin resistance, Helicobacter pylori (H. pylori) infection be treated with 4 drugs. Compliance with this recommendation among primary care physicians (PCPs) is low. We aimed to examine whether PCP compliance with H. pylori treatment recommendations increased following a targeted educational intervention. Methods A questionnaire assessing H. pylori treatment was sent to >2000 PCPs in June 2015 and June 2018. In the interim, 3 interventions were performed: distribution of printed materials, educational outreach visits, and education over a social media platform. Results A total of 635 PCPs returned questionnaires, including 314 in 2015 and 321 in 2018 (148 [46.3%] male, age 44.7±10.9 years). The number of PCPs who recommended a 4-drug treatment protocol increased from 12 (3.8%) in 2015 to 119 (37.1%) in 2018 (P<0.001). The number of PCPs who recommended bismuth- or levofloxacin-based therapy for second-line treatment increased from 95 (30.3%) in 2015 to 247 (77.1%) in 2018 (P<0.001). Independent predictors for a 4-drug treatment protocol included central clinic location (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.38-5.60; P<0.003), exposure to printed educational materials (OR 1.64, 95%CI 0.99-2.72; P=0.04) and exposure to the social media platform (OR 6.60, 95%CI 3.08-14.13; P<0.001. There were no independent predictors of compliance with second-line treatment. Conclusions PCP compliance with H. pylori guidelines remains suboptimal. Educational initiatives may be effective in increasing PCPs’ knowledge and compliance with guidelines. Direct web-based interaction between PCPs and gastroenterologists may be particularly effective.


Introduction
Helicobacter pylori (H. pylori) infection has a direct impact on public health due to its role in the development of chronic gastritis, peptic ulcer disease (PUD) and gastric cancer. Eradication of the organism may improve the outcomes of these diseases [1]. The optimal regimen for treating H. pylori infection varies according to geographic region, since the choice of antibiotics must be tailored according to local resistance data. Failure to account for regional differences in H. pylori antibiotic resistance may significantly reduce the efficacy of H. pylori eradication regimens [2]. Therefore, ineffective eradication regimens not only fail to reduce the burden of H. pylori infection and associated pathologies, but also introduce secondary public health concerns, such as selection of antibiotic-resistant H. pylori strains, increased morbidity related to repeated antibiotic exposure, and increased costs. Current guidelines, including the Maastricht V/Florence Consensus Report, the American College of Gastroenterology Clinical Guideline and the Toronto Consensus, recommend adding a nitroimidazole drug to traditional clarithromycin (CLA)-based triple therapy (TT) for H. pylori eradication among treatmentnaïve subjects, in regions with a high rate of CLA resistance [2][3][4]. Nevertheless, the implementation of this recommendation is suboptimal. In a study performed by our group in 2015 we found that over 93% of primary care physicians (PCPs) continued to prescribe TT despite the fact that our region has a high rate of primary CLA resistance [5][6][7]. Furthermore, only 30% of PCPs provided a second-line eradication regimen compatible with current guidelines. Additional gaps were identified regarding the indications for H. pylori testing and attitudes towards the oncogenic potential of the organism.
It has previously been shown that educational outreach visits (EOV) involving face-to-face meetings with healthcare professionals lead to changes in prescribing practices [8]. Such visits are more effective in changing PCP behavior than are alternative methods, such as audit with feedback. Likewise, the distribution of printed educational materials may have a beneficial effect on professional practice outcomes [9]. Over the past decade, electronic consultation (e-consult) has become an increasingly popular tool to facilitate provider-to-provider communication and may positively impact decision making [10][11][12]. Social media platforms also allow effective collaboration between healthcare professionals and have been shown to enhance educational interactions between health providers [13][14][15].
Following publication of the Maastricht/Florence V consensus report we advanced a national educational initiative to address the gaps identified in our previous study [5]. The aim of the present study was to assess the change in H. pylori-treatment practices following the implementation of a targeted educational intervention and to assess the relative effectiveness of each initiative.

Intervention
Following the publication of our previous survey [5] three interventions were performed. Firstly, printed materials were distributed to PCPs at a national level. These included patient education flyers regarding the implications of H. pylori infection and treatment protocols, a letter addressed to PCPs summarizing the key statements of the Maastricht/Florence V Consensus Report [2], and how-to-prescribe cards. Secondly, EOVs were performed by trained personnel, during which the contents of the printed materials were conveyed orally. Thirdly, the key statements of the Maastricht/Florence V Consensus Report were transferred over a preexisting social media platform. This social media platform is a forum through which PCPs can interact with a single consultant gastroenterologist. The platform functions as a message board, on which all participants can view all of the comments posted, and may be accessed from both desktop and mobile devices.
The consultant gastroenterologist typically responds to questions posed by PCPs within 1 h, and often in real-time.

Questionnaire
The questionnaire previously sent in June 2015 was redistributed in June 2018 with the addition of one question (Question 14) which assessed attitudes towards testing H. pylori prior to commencing long-term aspirin or nonsteroidal anti-inflammatory drug (NSAID) therapy in patients with a history of PUD. This question was included to differentiate adherence to the Maastricht V/Florence Consensus Report, which recommends H. pylori testing prior to aspirin and NSAID therapy in subjects with a history of PUD, from adherence to the ACG Clinical Guideline, which mandates testing prior to aspirin and NSAID therapy, regardless of any history of PUD [3].
The final questionnaire consisted of 14 multiple choice questions, including 2 related to treatment, 5 related to H. pylori detection, 3 related to gastric cancer and 4 related to screening. Questions were jointly written by an expert panel of 3 consultant gastroenterologists, including one contributor to the Maastricht IV and Maastricht V/Florence Consensus Report. The panel sought to address topics within the realm of general practice yet are presumed to be poorly managed. Study questions with answer options are shown in Supplementary Table 1. Demographic variables were collected, including age, sex, clinic location and estimated number of H. pylori diagnosis or treatment encounters per month. In addition, subjects were asked about exposure to printed materials or EOVs during the preceding 3 months. PCP participation in the social media platform was correlated with electronic data from the system administrator.

Distribution
Questionnaires were distributed by e-mail to the personal accounts of approximately 2000 PCPs working for Clalit Health Services (CHS) in Israel. CHS is the largest health maintenance organization in Israel and the second largest health maintenance organization in the world, with a staff of 34,000 employees and more than 3.8 million enrollees. Healthcare is delivered through a network of facilities that include 14 hospitals, 1300 primary and specialized clinics, and a network of pharmacies and dental clinics throughout 8 districts.
Responses were collected electronically during a period of 14 days, after which no further responses were allowed. PCPs who responded to <90% of questions were excluded. Only one response per IP address was permitted.

Endpoints
The primary outcome measure assessed was the change in the proportion of PCPs who provided first-and second-line therapy consistent with current guidelines, as defined below. Secondary measures included changes in PCP attitudes with respect to H. pylori detection, malignant potential and screening.

Statistical analysis
Given the PCP population size of 2000, we calculated that a sample size of 322 would be necessary to allow a margin of error of 5% with 95% confidence. Data analysis was performed using SAS 9.4 statistical analysis software (SAS Institute Inc. NC, USA). Continuous variables were reported as mean ± SD. Normality of distribution of continuous variables was assessed using the Kolmogorov-Smirnov test (cutoff at P=0.01). Categorical variables were described using frequency distributions and were presented as frequencies: n (%). Depending on the distribution, continuous variables were compared across groups using oneway analysis of variance (ANOVA) or the Kruskal-Wallis test. Pairwise, post hoc comparisons for significance across differences were assessed by Bonferroni's test or the Mann-Whitney U test. Categorical variables were compared across groups using the chi-square test (exact as necessary). Pearson's correlation coefficient was used to test for correlations between variables. A multivariate regression model to assess for predictors compliance with first-and second-line treatment included the following variables: sex, clinic location, volume of H. pylori patients and educational interventions. The dependent variable of compliance with guidelines was defined as any 4-drug regimen for first-line therapy, and bismuth-based quadruple (BQT) or levofloxacin-based therapy for second-line eradication. PCP respondents who chose to refer patients to a gastroenterologist for second-line treatment were omitted from the model. All tests were 2-sided and considered significant at P<0.05.

Respondents
A total of 332 PCPs returned questionnaires. Eleven respondents completed less than 90% of the survey and were excluded. Therefore, 321 respondents (age 44.7±10.9 years) were included in the final data set, including 148 (46.3%) males. The characteristics of respondents are shown in Table 1. Two hundred seventy-seven PCPs (86.3%) reported a low number (<10) of H. pylori encounters per month. Exposure to ≥1 educational initiative was reported by 208 (64.8%) PCPs, including 98 (30.5%) exposed to EOVs, 150 (46.7%) exposed to printed materials and 48 (15%) who accessed the social media platform.

H. pylori treatment
The most commonly recommended first-line treatment was standard TT for 7-  . Among PCPs who did not "usually" or "consistently" screen prior to NSAID therapy, 79 (29.0%) would nevertheless "usually" or "consistently" screen prior to NSAID therapy if the patient had a history of PUD.     (Table 4). Factors significantly associated with compliance with second-line treatment guidelines included female sex (OR 1.54, 95%CI 0.97-2.44; P=0.02), and lack of EOVs (OR 0.34, 95%CI 0.14-0.85; P=0.02). None of these factors remained significant following multivariate analysis.

Discussion
In our follow-up survey of PCPs, we found that, despite suboptimal compliance with the recommendation to treat H. pylori with 4 drugs (37.1%), compliance has risen almost tenfold since 2015. Interventions such as distribution of educational printed material and electronic consultation over a social media platform may be effective in increasing the implementation of H. pylori treatment guidelines. Compliance with guidelines is superior among PCPs working in central, urban clinics, compared with those working in the rural periphery. This is the first study to assess changes in compliance with H. pylori treatment guidelines following a targeted intervention to educate PCPs.
Our finding that most PCPs do not account for a high degree of CLA resistance when prescribing first-line treatment for H. pylori infection is consistent with others [16,17]. A recent South American study found that over 95% of PCPs prescribe standard TT despite the high rate of local resistance of H. pylori to CLA (>35%) [18,19]. A similar proportion of PCPs favoring TT has been reported in Italy, Turkey and South Korea [20][21][22]. On the other hand, a lower proportion of PCPs prescribed standard TT in Pakistan (61%) and Mexico (64%), and in our study (63%) [23,24]. The degree of CLA resistance in Israel is >20% in adults; therefore, first-line treatment with TT should be abandoned [6,7]. According to the Maastricht V/Florence Consensus Report and the Toronto Consensus, treatment options include concomitant therapy with amoxicillin, CLA and a nitroimidazole, or BQT with bismuth, tetracycline, and a nitroimidazole, together with a proton pump inhibitor [2,4]. According to the American College of Gastroenterology's Clinical Guideline, sequential therapy with amoxicillin followed by CLA and a nitroimidazole, together with a proton pump inhibitor, remains a valid alternative [3]. We noted a significant increase in the number of PCPs who recommended treatment for H. pylori regardless of symptoms, and who recommended confirming eradication with a noninvasive test. This practice is consistent with the principles set forth in the Kyoto global consensus, in which H. pylori was characterized as an infectious disease [25]. H. pylori is considered an obligate pathogen and causes histological gastritis, which correlates poorly with symptoms. It follows, therefore, that treatment should be offered regardless of symptomatology and that eradication should be confirmed in all patients following treatment. Our results might suggest an increased acceptance of the Kyoto consensus.
We found that compliance with recommendations for second-line treatment was higher than compliance with recommendations for first-line treatment. After excluding PCPs who chose to refer patients to a gastroenterologist for second-line treatment, the proportion of PCPs who recommended guidelineappropriate second-line treatment was 92.5%. This high baseline level of compliance may be the reason that exposure to printed materials and electronic consultation were not found to be significant predictors of compliance. Another reason for the lack of significance could be the fact that printed materials focused mainly on first-line, rather than second-line treatment.
Interestingly, we found that exposure to EOVs in the 3 months prior to completing the questionnaire was associated with lower compliance with second-line treatment recommendations. This, too, may be attributable to the high baseline adherence among respondents with and without EOV exposure (86.8% and 95.1%, respectively), or the fact that EOVs focused mainly on firstline treatment. Furthermore, there is a questionable correlation between EOVs within 3 months of participation and EOVs during the 3-year period during which our intervention was implemented. Another possibility is that EOVs unrelated to our study occurred (such as visits from industry representatives) and were recalled by study respondents.
We found that compliance with H. pylori screening prior to commencing long-term NSAID therapy is suboptimal, and that compared to 2015 these results are unchanged. A nonsignificant trend towards improvement in PCPs' screening of first-degree relatives of gastric cancer patients was observed, although rates remain inappropriately low Limitations of our study include those inherent to any voluntary questionnaire, such as selection bias. PCPs mindful of continuing medical education are more likely to have completed the questionnaire. We could not reliably assess the frequency or distribution of EOVs during the three-year intervention period (much less that of the printed materials). For this reason we chose to assess EOVs and exposure to printed materials in the 3 months preceding the questionnaire as a surrogate. We could not presume that PCPs could reliably recall an encounter more than 3 months previously. The validity of this surrogate endpoint is unknown. Therefore our study lacks a true control group, not exposed to our interventions. Correlation between compliance with guidelines and exposure to EOVs and printed materials within the 3 months may not necessarily indicate a correlation between compliance with guidelines and exposure to our educational initiative, which took place over a period of 3 years. Another limitation is that we do not know how many of the PCPs who participated in the 2015 survey did so again in 2018. However, the impact of our intervention was measured on a representative sample of the entire PCP population, rather than on individual PCPs. Finally, we cannot be sure that the improvement in outcomes is entirely attributable to our intervention.
In conclusion, targeted education of PCPs seems to be an effective method to increase compliance with guidelines for the treatment of H. pylori. Internet and social media platforms may be the most effective means to enhance information-sharing between PCPs and gastroenterologists, and thereby enable a streamlined approach to H. pylori treatment. Nevertheless,