Community-based research - A framework for problem formulation: The case of upper endoscopy for gastroesophageal reflux disease

Objective. To identify clinical hypotheses and information gaps underlying disagreement about the use of upper gastrointestinal endoscopy (EGD) for the diagnosis of gastroesophageal reflux disease (GERD), and to design a registry study to test these hypotheses. Design and setting. Structured group discussions with community-based practicing gastroenterologists. Results. Thirty-three gastroenterologists from 17 sites discussed a set of clinical scenarios concerning the use of EGD in GERD patients with different clinical histories. Clinicians identified patient characteristics and outcome variables missing from the original problem formulation. Using decision tables, the combinations of patient characteristics that provoked disagreement among clinicians were determined. The resulting decision tables specified which characteristics and outcome variables should be measured to test competing clinical theories of when to use EGD in patients with GERD. Subsequently, the clinicians conducted a practice-based study measuring uncertain variables associated with disagreement about the need for EGD in specific clinical situations. Conclusion. A structured, but flexible, approach to group discussion may help identify factors that are important in decision making and the hypotheses that should be addressed in resolving variations in practice styles. Technology assessors can use these methods to identify variables underlying clinicians' concerns about the clinical validity of recommendations about practice. This experience with eliciting patient characteristics and uncertain variables underscores the importance of involving practicing clinicians in the process and could be a useful model for problem formulation in guideline development and in community-based research.