Cancer Treatment in the Community – Options Appraisal Paper PET CT audit... · Web view2...
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Audit of the second 100 PET CT scans performed by the Christie Hospital NHS Trust on patients from North Wales
Transcript of Cancer Treatment in the Community – Options Appraisal Paper PET CT audit... · Web view2...
Audit of the second 100 PET CT scans performed by the Christie Hospital NHS Trust on patients
from North WalesBy Sue ArmstrongAudit Facilitator
Contents:
1) Executive Summary
2) Introduction and Context2.1) PET CT – The first audit2.2) PET CT update2.3) Waiting times
3) Aims and Objectives
4) Methodology4.1) Stage 1 – Establishing standard questions4.2) Stage 2 – Collection of data4.3) Stage 3 – Waiting Times4.4) Stage 4 – Comparisons between first & second audit
5) Results and analysis 5.1) Stage 1 & 25.2) Stage 3 Waiting times5.3) Stage 4 Comparisons
6) Discussion
7) Conclusion and recommendations
8) Footnote
9) Appendices
Appendix 1 Cancer Network internal PET CT referral procedureAppendix 2 PET CT request form templateAppendix 3 Patient Register (Log of referrals)
1. Executive Summary
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Following on from the first audit into this topic conducted by the North Wales Cancer Network in March 2009, this audit into the next 100 PET CT scans performed by the Christie Hospital NHS Trust proposes to assess the following:
Access Utilisation and activity Clinical, patient and financial implications Waiting times for scans Data completeness on Canisc
Upon analysis of all the data collated, the Cancer Network findings are as follows;
PET CT scans satisfactorily staged cancer in 90% of all cases. The evidence suggests that PET CT scanning had a positive influence
on the management of patients through staging cancer more accurately.
It is suggested that PET CT informed alternative treatment options in 22% cases with the greatest impact being suggested within colorectal cancers where 67% of PET scans informed potentially alternative treatment options.
PET CT scanning prevented potential co-morbidities in patients as a result of confirming disease stage and indicating alternative treatment pathways.
In 91% of cases the Cancer Network turnaround for forwarding requests through to the Christie was within 1 working day of receiving the faxed request. Of this 75% were processed on the same day.
In 93% of cases Christie hospital provided scan dates within 7 working days of receiving the request from the Cancer Network. Of this, 77% received appointments within 5 working days.
Within the relevant case notes in Canisc (78 out of the 100), 91% were complete with all the information required to conduct this audit.
2. Introduction and context2.1) PET CT – The first audit
The first audit conducted by the North Wales Cancer Network was completed in March 2009 and it examined the first 100 scans performed by Christie Hospital NHS trust on patients from North Wales from the 1st of April 2008. Part of the rationale being that utilising PET CT scanning informs decision making on treatment in a manner that reduces radical treatment associated with significant co-morbidity.
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The audit was well received and has prompted the Network to conduct a further audit into the second 100 scans which covers the period between mid-July to mid-November 2008. The audit has also been refined to include analysis on waiting times. When the referral mechanism for accessing PET CT scans changed in April 2008, one of the main concerns was the incorporation of yet another administrative layer into the process; that being the requirement to fax the completed pro-forma request to the Cancer Network with someone there forwarding it on to Christies NHS Trust. The concern being that there was the potential for delay. The first audit showed that this concern was not valid as the referring clinicians were happy with the responsiveness of the service and this was evidenced through the feedback from the satisfaction survey. This second audit takes this one step further and has calculated the waiting times and compared them with ‘best practice’ which would advise one day turnaround. The audit also looked into the responsiveness of Christies Hospital and has calculated the wait between the requests received date and the actual scan appointment date and compared this with the contract which requires that scans be performed within 7 working days of receiving the request. The results for both of these can be found summarised in section 1 (the Executive Summary) or in more detail in section 5 (Results and Analysis).
2.2) PET CT update
Since the first audit was conducted, Health Commission Wales (HCW) has expanded the criteria from the 1st of April 2009 to include extra indications in lung and lymphoma and other sites where there is complexity with staging, restaging or evaluating the possibility of recurrence. Therefore the following clinical criteria are included:
Head & Neck cancer: Imaging of patients with proven metastatic squamous cell carcinoma in
the head and neck in whom extensive investigation with cross sectional imaging and direct visualisation has failed to demonstrate a primary source.
Imaging of patients with suspected or confirmed recurrent or residual squamous cell carcinoma of the head and neck. Specifically including those patients who have previously undergone surgery and/or radiotherapy and in whom conventional cross sectional imaging and endoscopic evaluation have failed to clearly demonstrate either the presence or extent of recurrent disease. This group specifically includes patients enrolled in the UK PET-NECK trial.
Colorectal cancer: Assessment of recurrent colorectal carcinoma e.g. indeterminate
presacral masses.
Lymphoma:
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Staging, re-staging, assessment of residual masses, assessment of possible recurrence and pre-transplant assessment in Hodgkin’s lymphoma and of high grade non-Hodgkin’s lymphoma.
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Other: Other cancer sites (including thyroid, melanoma, sarcoma, testicular,
brain, spinal cord and unknown primary) where there is difficulty in staging, re-staging or assessment of possible recurrence.
These additional indications take effect from the 1st of April 2009 though and so do not feature in this audit of the second 100 scans.
There has also been a new contract negotiated with Christie Hospital which agrees delivery of 400 scans per annum for the population of North Wales, this is in line with the Department of Health Framework for the development of PET services in England (2004) which assessed demand for PET scans for the primary cancer indications at 800 scans per million population.
2.3) Waiting times
The waiting time standards of 31 days for non urgent suspected cancer referrals and 62 days for urgent suspected cancer referrals are applicable to PET scan services and therefore, there is a need to minimise any delays in the patient pathway in order to comply with these standards. Under the terms of the contract and mentioned in Health Commission Wales (HCW) document ‘PET Scan Commissioning Policy’ is the expected timescale for accessing a PET scan, which states;
‘All PET-CT scans will be undertaken and reported within 7 working days of receipt or referral.’
This audit aims to measure whether this guidance is being adhered to. Also this audit intends to evaluate the Networks performance on forwarding referrals to the Christie, best practice would be to authorise and forward requests within 1 working day. The results for both of these can be found summarised in section 1 (the Executive Summary) or in more detail in section 5 (Results and Analysis).
3. Aims and Objectives
The aim of the project is to analyse the details around the second 100 scans referred to the Christie, following on from the first audit conducted in March 2009. This being to explore the assumption that utilising PET CT will inform the decision making on treatment in a manner that reduces radical treatment associated with significant co-morbidity. Also, analysis of waiting times for scans and turnaround of processing requests will be done to see if ‘best practice’ is occurring.
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Objectives are:
To measure the usefulness of PET CT scans in staging cancer. To establish whether management of cancer patients is improved/altered
by the use of PET CT scanning. To provide firm evidence of the benefits to the Network and it’s
Stakeholders. To ascertain any potential cost savings. To look at the turnaround time for processing the requests by the Cancer
Network To look at the waiting time for scan appointments by the Christie To look at the completeness of relevant Canisc case notes included in this
audit
Intended Outcome:
As with the first audit this project should help identify any issues with the on-going service, confirm the level of utilisation and identify any benefits and savings. Additionally, it should also provide information around timescales for processing requests and waiting times for scan appointments.
4. Methodology
As stated previously and as was the case with the first audit, this project aims to prove the benefits of utilising PET CT scans for cancer patients. In order to test this theory a sample of the second 100 patients referred since the period April 2008 was taken from the Cancer Networks internal log, this mainly included patients referred between mid July to mid November 2008.
As in the first audit, the following standard questions were used for each referral criteria to determine the outcome and allow the data to be quantifiable, see below:
4.1) Stage 1 – Establishing standard questions
Criteria 1. Staging of non small cell lung cancer prior to surgery or radical
radiotherapy
Standard Questions:Was satisfactory staging achieved?Did the patient go on to have Radiotherapy?Did the patient go on to have Surgery?Did the patient go on to have treatment other than Surgery or
Radiotherapy?
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Criteria 2.Assessment of solitary pulmonary nodule only when biopsy not safe or
practical
Standard Questions:No question just the number of referrals
Criteria 3.Re-staging of colon cancer prior to surgery for removal of metastatic
disease from liver or lungs
Standard Questions:Was satisfactory staging achieved?Did the patient go on to have Surgery on liver or lungs?Did the patient go on to have other treatment?Did the patient go on to have no treatment?
Criteria 4.
Re-staging of colon cancer when conventional imaging has failed to show the cause of rising tumour markers Standard Questions:
Was satisfactory staging achieved?Cause of rising tumour markers shown?Did the patient go on to have no treatment?
Criteria 5.Re-staging of Hodgkin and high grade non Hodgkin lymphoma after
induction Therapy
Standard Questions:Was satisfactory staging achieved?Did the patient go on to have treatment?
Criteria 6.Staging of oesophageal cancer prior to radical surgery
Standard Questions:Was satisfactory staging achieved?Did the patient go on to have Surgery?
4.2) Stage 2 – Collection of data
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A spreadsheet similar to the first was used to capture all the information and the patient notes on the Canisc system were interrogated to gain answers to the standard questions. With the first audit conducted, the Canisc system was the main source of data, but in many instances where the data could not be found or the patient notes were insufficient, the information was sought from the MDT co-ordinators or the Trust Cancer Managers. While conducting the second audit, it was found that in 91% of cases all the information needed was held within the Canisc record which indicates an improvement in recording information. Once all the data was obtained the spreadsheet was updated and the results analysed.
4.3) Stage 3 – Waiting times
The next step was to calculate the waiting times, firstly the time taken by the North Wales Cancer Network in processing the requests and forwarding them onto Christies Hospital and secondly, the time between forwarding the request to Christies and the date of the actual scan. Once this was calculated the waiting times were categorised into the following:
North Wales Cancer Network:Requests processed same dayRequests processed within 1 day (best practice)Requests processed within 2 daysRequests processed after 3 days or moreUnknown (due to date sent not being recorded in the Networks’ log)
Christies Hospital:Scan appt within 5 days of receiving requestScan appt within 7 days of receiving request (best practice)Scan appt within 10 days of receiving requestScan appt after 10 days of receiving requestUnknown
4.3) Stage 4 – Comparisons between first and second audit
Lastly another spreadsheet was created to compare the data, where meaningful, from the first audit with the data received from the second audit. Column charts were generated to illustrate the differences and these can be found in section 5.3.
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5. Results and analysis5.1) Stage 1 & 2
Percentage of scans per hospital
Glan Clw yd27%
Wrexham Maelor37%
Bangor27%
Countess of Chester
8%
Liverpool Chest & Heart
1%
The chart above shows what percentage of the 100 scans examined were requested by each hospital, Wrexham Maelor requested the most scans at 37%. The chart below shows the percentage of scans conducted for each cancer site, as in the first audit this clearly shows that lung scans account for just less than half of all scans requested.
Percentage of scans per cancer site
Gynae1%
Lung48%
UGI24%
Colorectal18%
Haem9%
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The pie chart below illustrates the percentage of scans which may indicate success in staging cancer; this figure could be higher though, as the 10% that represents the ‘unknown’ category relates to data that is unobtainable rather than truly not known. When further analysed the 10% is split between missing data (3%) and data which relates to English patients (7%) whose details would not be recorded on Canisc.
Percentage of PET CT scans that helped to stage cancer satisfactorily
90%
0% 10%
Yes
No
Unknow n
The table and chart below show within which criteria (or cancer site) the PET CT scan may have been influential in informing a treatment decision choice that altered a clinical pathway that might have otherwise been followed without a PET- scan e.g. oesophagectomy.Most cases of treatment pathways being altered were within criteria 1 which relates to non small cell lung cancer. Within this cancer site potentially 7 clinical pathways were altered which may not only have resulted in a cost saving to the NHS (see table below) in terms of avoiding significant and traumatic surgery, but also caused less co-morbidity for patients found to have extensive disease.
TREATMENT CRITERIA1 Staging of non small cell lung cancer prior to surgery or radical radiotherapy2 Assessment of solitary pulmonary nodule only when biopsy not safe or practical3 Re-staging of colon cancer prior to surgery for removal of metastatic disease from liver or lungs4 Re-staging of colon cancer when conventional imaging has failed to show the cause of rising tumour markers5 Re-staging of hodgkin and high grade non hodgkin lymphoma after induction therapy6 Staging of oesophageal cancer prior to radical surgery
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7
0
4
2
3
6
0
1
2
3
4
5
6
7
No of treatments
1 2 3 4 5 6
Criteria
Number of unnecessary treatments prevented per criteria
The table below shows 3 of the 6 criteria within which scans are requested, these have been chosen as it is possible to postulate a course of treatment action that might previously have been taken had the scan not taken place. It is possible to conclude that management of patients within the other criteria was also altered as a result of the scan, but this is more difficult to place a cost on. The costings are taken from the 2008-09 Admitted Patient Care Tariff which is used in England; this has been used as there isn’t a national tariff for Wales. The potential cost savings achieved are shown in the table below:
Costings for surgeries prevented by PET CT scanning
CriteriaHRG Code Narrative
*Cost (£)
No. of procedures
preventedPotential
cost
***Cost of PET CT
scansPotential savings
1Staging of non small cell lung cancer prior to surgery or radical radiotherapy
D03 Major Thoracic Procedures £4,090 7 £28,630 £6,265 £22,365
3Re-staging of colon cancer prior to surgery for removal of metastatic disease from liver or lungs
G02Liver - Complex Procedures £5,956
4 **£40,184 £3,580 £36,604
D03Major Thoracic Procedures £4,090
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Staging of oesophageal cancer prior to radical surgery
F02Oesophagus - Very Major Procedures
£3,574 6 £21,444 £5,370 £16,074
Totals 17 £90,258 £15,215 £75,043
* costs taken from 2008.09 Admitted Patient Care Tariff used in England** this cost represents maximum potential cost if both procedures were required i.e. surgery on both liver and lungs*** based on £895 per scan
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The potential savings have been calculated by selecting the appropriate procedure from the tariff and multiplying by the number of procedures that were prevented to derive the potential cost, then the cost of the PET CT scans was calculated and deducted from the potential cost to give the potential savings.
Number of scans per site per hospital
5
1 1
4
7
0 0 0 0 120 0
5
2
13
20
13
20
75
0
57
0
5
10
15
20
25
Glan Clwyd(27/100)
Countess ofChester (8/100)
Liverpool Chest &Heart (1/100)
Bangor (27/100) Wrexham Maelor(37/100)
Referring hospital (no of scans out of the 100)
Colorectal
Gynae
Haem
Lung
UGI
The bar chart above displays the number of scans requested by each hospital and shows, of the total number of scans requested how many related to what cancer site. Clearly, lung scans are the most frequently requested by each hospital followed by UGI scans.
The bar chart over the page displays the number of scans requested relating to each cancer site and shows, of the total number of scans requested for each site how many relate to which hospital. As mentioned earlier this shows that Wrexham Maelor requested the most scans followed jointly by Bangor and Glan Clwyd hospitals.
One anomaly discovered was that there was a scan performed for gynaecological cancer requested by Wrexham Maelor. Although not strictly within the criteria, the scan was requested on the advice of a radiologist at the Gynae MDT to see if it could show the cause of rising tumour markers. The results were helpful and showed numerous metastases; therefore the patient went on to have palliative chemotherapy.
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Number of scans per hospital per site
5
02
13
7
10 0
2
5
10 0 0 0
4
0
5
13
57
12
20
7
0
5
10
15
20
25
Colorectal(18/100)
Gynae (1/100) Haem (9/100) Lung (48/100) UGI (24/100)
Cancer site (no of scans out of the 100)
Glan Clw yd
Countess of Chester
Liverpool Chest & Heart
Bangor
Wrexham Maelor
The column chart below shows the completeness of case notes within Canisc which were accessed to provide the bulk of data for the audit.
Canisc data completeness (excludes criteria 2 records)
14
1
6
31
19
3
0
31
00
5
10
15
20
25
30
35
Colorectal Gynae Haem Lung UGI
Site
No
of re
cord
s (o
ut o
f 78)
Complete
Incomplete
For 91% of case notes accessed, the information needed was available within the case note; case notes relating to criteria 2 were excluded for this analysis
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as no information was required from the actual case notes, as were English patients whose information would not be recorded on Canisc.
5.2) Stage 3 Waiting times
The column chart below shows the Cancer Networks turnaround time in days for processing the PET CT scan requests and forwarding them on to Christie hospital. Best practice would be requests authorised and forwarded with 1 working day.
Wait in days between request received by NWCN and request forwarded to Christies NHST
75
16
41
4
0
10
20
30
40
50
60
70
80
Same day Within 1 day Within 2 days 3 days or more Unknow n
Wai
t in
days
As is clearly shown above, 91% of requests are forwarded within one day, with 75% being forwarded on the same day as receiving the request. This figure could be higher though as the 4% which refers to the ‘unknown’ category relates to the date sent not having been recorded in the Cancer Networks internal log which means the wait cannot be calculated.
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Wait in days between request forwarded to Christies and date of PET CT scan
77
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4 2 10
10
20
30
40
50
60
70
80
90
Within 5days
Within 7days
w ithin 10days
over 10 days Unknow n
Wai
t in
days
The chart above illustrates the wait in days between the request being forwarded to Christie hospital and the actual date of the PET CT scan. Clearly the bulk of scan requests resulted in a PET CT scan appointment within 5 working days. This exceeds the guidance which requires appointments to be given within 7 working days. The cumulative percentage for 7 working days is 93%. The 1% which refers to the ‘unknown’ category relates to a scan that has not yet taken place due to the patient being unwell.
5.3) Stage 4 Comparisons between first and second audit
The chart below shows a comparison of the percentage of PET CT scans that helped to stage cancer satisfactorily between the first 100 patients and the second 100 patients. This illustrates clearly that PET CT scans are a fundamental tool for staging cancer with 87% successfully staged in the first audit and 90% in the second audit.
In the first audit there was one instance of the PET CT scan being inconclusive and therefore not helpful with staging. In this audit though this anomaly did not occur and there were no scans that were unhelpful.
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Comparison of percentage of PET CT scans that helped to stage cancer satisfactorily
87%
3%10%
90%
0%
10%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Yes No Unknown
First 100 patients
Second 100 patients
The chart below compares the number of unnecessary treatments that may have been prevented per criteria between the first 100 and second 100 patients. Clearly, there has been a shift between sites from the first audit where the most treatments prevented were within criteria 6 oesophageal cancers. This second audit has shown that the most treatments prevented were within criteria 1 lung cancers.
Comparison of potentially unnecessary treatments prevented per criteria
4
0
2 2
6
14
7
0
4
23
6
0
2
4
6
8
10
12
14
16
1 2 3 4 5 6
Criteria
Trea
tmen
ts p
reve
nted
First 100 patients scanned
Second 100 patientsscanned
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The following chart shows a comparison of cases per site between the first 100 and second 100 patients.
Comparison of percentage of cases per site
3%0%
8%
48%
19%26%
44%
18%
0% 1%
9%
24%
0%
10%
20%
30%
40%
50%
60%
First 100 patients scanned
Second 100 patients scanned
The level of requests per site is roughly similar to the first audit, but interestingly, there were no head and neck scans requested for the second 100 patients. There was a gynaecological scan requested though, which did not occur with the first 100 patients.
The chart below compares the number of scans requested per hospital between the first audit and the second audit.
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Comparision of scans per hospital
7%
0%
25%
37%41%
27%27%
1%
8%
27%
0%5%
10%15%20%25%30%35%40%45%
First 100 patientsscanned
Second 100 patientsscanned
The level of scans requested for Glan Clwyd hospital has significantly decreased between the first and second audit sample, while Wrexham Maelors level has significantly increased. Bangor hospital, Countess of Chester and Liverpool Chest and Heart request levels have remained fairly static.
6. Discussion
This second audit was built on the foundations of the first and conducted, mainly, with the same aims; to gain insight into how PET CT scanning assisted in the cancer patients’ pathway. It can be argued from the findings, that the scans impacted on patient care in 2 distinct ways. Firstly, it suggests the use of PET CT scanning influenced the management of patients by staging cancer more accurately resulting in a better service for the patient. Secondly, the results indicate that the use of PET CT scans could have prevented unnecessary, invasive procedures in 22% of cases, this is not to infer that the PET CT had a positive outcome for the patient, merely that the scan showed that the option of invasive treatment might not be beneficial and this finding altered the treatment pathway for that patient. This has wider implications for the NHS as a whole. in terms of ensuring resources are better utilised. Although there is evidence to support this finding, it is, however very difficult to attempt to place a cost upon it, with some criteria being more calculable than others. This has been attempted in the ‘Costings for surgeries prevented by PET CT scanning’ table in the results section of this report. This table shows a potential saving to the NHS of just over £75,000. This figure however, warrants a note of caution. as it is very
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difficult to predict what ‘might have been’ and it has been calculated using a number of assumptions.
Firstly, it is assumed that each of the procedures ‘prevented’ would have definitely resulted in the significant treatment identified. While this is a logical assumption in each case, especially those within criteria 6 who had suspected oesophageal cancer, it cannot be conclusively stated as fact. Secondly, the costing for criteria 3 ‘Re-staging of colon cancer prior to surgery for removal of metastatic disease from liver or lungs’ assumes that surgery was performed on both liver and lungs in both cases, whereas it might just have been on one or the other.
There is also great difficulty in placing a cost saving on what might have been prevented within criteria 4 – ‘Re-staging of colon cancer when conventional imaging has failed to show the cause of rising tumour markers’ and criteria 5 – ‘Re-staging of hodgkin and high grade non hodgkin lymphoma after induction therapy’. While a cost can be calculated it is difficult to predict with any degree of certainty the alternative treatment that might have been undertaken; however there can be little doubt of the benefit to patients, in terms of earlier intervention and more precise treatment.
There were some interesting comparisons to be drawn from the first audit to the second; one of these being the type of scans requested that didn’t fit exactly within the criteria. In the first audit sample there were a small number of head & neck scans performed, but none requested within the second audit sample. Conversely, there was a gynaecological scan conducted within the second audit sample, but none of this type within the first. Although, these were strictly outside the criteria, they were still authorized and found to be helpful. This may have contributed to HCW expanding the clinical criteria to include;
‘Other cancer sites (including Thyroid, melanoma, sarcoma, testicular, brain, spinal cord and unknown primary) where there is difficulty in staging, restaging or assessment of possible recurrence.’
Another comparison that can be examined is the number of alternative treatment options that resulted from the PET scan. Within the first audit sample the site with the greatest impact was haematological where, it can be argued, 75% of patient pathways were altered as a result of the information received from the PET scan. This was not found within the second audit where the percentage had decreased to 33%. However, 67% of colorectal cancer treatment pathways were found to have been altered as a result of the PET. This figure was 20% in the first audit. Also there were fluctuations within criteria 6 oesophageal scans and criteria 1 lung scans. Oesophageal treatments were altered by 25% in the first audit and this increased significantly to 56% in the second audit. Conversely lung treatments decreased from 21% to 14%. These variations demonstrate that the PET CT scan is useful across all cancer sites at identifying alternative treatment pathways.
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Another interesting point that was identified during the audit was the increased amount of information that was available via Canisc. In the first audit a significant amount of information was not recorded within Canisc which resulted in the various MDT co-coordinators and the Trust cancer managers having to dig out the case notes to make available the information needed. In some cases the consultant providing the treatment had to supply the missing information. This delayed the audit due to having to wait for the information to be provided. While conducting the second audit though, these problems had significantly diminished, out of 78 case notes that were accessed 91% of these contained all the information needed to complete the audit and answer the standard questions. This indicates that the recording of information is improving and is far more comprehensive than it has previously been.
This second audit has been refined to include data on waiting times. First calculated was the time taken by the Network to process the forms. This should be done within one day of receiving the request; in 91% of cases this was achieved. Of this figure 75% were processed within the same day as receiving the request. Of the 9% that took longer to process 4% were sent within 2 days and 1% within 3 days or more. It can be assumed from anecdotal evidence that the main delays with processing are not the fault of the Network but rather, due to incompletion of the request forms. Frequently there is mandatory information missing such as the patient’s weight or whether they are an inpatient or outpatient and this requires the Network to obtain this information before authorizing and forwarding on. Also due to the forms being completed manually there is often problems with legibility. There would seem to be some merit in receiving the form electronically to cut out the need for transcribing and to reduce the number of queries back to the clinicians and secretaries regarding having to clarify hand writing which can delay things. The remaining 4% have been classified as ‘unknown’ as the date the request was forwarded to Christie hospital has not been recorded in the log so the wait cannot be accurately calculated. However there is no need for concern here as comparing the date the request was received by the Network (rather than the date the Network sent it on to Christie hospital) to the date of the scan shows that the longest wait would only have been 5 days which would have been well within the recommended timescales.
Secondly the time taken by Christie hospital to provide a scan appointment was calculated. As mentioned earlier, guidance states that;
‘All PET-CT scans will be undertaken and reported within 7 working days of receipt or referral.’
This target was achieved in 93% of cases and exceeded in 77% where scans were performed within 5 working days. The remaining 7% is split between within 10 days (4%), over 10 days (2%) and 1% refers to a scan not yet performed due to the patient not being well enough.
As referred to in section 2.2 (PET CT update) HCW has expanded the clinical criteria under which a PET CT scan will be funded, this is mainly due to the
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recommendations of HCW’s 2008 ‘Review of the PET Scan Policy’. The review suggested broadening the criteria based on recent clinical evidence, current practice and the potential inequality of access within North Wales. This inequality has not restricted access though as historically North Wales has had wider access as the LHB’s agreed to fund PET CT in oesophagus as part of the rationalization of oesophageal surgery to Wrexham. Christie hospital has now been commissioned to provide 400 scans per annum for the population of North Wales. As touched on earlier the demand for scans has been calculated at 800 per million population. According to the ‘Population Based Palliative Care Needs Assessment’ (P Tebbitt 2005) North Wales has an estimated population of approximately 670,000 but if this is weighted to allow for the greater needs of an aging population this figure could be significantly higher. Just on the estimate of 670,000 though this would signify a need for 536 scans per annum which is obviously in excess of the current contract level of 400. Based on the financial year April 08 to March 09 approximately 330 scans were performed under the early restricted guidance. This gives room for an extra 70 scans to be performed in the new year under the new expanded criteria. Whether or not this is sufficient will, no doubt, become apparent as the year progresses.
Overall, this audit demonstrated the on-going need for PET CT scanning and illustrated how useful it really is and how well the systems around it are performing.
7. Conclusion and recommendations
The results achieved support all the initial hypotheses made regarding the benefits of PET CT scanning.
Upon reflection of the findings of this audit and the comments provided, the following recommendations are made;
The continued use of PET CT scanning should be supported and funding should be provided to enable this.
There should be a further audit conducted on requests made from the 1st of April 2009 which would include the additional indicators.
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The current referral mechanism should be refined to a) require that the faxed referrals not be handwritten but completed electronically to remove problems with legibility of the forms and b) allow these faxed referrals to be scanned (via a networked scanner) and emailed to Christies NHST, this will save time.
A further audit should be conducted concentrating on the provision of the service from Christies NHS Trust and levels of satisfaction with it. This should also include an examination into the reporting and whether reports are received within 48 hours of the scan being performed.
8. FootnoteAt the time of writing the second consultation regarding the replacement of Health Commission Wales is reaching its conclusion. The structures being suggested may well leave the planning of PET scanning to the new single organisation in North Wales and thus the process regarding PET scanning may well be subject to change as the new organisation adopts greater local control of access to such services.
9. Appendix 1.
PET-CT – Christies Referrals Procedures
Receiving a Referral
Receiving a hand written faxed referral:
Transcribe fax to the electronic Christies request form Located on the Network drive – data on ‘nrcldc01’ (F:) > Cancer Network folder, File name – Electronic referral form – Final PET CT Investigation Request.doc Ensure all mandatory items are completed – if not refer back to
the referring Clinician or Secretary When the form has been approved input ‘Verified by D Heron’
within the referrers signature sectionGo to section: Encrypting Word Files
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Receiving an electronic typed referral by email:
Note: this will only apply when it has been pre-arranged with a member of the Cancer Network team Ensure all mandatory items are completed – if not refer back to
the referrer When the form has been approved input ‘Verified by D Heron’
within the referrers signature sectionGo to section: Encrypting Word Files
Encrypting Word Files – Password Protection
Open document, and complete necessary fields Click ‘Tools’ located on the main menu bar, then ‘Options’
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An information box will then appear, select the ‘Security’ tab
Enter in password: ****** (one word and all in caps) located under the heading – File encryption for this document indicated by the arrow
Click ‘OK’, another information box will appear requesting you to re-type the password for confirmation then click ‘OK’
Then save the document as usual
Emailing a request
PET CT requests must be encrypted before attaching to a mail message Emails must be sent to: ******* & *******
Registering a request
Each PET CT request needs to be logged on the Network registerLocated on the Network drive – data on ‘nrcldc01’ (F:) > Cancer Network folder, File name – Electronic referral form – PATIENT REGISTER FOR PET CT.doc Complete all columns with the exception of the last, which will be
completed at a later date
.
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8. Appendix 2.
PET CT Investigation Request
Patient Demographics Consultant Referrer
NHS No:Private Pt. Name:
Surname: GMC NoForename: Signature: VERIFIED BY DAMIAN HERONAddress: Address for
Report:Postcode: DoB: E-mail:Home No: Tel. No:Mobile No: Fax No:
Mandatory InformationInpatient? Hosp: Ward: Pregnant? Yes No Contact No: Breast feeding? Yes No
Diabetic? Yes No Communicable infection? Yes No
If Yes, specify? Insulin Tablets Diet If Yes, specify:Pt. weight (kg): Claustrophobic? Yes No
Clinical Indication Staging of non-small cell lung cancer prior to surgery or radical radiotherapy Assessment of solitary pulmonary nodule ONLY when biopsy not safe or practicable Re-staging of colon cancer prior to surgery for removal of metastatic disease from liver or lungs Re-staging of colon cancer when conventional imaging has failed to show the cause of rising tumour markers Re-staging of Hodgkin and high grade non Hodgkin lymphoma after induction therapy Staging of oesophageal cancer prior to radical surgery
Histology and StagingHistologically confirmed cancer?
Yes No Type:
Current clinical stage: T N M
Treatment and InterventionHas this patient had:Surgery? Yes No Type: Date complete:Radiotherapy? Yes No Type: Date complete:Chemotherapy? Yes No Type: Date complete:
Other Clinical Details
For Departmental Use Only DB LT FX Date & Time of Appointment:Christie Hospital No: Authorised:
Please ensure form is fully completed before referring. Thank you. Fax requests to: 01745 589 917
Date Target Patient? (please circle) N / 31 / 62
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8. Appendix 3. North Wales Cancer Network register of referrals.
NORTH WALES PET CT ACTIVITY
TREATMENT OPTIONS
1 STAGING OF NON SMALL CELL LUNG CANCER PRIOR TO SURGERY OR RADICAL RADIOTHERAPY LUNG
2 ASSESSMENT OF SOLITARY PULMONARY NODULE ONLY WHEN BIOPSY NOT SAFE OR PRACTICAL LUNG
3 RE-STAGING OF COLON CANCER PRIOR TO SURGERY FOR REMOVAL OF METASTATIC DISEASE FROM LIVER OR LUNGS COLORECTAL
4 RE-STAGING OF COLON CANCER WHEN CONVENTIONAL IMAGING HAS FAILED TO SHOW THE CAUSE OF RISING TUMOUR MARKERS COLORECTAL
5 RE-STAGING OF HODGKIN AND HIGH GRADE NON HODGKIN LYMPHOMA AFTER INDUCTION THERAPY HAEM
6 STAGING OF OESOPHAGEAL CANCER PRIOR TO RADICAL SURGERY UGI
NO PATIENT
NHS NOPOST CODE/LOCATION
REFERRINGCLINICIAN
SITE TRUST DATE REC'D
DATE SENT TO CHRISTIE
DATE OF PET
CRITERIA PICK LIST REF FORM
OUTCOME EMAILED TO CHRISTIE
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