New Pathways to Diagnosis
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Transcript of New Pathways to Diagnosis
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New Pathways to DiagnosisNovember 2013
Ed Seward on behalf of the Diagnostics Group
Phil Andrews Colorectal Pathway
London Cancer
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Our remit• Optimising the diagnostic pathway
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The Background• Colorectal cancer is a preventable disease
• As a country, we relatively under investigate, and have poor outcomes for colorectal cancer. These facts are probably related.
• Easy and timely access to diagnostics should save lives
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The Background• Colorectal cancer is a preventable disease
• As a country, we relatively under investigate, and have poor outcomes for colorectal cancer. These facts are probably related.
• Easy and timely access to diagnostics should save lives
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Monday 26th March 2012
National Cancer Intelligence Network Press Release
‘Nearly 10% of bowel cancer patients die within a month of diagnosis’
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Wednesday 11th April 2012
DoH Direct Access to Diagnostic Tests for Cancer
Best Practice Referral Pathways for General Practitioners
25% of pts with CRC are diagnosed as an emergency presentation, 26% are diagnosed as a 2WW, 24% are diagnosed as a GP referral not through the 2WW pathway
Suggests dropping age requiring investigation from 60 to 40 yrs
Suggests open access sigmoidoscopy access +/- ‘one stop shops’
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Monday 5th March 2012
DoH NHS Improvement Agency
Rapid Review of Endoscopy Services
Demand for endoscopy set to double over the next 5 years
Emphasises the importance of organisational change to improve efficiency, data collection, service and user involvement, optimise capacity, guarantee patient care
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What used to happen
Consultant triageGP referral
Out-patients
Lower GI investigation
Out-patients
8 weeks
6 weeks
3 months
BUT27% of patients diagnosed on non 2WW pathway
AND85-90% conversion rate to lower GI investigation
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What will now happen
Nurse telephone assessmentGP referral
Lower GI investigation
? Out-patient review
3 days
2-4 weeks
Reduces waits in the systemReduces costs
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How does it work?• Nurse assessment and triage• Given as a ‘choose and book’ appointment
• List of questions, including symptoms and any anticipated problems with bowel prep. Simple algorithm to follow
• Able to book in for an appointment
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How does it work?• Lower GI Investigation• Assessed by a consultant/senior health care professional
• Decision made by them as to whether further input is required
• Database/audit ongoing
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But does it work?• Tried and tested
• Northumberland
• Dorchester
• St Marks
• Whittington
• Homerton
• Leeds
• Imperial
• Other areas e.g. cardiology
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Pics on stick
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GP referral = 2WW/ non 2WWAfter TAC Triage = 2WW/ non 2WWPresenting problem:Bowels - Loose / frequent / constipation / alternating pattern / same as alwaysHow long have bowels been like this?Rectal bleeding - yes / no If so how often___________________________Fresh or dark blood - Toilet pan / tissue / mixed with stoolAnal symptoms – pain on defecation, lump/prolapse, itchAbdominal pain - yes / no – where? How long?Weight – up / down / stable?Appetite – up / down / stable?
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O/E (by GP)Family history of CA colon / IBD / other bowel diseases?Has your GP taken any blood tests from you recently? Yes / No ;Any bowel or digestive problems in the past?List current medicines:(especially ACE-I, diuretics, NSAIDs, anti-depressants, lithium, carbamzepine, OCP)Have you had any previous bowel investigations? Yes / NoAny previous abdominal operations?Any problems swallowing? Yes / NoDo you have any cardiac past medical history?Any renal problems?Do you take any anti-coagulants?Are you diabetic? If so do you take tablets or insulin?Do you live alone?How mobile are you / do you need help getting around?What support do you have around you?TAC OUTCOME:
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So what’s the algorithm?Anorectal Flexible sigmoidoscopy
e.g. sensation of a lump/ piles/ fissure/ prolapse
Bright red rectal bleeding <40 yrs
Diarrhoea Colonoscopy
Dark/ altered blood Colonoscopy
Bright red rectal bleeding >40 Colonoscopy
Previous polyps/ FHx CRC Colonoscopy
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Our data• 59 pts so far – 39 on 2WW pathway
• Mean age 60 yrs (34-88 yrs)
• Mean wait for TAC 2 days (0-6 days)
• 2 flexis, remainder colonoscopies
• Usual indication CIBH or PRB
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Our data• Mean total wait : 2WW 8.2 days
• 18WW 11.6 days
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Our data• Endoscopic findings: 1 CRC (in 18WW)
• 3 IBD
• 9 patients with polyps (inc 1 FAP)
• 1 pancreatic cancer (in 2WW)
• Usually – diverticular disease or normal
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Our data• 2 DNAs (both 2WW= sent clinic appt)
• 8 ‘new’ clinic appts for further follow up
• 1 pt unable to contact by phone (=sent clinic appt)
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Our data• Estimated savings to commissioners
• 48 clinic slots x £273.5 = £13128 (but nurse salary etc)
• Time on pathway saving (maximum) of 71% 2WW
• 88% 18WW
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Other benefits• Every patient gets pre-assessed
• Same diagnostic criteria applied to every patient
• Intense scrutiny of pathway and outcomes
• Huge QIPP benefit
• Helps massively with breaching
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Our pathway• Enormously popular with patients
• GPs love it
• Commissioners think it’s great
• Endoscopy staff cautiously welcoming
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What’s next?• Expand numbers
• Look at other areas e.g. upper GI, hepatology
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Interested?• Business case available
• Happy to share learning
• Speak to EVERYONE, in and out the hospital
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