New Pathways to Diagnosis
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New Pathways to Diagnosis November 2013 Ed Seward on behalf of the Diagnostics Group Phil Andrews Colorectal Pathway London Cancer [email protected]
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New Pathways to Diagnosis. November 2013 Ed Seward on behalf of theDiagnostics Group Phil AndrewsColorectal Pathway London Cancer [email protected]. Our remit. Optimising the diagnostic pathway. - PowerPoint PPT Presentation
Transcript of New Pathways to Diagnosis
New Pathways to DiagnosisNovember 2013
Ed Seward on behalf of the Diagnostics Group
Phil Andrews Colorectal Pathway
London Cancer
Our remit• Optimising the diagnostic pathway
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
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
Monday 26th March 2012
National Cancer Intelligence Network Press Release
‘Nearly 10% of bowel cancer patients die within a month of diagnosis’
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’
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
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
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
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
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
But does it work?• Tried and tested
• Northumberland
• Dorchester
• St Marks
• Whittington
• Homerton
• Leeds
• Imperial
• Other areas e.g. cardiology
Pics on stick
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?
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:
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
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
Our data• Mean total wait : 2WW 8.2 days
• 18WW 11.6 days
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
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)
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
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
Our pathway• Enormously popular with patients
• GPs love it
• Commissioners think it’s great
• Endoscopy staff cautiously welcoming
What’s next?• Expand numbers
• Look at other areas e.g. upper GI, hepatology
Interested?• Business case available
• Happy to share learning
• Speak to EVERYONE, in and out the hospital
