Transcript Document
New Pathways to Diagnosis November 2013 Ed Seward Phil Andrews on behalf of the Diagnostics Group Colorectal Pathway London Cancer [email protected] 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 BUT 27% of patients diagnosed on non 2WW pathway What used to happen GP referral Consultant triage Out-patients AND 85-90% conversion rate to lower GI investigation Lower GI investigation 8 weeks Out-patients 6 weeks 3 months What will now happen Reduces waits in the system Reduces costs GP referral Nurse telephone assessment 3 days 2-4 weeks Lower GI investigation ? Out-patient review 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 • Leeds • Dorchester • Imperial • St Marks • Other areas e.g. cardiology • Whittington • Homerton Pics on stick GP referral = 2WW/ non 2WW After TAC Triage = 2WW/ non 2WW Presenting problem: Bowels - Loose / frequent / constipation / alternating pattern / same as always How long have bowels been like this? Rectal bleeding - yes / no If so how often___________________________ Fresh or dark blood - Toilet pan / tissue / mixed with stool Anal symptoms – pain on defecation, lump/prolapse, itch Abdominal 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 / No Any previous abdominal operations? Any problems swallowing? Yes / No Do 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 • [email protected] • [email protected]