Straight to Test Colonoscopy Pilot Sas Banerjee Matt
Straight to Test Colonoscopy Pilot Sas Banerjee, Matt Hanson, Aman Bhargava and Joseph Huang Consultant General & Colorectal Surgeons Noel Thin & Paul Vulliamy Surgical Registrars Victoria Harrison Surgical Services General Manager Angela Ridgeon Specialist Nurse STT Steering group 11 th April 2016
AIMS OF PRESENTATION • Current state at BHR • Pilot • Outcomes • Recommendations
WHY STT? • CONCORD-2 study 2014 • UK cancer survival still lags behind other European Countries • Early diagnosis and early treatment around world increases cancer survival • Driver: improving Colorectal Cancer survival
NATIONAL OPERATING STANDARDS: THE FOLLOWING STANDARDS APPLY TO ALL PATIENTS: • All patients with suspected cancer who are referred urgently by their GP must be seen within 14 days of the GP decision to refer being made. • All patients diagnosed with any form of cancer will receive their first treatment within 31 days of diagnosis. • All patients referred through the urgent 14 day cancer referral route and subsequently diagnosed with cancer will receive their first treatment within 62 days of the date of referral.
INTRODUCTION: PATHWAY – REFERRAL OPTIONS Pt presents at GP with colorectal symptoms Manage the patients in Primary care Routine 18 week referral Urgent 2 week wait (2 WW) referral
CURRENT PATHWAY – STANDARD 2 WW REFERRAL Outpatient appt within 14 days Sent for diagnostics *£ 280 for a colonoscopy or £ 394 for a colonoscopy with biopsy Prescribed medication Treated *£ 138 First attendance – General Surgery function code Refer back to GPDischarged Follow up appointment *£ 84 follow up attendance – General Surgery function code Refer back to GP Further diagnostics Discussed at MDT Decision to treat – with 31 days of DTA and 62 ref Refer to Oncology or other provider *£ 94 follow up attendance – clinical oncology function code Discharge *All tariffs exclude MFF and are for demonstrative purposes 2016/17 PBR document used
BHRUT Data Total Number of Two-week Wait Referrals, All Cancers
BHRUT Data Total Number of Two-week Wait Referrals, Suspected Lower GI Cancer
Monthly Number of Colonoscopies Resulting from 2 WW Referrals, 2013 -15
BHRUT Data Proportion of 2 WW Referrals Diagnosed with Colorectal Cancer
Proportion of Patients Seen Within Two Weeks of Referral Suspected colorectal cancer, p=0. 10 All suspected cancers, p=0. 05
AN ALTERNATIVE PATHWAY? – STT REFERRAL Telephone Patient Triaged STT Standard 2 WW pathway OPA and colonoscopy on the same day within 14 days of ref Refer back to GP Discussed at MDT Decision to treat – with 31 days of DTA and 62 ref Refer to Oncology or other provider *local tariff has not be agreed Discharge Further investigations Follow up appointment
FEASIBILITY OF STT AT BHR? STT PILOT • Measures – Determine if it is pragmatically possible to co ordinate and facilitate at BHR – Determine resource +/- training needs – Determine endoscopy capacity – Staff and Patient feedback – Does it facilitate the 2 WW pathway? – Cost effectiveness?
SET UP AND EVALUATION • Trust committed to running a 2 phase STT pilot trial • Phase 1: 3 week pilot in November 2015 • Phase 2: 8 week pilot in January and February 2016 • Specialist nurse was appointed and specific endoscopy lists ring fenced for pilot. • Pilot led by SAB chairing weekly steering group meetings • After Phase 1 results were reassessed and presentation made to NHS England • Re-evaluation and expansion of pilot in Phase 2
Normal or minor haemorrhoids – discharge 2 WW Referral Seen by consultant; Reviewed by CNS- vetted by consultant Phone Consultation – Nurse Led criteria not met 2 WW Clinic history & examination performed, + Colonoscopy + Management decision made and results and dictated letter generated IBDreferred to Gastro as a new patient Polyp surveillance Colonoscopy unsuccessful– referred for same day CT pneumocolon Cancer – referred to MDT with staging CT scans requested
EXCLUSIONS AT POINT OF REFERRAL • • • > 80 years of age Mobility problems Uncontactable by phone Language barrier Recent Colonoscopy Iron deficiency anaemia Abdominal mass Mental Health issues/memory problems/Dementia Anticoagulation Minority of patients choose clinic first
Referrals over 11 weeks (Nov Jan/Feb) N= 478 Excluded N=37 (24%) Offered 2 WW clinic Normal/Benign condition N=87 Telephone triage N= 152 (32%) Appropriate STT N=115 (76%) Drop outs N=7 (6%) Completed STT N=108/115 (91%) 1 seen in OPD 2 DNA 2 Cancelled 2 Abandoned Other Investigation N=16 (15%) (CT, CTC, OGD) Biopsies taken N=60 (55%) OPD FU N=27 (24%) Taken off 2 WW Suspected IBD N=7 Polyps N=13 Cancer N=1
COMPARATOR GROUP: CURRENT 2 WW PATH • In same time period – 100 pts rejected from STT, matched as a pseudo control group – 50% Males, median age 65. 5 (range 24 -91) • Reasons for exclusion/OPD: – Over age limit: 17% – No answer to telephone triage = 30% – No available carers = 10% – Iron deficiency anaemia= 11% – Abdominal mass= 2% – Other = 30%: already had appt, request tx to another trust, unable to take time off, recent colonoscopy, not able to communicate in English
Failed to attend N=12 (6 DNA, 6 inappropriate) Discharged N=3 (3%) 2 WW N=100 Normal/Benign condition N=56 2 WW OPA N=88 Suspected IBD N=4 2 WW c/scope N=74 (84%) Colonoscopies completed N= 70 (95%) Other Investigation N=21 (30%) (CT, MRI scans, OGD) OPD FU N=31(44%) Back to ref Biopsies taken N=38 (54%) Polyps N=6 Cancer N=4
STT PILOT TIME INTERVALS • 106/108 (97%) met the 2 WW target, (2 breaches) – 1 did not receive prep and 1 DNA first appt • Time from referral to first consultation – Median 10 days (range 6 -21) • Time from referral to colonoscopy – Median 10 days (range 6 -21) • Time from colonoscopy to biopsy result – Median 15 days (range 4 -23) • Time from referral to decision to take off 2 WW – Median 10 days (range 6 -21)
CURRENT PATHWAY: 2 WW TIME INTERVALS • No 2 WW breaches • Time from referral to first consultation – Median 8 days (range 3 -22) • Time from referral to colonoscopy – Median 26 days (range 8 -92) • Time from colonoscopy to biopsy result – Median 13. 5 days (range 6 to 31) • Time from referral to decision to take off 2 WW – Median 31 days (range 4 -68)
COMPARING PATHWAYS Fig: 1 Fig: 2 Fig: 3
MEDIAN TIMELINE Days 1 2 3 4 5 6 7 8 9 STT 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 D Days 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Days 1 2 WW D Days 32 33 34 35 36 37 38 39 40 41 42 43 Wait for consultation Wait for colonoscopy Wait for biopsy result 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62
STT: PATIENT AND STAFF SATISFACTION • In general patients and staff thought STT was quicker and more convenient for the patient Patient Satisfaction Scores 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
LEARNING ABOUT RESOURCE ALLOCATIONS: • 2: 1 ratio of phone calls made for one pt to have STT • Time spent for each phone call was average 20 minutes • Endoscopy capacity: Each STT was appointed a 2. 5 standard endoscopy slot as opposed to standard colonoscopy at 2 points • It was agreed that ring fenced colonoscopy lists would be used • Each week 5 lists (2 x SAB) , (1 x MH), (1 x JH)and (1 x AB)
EXAMPLE OF ENDOSCOPY UTILISATION STT Activity DNA/Cancelled Mon 16. 11. 15 am List cancelled Wed 18. 11. 15 am 3 (+1 colon +1 flexi) (1 not STT) Wed 18. 11. 15 pm 2 (+ 1 flexi) 2 Mon 23. 11. 15 am Consultant Post Take Wed 25. 11. 15 am 4 (+1 colon) Wed 25. 11. 15 pm 2 (+1 colon, +1 OGD) 1 Mon 30. 11. 15 am 3 (+1 colon) 1 Wed 02. 15 am 4 Wed 02. 15 pm 5 Mon 07. 12. 15 am 1 (did not initially receive prep)
COST EFFECTIVENESS? Vs.
CLINICAL LEARNING POINTS FROM PILOT • Decision making seems quicker on STT • Who are the decision makers in the pathway? – Clinician in OPD vs. Endoscopists vs. Clinicians who review results – Who is responsible for ordering extra investigations to aid decision (rpt colonoscopies or CT scans) • How do unexpected biopsy results effect the pathway? • Only 1 cancers was found in STT pilot • Who will provide service for STT – Colorectal Consultants or other Endoscopists also.
PROCESS LEARNING POINTS • Directly the tariff for STT and 2 WW will be the same • By improving the speed/efficiency of treatment – breaches and therefore penalties may be avoided. • Efficiency of endoscopy sessions vs that of extra clinics + endoscopy sessions may bring a cost saving benefit • Is it possible pathway for all comers • Consider cost of extra Specialist Nursing staff to run telephone triage clinics • Consider training/education about appropriate roles of endoscopists in facilitating appropriate data capture
STT AT BHRUT – LOOKING AHEAD • Agree tariff for Telephone Triage Clinic • Offer capacity of 20 colonoscopy slots per week • Aim to increase capacity and reduce the pressure on 2 week wait pathway • Ensure robust audit of pathway and monitoring of satisfaction surveys • Advice from London Cancer, NHS England, underpinned by numbers needed to treat, financial and clinical outcomes.
THANK YOU Questions ?
- Slides: 31