Transforming the outpatient model – 15 ideas with some evidence

 

Transforming the outpatient model

 

 

The paper starts with some basic principles and considerations then some specific ideas. It is principally an illustration of the art of the possible. It is not intended to be comprehensive. Some of the areas below may have been explored locally already. This is the result of a very rapid scoping review around alternative models of outpatient care. It is further informed by soft intelligence.

 

 

the 15 areas set out are as follows

 

1          E consultation

2          Patient initiated follow up

3          Group based follow up for some conditions versus individual appointments.

4          Improved use of lifestyle change interventions to improve value

5          PwSI model / community clinic model

6          Nurse led OP care vs doctor led OP care

7          Technology – Telephone follow up, skype, video link &                                   Telecare

8          Low value pre operative care as a target

9          Referral refinement – often used strategy in glaucoma

10        What’s the super 6 of specialty x, y or z

11        Cancer follow up and risk Reduction in cancer and other forms of follow up

12        non GP referrals

13        DNAs and SMS messaging

 

Greg Fell

Oct 15

 


Introductory thoughts

Is the care NEEDED

The follow up debate tends to be overwhelmed with shifting care from hospitals to primary care. This perhaps ducks the real question is whether the activity should take place at all – what is the aim, what is the value, to who.

Don’t ignore the underpinning economics

Obviously a great deal of follow up care might be considered “profitable”. Relatively low margin but high volume. Thus we shouldn’t forget the underpinning economics and the position of the FT as an employer – that they have staff and capital costs to pay.

It’s all a story of capacity and supply

Places that seem to have more capacity seem to struggle more to control demand…….demand is never ending If there is supply it WILL be filled.

First OP appointments. NICE referral advice here

Tools available are blunt – for example 1st:FU ratio

“aggressive management” of first to follow up – where the net effect was drop off on follow ups but a significant hike in OP procedures

Net cost overall. Thus tread carefully

The management tools are blunt and mostly don’t affect real patient flow or really how pop of patients is managed. Affects how things are coded and counted.

 

Unintended consequences of 1st :FU management can be

  • GP referrals↓ ; Cons-Cons referrals↑
  • Rebound patient demand
  • Impact on Community Services
  • Impact on GP Practices
  • Impact on Social care
  • Quality Assurance in primary Care

 

many stories that when commissioners have tried to curb never ending follow-ups (in breast cancer) the response was to discharge them with instructions to GPs to make a new referral.

Nuclear options – If responding to immediate pressures – discharge all but with open opportunity to come back to talk to clinician who knows your case. Tested in Kirklees; nobody took up the opportunity but gave people confidence they could.

 

Other OP indicators

  • discharge at first OP appt
  • conversion of OP to admission


Workforce

Are we prepared to blur the boundaries between different aspects of workforce. Training and skill mix issues

 

Being mindful of the broader context about “transferring work to the community”

assumptions that “GPs can just soak up – they cant, also wrong assumptions re follow up ratios in LTCs.

Reducing first outpatient appointments by innovative ways of exchanging information between clinicians and GPs that does not involve a patient appointment.

 

Key policy documents

http://www.england.nhs.uk/statistics/statistical-work-areas/hospital-activity/monthly-hospital-activity/

http://www.nhs.uk/NHSEngland/AboutNHSservices/NHShospitals/Pages/hospital-outpatient-appointment.aspx

https://www.gov.uk/government/publications/national-tariff-payment-system-2014-to-2015

http://www.hsj.co.uk/home/innovation-and-efficiency/-take-outpatient-clinics-out-of-the-system/5065240.article

http://www.health.org.uk/areas-of-work/programmes/innovation-to-improve-outpatient-clinic-efficiency/

http://docs.health.vic.gov.au/docs/doc/2135E6586F8B725CCA2579170003AB64/$FILE/progress0508.pdf

http://www.institute.nhs.uk/option,com_joomcart/main_page,document_product_info/products_id,945/cPath,106.html http://evidence.nhs.uk/search?q=Hospital%20outpatient%20clinics&ps=50

 

 


Overarching evidence review

SDO – Outpatient Services and Primary Care: A scoping review of research into strategies for improving outpatient effectiveness and efficiency

Roland et al. SDO 2006.

http://www.population-health.manchester.ac.uk/primarycare/npcrdc-archive/Publications/82-research-summarySDO.pdf

 

Key points

The paucity of high-quality research for any one intervention

high degree of consistency in outcomes across the range of interventions included within each of the four models of care investigated.

 

Considered four main strategies

Transfer of outpatient services to primary care

Effective strategies that maintain quality are: primary care clinics for chronic diseases; discharging hospital outpatients to no follow-up, patient-initiated follow-up or GP follow-up; and direct access by GPs to hospital-based diagnostic tests, investigations and treatments.

The merits of GPs with Special Interests (GPSI) clinics require further investigation.

GP minor surgery may reduce quality of care.

 

Relocating specialists into community settings

This does not reduce outpatient demand but may improve access in remote areas.

 

Liaison between primary care and specialists

This may improve service quality but does not reduce outpatient attendance.

 

Professional behaviour change

Specialist educational outreach and structured referral sheets reduce GP referrals.

‘In-house’ second opinion before referral requires further investigation.

Ineffective interventions include: passive dissemination of referral guidelines, audit-and-feedback of referral rates; discussion of referral rates with an independent medical advisor.

Financial incentives to reduce referrals may also reduce the quality of care.

 

Other issues

The quantity of available research varied widely across individual interventions,

Unintended consequences and impacts on allied health sectors received less attention.

No effective strategy involving primary care was without risk.

 

 

 

 

 

Some ideas

 

1          E consultation

 

Stoves et al http://qualitysafety.bmj.com/content/19/5/1.53.abstract

 

Led to significant reduction in paper referrals from implementation practices.

E-consultation provided nephrologists with access to more clinical information. GPs reported that the service was convenient, provided timely and helpful advice, and avoided outpatient referrals.

Specialist recommendations were well followed, and GPs felt more confident about managing chronic kidney disease in the community.

Most appropriate for management of patients with mild-to-moderate chronic kidney disease in primary care where there is some uncertainty as to whether specialist referral is warranted

Allows specialist resources to be directed towards supporting patients with more complex needs.

This general model is now being applied with great effect in rheumatology, haematology, cardiology, soon to be gastro.

 

 

 


2          Patient initiated follow up

Patient to decide if and when they see OP, rather than “the system” dictating it.

 

Often follow up reviews can occur when the patient is well – arguably poor value use of time for all concerned.

 

Patient initiated model is being tested in SW CHLARC – RA patients.

There are a number of other research papers

This is being applied in rheumatology. Has potential application in other areas

The clinics offer increased patient autonomy and the opportunity for greater self-management of chronic disease. This fits with new models of care where the patient is considered to be ‘the expert’.

Fits into broader debate about self care, and shifting the locus of control from clician / system to patient.

 

paper on the impact in terms of clinic visits is about to be puvlished. Author states (email to GF March 15)  that over 12m there has been fewer face to face contacts in those using patient led system vs standard model.

Being expanded into other areas within rheumatology.

 

Some practical implementation issues, especially safety net and exclusions, need to be considered carefully.

 

 

COPD – The effect of an outpatient care on demand system on health status and costs in patients with COPD. A randomized trial.

http://www.ncbi.nlm.nih.gov/pubmed/24931900

small study (n=49). An on-demand-system was comparable with usual care, had a cost-saving tendency, and can be instituted with confidence in the COPD outpatient care setting.

 

A patient-initiated DMARD self-monitoring service for people with rheumatoid or psoriatic arthritis on methotrexate

McBain RCT (Ann Rheum Dis 2015;0:1–7) demonstrated clear reductions in in primary and secondary healthcare services with patient initiated self monitoring. No loss of clinical or psychological well being. Small RCT, needs careful thought.,

Local opinion has indicated there may be relatively small proportion of patients for whom this would be suitable – patients with significant compliance issues would be excluded, and many patients have overlapping fibromyalgia – frequent service access. Most often oral DMARDS are GP monitored but plenty of SC MTX ones not. Danger this may create more work as patients become concerned about minor abnormalities in the bloods that clinician would ignore. This needs robust test.

3          Group based follow up for some conditions versus individual appointments.

 

Robertson concluded that providing rehabilitation in a group format results in equivalent clinical outcomes to provision of similar therapy in an individual format in the treatment of back pain and urinary incontinence.

http://www.ncbi.nlm.nih.gov/pubmed/25064775?dopt=Abstract

 

Heyworth et al considered patient satisfaction over 3 years of shared medical appointments. Concluded that patients were MORE satisfied with shared appointments relative to standard care.

Ann Fam Med. 2014 Jul;12(4):324-30. doi: 10.1370/afm.1660.

 

Seesing et al considered the cost effectiveness of shared medical appointments (SMA) for neuromuscular patients in an RCT.

The study found that there were no substantial differences between SMAs and individual visits. The findings were sensitive to group size (min of 6 recommended as optimal) and the % of patients that see their treating neurologist (75% cited as ideal).

The study is taken to provide some evidence that SMAs are not significantly more cost-effective than individual appointments, This implies that SMAs may be a means to increase productivity of the physician without compromising quality of care. However The study lacks the precision to exclude important differences in cost-effectiveness between SMAs and individual appointments.

Neurology. 2015 Jul 17. pii: 10.1212/WNL.0000000000001857

 

4          Improved use of lifestyle change interventions to improve value – wellness focus

 

Lifestyle intervention to be the default and on-going treatment in all care pathways delivered in OP clinics – Much require a greater emphasis on behaviour change training in education and cpd

 

Wellness plan not care plan – all patients leave OP with a plan for their care, but also a plan of things they need to do to keep well

 

 

Manage the risks for future need at OP / improve the value of current OP care

Smoking and prior cataract surgery are key risk factors for AMD (http://www.biomedcentral.com/1471-2415/10/31)

As cataract is high volume – increase the route from cataract surgery to stop smoking interventions.

 

Managed system to improve / increase the flow of patients from hospital OP clinics to stop smoking interventions

This is simply a no brainer

 

Rheumatoid Arthritis: Smoking Exacerbates Disease Activity.

http://www.medscape.com/viewarticle/821446

same can be said of many to most treatments.

 

Needs to be done at scale and over a long period.

 

 


5          hospital v PwSI model / community clinic model

 

Well tested. Mixed results

Not much more to say here

http://bjcardio.co.uk/2015/06/introducing-integrated-care-potential-impact-on-hospital-cardiology-clinic-workload/

this article suggests reduction of new referrals by a third

 

Southport have introduced community cardiology.

Apparently to great effect. I haven’t seen any data yet.

 

 

McLoed tested the introduction of consultant-led ‘satellite’ clinics to two community settings for general paediatric outpatient services.

Objectives were to reduce non-attendance by improving geographic accessibility.

Satellite clinics did not increase attendance beyond their contribution to shorter travel distance, which was associated with higher attendance. Children living in the most-deprived areas were 1.8 times more likely to miss appointments compared with those from least-deprived areas.

The satellite clinics’ contribution to activity in catchment areas and to total capacity was small. However, one of the two satellite clinics was efficient compared with most hospital-based clinics.

The study concluded that such outreach models may help but do not provide a panacea; a wider more holistic approach is needed.

McLoed et al. BMJ Qual Saf. 2014. doi:10.1136/bmjqs-2014-003687

 

Reconsider the extent to which OSA can be community vs hospital managed

Many places beginning to think about community / ambulatory model. treatment provided in a PC setting did not result in worse CPAP compliance compared with a specialist model and was shown to be a cost-effective alternative. http://dx.doi.org/10.1136/thoraxjnl-2014-206287

 

 

 


6          Nurse led OP care vs doctor led OP care

In RA – Leeds based study demonstrated equivalence in terms of nurse led vs consultant led care.

Some caution needed re the economics of this study.

Ndsoi doi:10.1136/annrheumdis-2013-203403. Ndosi et al ARD 2013.

 

Community Nurse Led care for RA

Watts et al (http://dx.doi.org/ 10.1136/bmjopen-2015-007696) tested the outcome and cost effectiveness of nurse-led care in the community in RA. Not necessarily cheaper than hospital model, but may free up capacity. Similar outcomes.

Builds on the Ndsoi study of hospital based nurse led RA care – same quality as doctor led care.

 

Meta analysis of Nurse-Managed Protocols in the Outpatient Management of Adults With Chronic Conditions found positive effects on the outpatient management of adults with chronic conditions, such as diabetes, hypertension, and hyperlipidemia.

Shaw et al Ann Intern Med. 2014;161:113-121. doi:10.7326/M13-2567

 

 

7          technology  – phone / skype etc

Change the default

Phone OP to be the default for all

Followed by Skype

 

Saves money and carbon, more efficient use of everyones time.

For some post-op care, a phone call may be all that’s needed

Scheduling a call instead of an in-person visit could reduce patient no-shows, which would help physicians better manage patient loads and follow-up care.

Hwa et al – open hernia repair or laparoscopic cholecystectomy patients who followed up their surgery with a phone call instead of a OP visit had the same rate of complications of those who showed up at the OPD.

 

Telephone follow up – Post op or as part of LTC care

Why is there a need for face to face appointment when telephone appointment will do equally well.

 

Operational issues – need:

  • careful scheduling,
  • protocol based management,
  • careful script.
  • Safety net and exclusions.

JAMA Surg. 2013;148(9):823-827. doi:10.1001/jamasurg.2013.2672

JAMA Surg. doi:10.1001/jamasurg.2013.2672 (editorial)

 

Similar has been implemented in some areas – AGH implemented (through CQIN) and saw follow ups fall by 25%

 

Video follow up

using virtual clinic follow up for joint replacement patients.

Royal Cornwall Hospital Trust (RCHT) orthopaedic team

National guidelines require joint replacements to be monitored at regular intervals; usually at one, five and every subsequent five years following surgery. Traditionally carried out via a face-to-face appointment with the surgical team, with questions asked about pain and function and an x-ray film of the joint replacement taken and checked.

Between 90-95% of these patients will be doing well at the 10-year point, which means that most patients are brought back to clinic just to tell their surgeon that they’re doing well.

Setting up a virtual clinic to follow up our patients with hip or knee joint replacement.

  • Those patients choosing to do so register with the MyClinicalOutcomes web-based system and complete a set of patient reported outcome measures (PROMs). PROMs are short sets of questions developed from clinical research that measure patient symptoms, such as pain and function.
  • A symptom score is generated, allowing patients to compare themselves to other similar patients and to track their health over time looking out for any deterioration or improvement.
  • Patients can consent to share this information with their hospital team, allowing easy monitoring between face-to-face appointments.
  • Following joint replacement, patients are seen face-to-face at 6 to 8 weeks and then entered, if they prefer, into the virtual clinic pathway.
  • An x-ray film is booked at their local clinic one year after surgery and this is reviewed alongside the patient’s symptom score by the surgical team.

A report is emailed and further follow-up arranged as required.

 

Postoperative Telehealth Visits

Vella et al. JAMA Surg. Published online September 23, 2015

Tested online post op care – lap choley, heria repair.

Making use of online digital images. Patient uploads image to portal using phone. Surgeon views image and asks patients about symptoms and wound healing, at time of their convenience, by email.

For 68% of group – no difference in outcomes between online post op vs standard model.

Small study n=50. Study designed to assess paitent acceptability rather than outcomes.

 

Tele follow up vs standard hospital model OSA

Isetta (Thorax 2015;0:1–8) concluded that a telemedicine-based strategy for the follow-up of CPAP treatment in patients with OSA was as effective as standard hospital-based care in terms of CPAP compliance and symptom improvement, with comparable side effects and satisfaction rates.

The telemedicine-based strategy had lower total costs due to savings on transport and less lost productivity (indirect costs).

Table 4 of the paper is key – excluding travel related costs seemingly no difference in cost between standard follow up and telefollow up in terms of health service costs. No differences in effectiveness. Social return (carbon, travel time) as opposed to NHS financial benefit?

 

Telemedical and Standard Outpatient Monitoring of Diabetic Foot Ulcers Rasmussen (Diabetes Care. 2015 Jun 26)

CONCLUSIONS: The findings of no significant difference regarding amputation and healing between telemedical and standard outpatient monitoring seem promising. However higher mortality – requires more investigation. Maybe a sub group issue?

 

in clinic v tele OP Appt

Pain Med. 2015 Jun;16(6):1045-56. doi: 10.1111/pme.12688. 2015 Jan 23.

Telehealth may cost about the same as in-person appointments, but may reduce the number of steps in patient pathway, http://www.ncbi.nlm.nih.gov/pubmed/25616057

 

Teledermatology. Great potential to reduce OP attendances.

Bristol case study. NICE QIPP database. Nov 2012.

improves productivity in sec care (doc can see more pt per hour by looking at pics rather than real patients etc).

Of the 347 patients referred via teledermatology in that period, 32% were subsequently referred to secondary care, with 68% managed in a primary care setting.

An estimated net saving from avoidance of referrals of £45,784 was delivered. Across 18 practices, 9 months. Subsequent wider roll out found a net saving of c£43 / 100k population.

 

Browns et al RCT on image capture, store and forward vs standard care.

“In view of the difficulties in recruitment and the potential biases introduced by selective loss of patients and the delay in obtaining a valid second opinion in the study group, no valid conclusions can be drawn regarding the clinical  performance of this model of SF telemedicine. With regard to digital photography in suspected skin cancer, it is unlikely that this approach can dramatically reduce the need for conventional clinical consultations, whilst still maintaining clinical safety. Additional research on the assessment of diagnostic and management agreement between clinicians would be valuable in this and other fields of research.” Obviously need to test the generalisabity of THIS study to what you are discussing

Health Technology Assessment 2006; Vol. 10: No. 43

 

 

Telecare to enable no follow up. Virtual Fracture

Virtual Fracture.

Emerging evidence from Glasgow and elsewhere. Virtual review of radiographs following ED visit, reduces need for patient to be followed up in fracture clinic. Paitents with simple fractures discharged with written advice from ED, only requested to attend follow up with Ortho dept review the image and consider it necessary.

 Vardy BMJ Open 2014. Describes Glasgow model – http://www.ncbi.nlm.nih.gov/pubmed/24928593.

In pop of 300k savings quoted of £156k (a 25% reduction in costs – based on Jenkins paper http://www.fractureclinicredesign.org/wp-content/uploads/2013/09/BJJ-Article.pdf comparing old model to new model. Frees up consultant time for more complex – thus better use of time, more efficient etc.

 

Virtual Outreach may not be the panacea we hope

Wallace et al published a RCT and economic evaluation of joint teleconferenced medical consultations. The study was designed to test the hypotheses that virtual outreach (with consultation between patient, GP, specialist) would reduce offers of hospital follow-up appointments and reduce numbers of medical interventions and investigations, reduce numbers of contacts with the health care system, have a positive impact on patient satisfaction and enablement, and lead to improvements in patient health status. NHS costs over 6 months were greater for the virtual outreach consultations than for conventional outpatients, £724 and £625 per patient, respectively. The index consultation accounted for this excess.

 

Cost and time savings to patients were found. Estimated productivity losses were also less in the virtual outreach group. Virtual outreach consultations result in significantly higher levels of patient satisfaction than standard outpatient appointments and lead to substantial reductions in numbers of tests and investigations, but they are variably associated with increased rates of offer of follow-up according to speciality and site. Changes in costs and technological advances may improve the relative position of virtual consultations in future.

 

The extent to which virtual outreach is implemented will probably be dependent on factors such as patient demand, costs, and the attitudes of staff working in general practice and hospital settings. Further research could involve long-term follow-up of patients in the virtual outreach trial to determine downstream outcomes and costs; further study into the effectiveness and costs of virtual outreach used for follow-up appointments, rather than first-time referrals; and whether the costs of virtual outreach could be substantially reduced without adversely affecting the quality of the consultation if nurses or other members of the primary care team were to undertake the hosting of the joint teleconsultations in place of the GP. Qualitative work into the attitudes of the patients, GPs and hospital specialists would also be valuable.

Health Technol Assess. 2004 Dec;8(50):1-106, iii-iv. http://www.ncbi.nlm.nih.gov/pubmed/15546515

 

 

 

8          Low value pre operative care as a target

Preoperative Consultation Before Cataract Surgery.

US Study. Between 1995 and 2006, the frequency of preoperative consultation for cataract surgery increased substantially. Referrals for consultation seem to be primarily driven by nonmedical factors, with substantial geographic variation.

JAMA Intern Med. doi:10.1001/jamainternmed.2013.13426

Are we Choosing Wisely or Is This Simply Low-Value Care? oi:10.1001/jamainternmed.2013.12298

Same principles might be applied to lots of other conditions


9          Referral refinement – often used strategy in glaucoma

 

Ratnarajan et al compared glaucoma referral refinement schemes (GRRS) in the UK during a time period of considerable change in national policy and

guidance.

 

Key points

  • Approx 2000 paitents were included.
  • The first-visit discharge rate (FVDR) for all time periods for Optoms with Special interest (OSI) in glaucoma was 14.1% compared with 36.1% from non-OSIs
  • The FVDR increased after the April 2009 NICE glaucoma guidelines compared with pre-NICE
  • Elevated intraocular pressure (IOP) was the commonest reason for referral for OSIs and non-OSIs, 28.7% and 36.1%,
  • The proportion of referrals for elevated IOP increased from 10.9% pre-
  • NICE to 28.0% post-NICE for OSIs, and from 19% to 45.1% for non-OSIs.
  • The study concluded that for demand management, OSIs can reduce FVDR of patients reviewed in secondary care
  • overemphasis on IOP as a criterion for referral is having an adverse effect on both the non-OSIs and indeed the OSIs ability to detectICLE SUMMARY
  • The study was designed to test whether specialist trained optometrists can reduce the first-visit discharge rate of patients identified in primary care as being at risk of glaucoma and therefore reduce the burden on the hospital eye
  • Service

 

The study recommended that patients with a high chance of being diagnosed with glaucoma based on the examination findings of the nonspecialist optometrist should be referred directly to secondary care and those at lower risk could effectively be reviewed by a specialist trained optometrist carrying out a comprehensive eye examination.

 

Again, there are applications of this to many other areas.

 

Ratnarajan et al. BMJ Open. http://dx.doi.org/10.1136/bmjopen-2013-002715

 

10        What’s the super 6 of specialty x, y or z

Super 6 is increasingly proven in diabetes care. ONLY certain types of diabetic patient NEED to be seen in hospital.

Satisfaction data available for a while, beginning to see outcome data.

What is the application of the concept into other areas

 

What things NEED to be under the care of consultant

What can be shared across a broader system by skill mix

What MUST be seen in hospital by consultant

What COULT be seen in hospital but by non consultant

What OUGHT to be seen out of hospital

What SHOULDNT be seen in a hospital

 

 


11        Cancer

14a     Cancer follow up

Lots of potential for reducing the many mandated specialist hospital follow-up cancer clinics post-treatment. Could all be cut down drastically without affecting patient outcomes and would also cut down costs considerably.

NHS Improvement produced a comprehensive set of how to guides and pathways to risk stratify follow up

Also NICE QIPP Case study, Sept 2013.

Assuming this is all in place

 

Colorectal – rsk stratified follow up in Colorectal Cancer. Mr Griffiths (BTH) has done the work up. High risk patients (50% of the cohort) get more intense follow up, low and medium risk (25% and 25%) get less intence.

 

Breast Cancer – some work around breast cancer and other sites (from Leeds – Chris Fosker). An be argued that some follow up is justified in the 1st 2 years in terms of early detection of curable local recurrence, but how much of this is detected by mammography as opposed to clinical examination. Thereafter it is mainly for detection of a contralateral primary (and as many women are in the screening age range – what does this add) or asymptomatic metastatic disease where early intervention has not as far as I know been shown to be of benefit beyond lead time bias. There are claims that it provides ongoing psychological support but are surgeons/oncologists (and there can be quite a lot of duplication of follow up between specialties) best placed to provide this and what % of patients ‘need’ it.

The COG for breast cancer did suggest some approaches – predominantly around telephone support from breast cancer specialist nurses for those pts whose breast ca was pretty straight forward.

Ive seen emails suggesting that most paitents are happy with nurse based phone follow up as long as they had access to the specialist nurse and to consultant/mammography as and when needed, and that In the context of recurrences, majority of pts did not feel that there was any value to be had by going back thru GPs as they felt that generally speaking, GPs did not have the expertise to cope with a pt who might have recurrence. A significant minority of women were keen to continue with the annual visit to the hospital.

 

Prostate – some work in Bradford around prostate. There is already a shared care agreement around prostap – consideration being given to expanding to include PSA testing (currently done in hospital). Algorithms needed to address the pathway, commissioning issues to be addressed.

 


Ontario’s ‘Models of Care for Cancer Survivorship’:

https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=258056

Breast Cancer – “For cancer survivors with breast cancer, if no ongoing treatment issues are observed after the completion of primary therapy (though hormonal therapy may still be ongoing), their discharge from specialist-led care to community-based family physician-led care is a reasonable option”

 

Colorectal Cancer – “In cancer survivors with colorectal cancer who have completed all treatment, discharge from specialist-led care to community-based family physician care is a reasonable option.”

 

Prostate Cancer – “In patients with prostate cancer who have completed primary treatment (radiation or surgery, but with hormonal therapy possibly still ongoing), the transition to nursing-led care within an institution is a reasonable option. Insufficient data exist to inform whether a discharge to primary care is equivalent, but, based on the disease trajectory, the expert opinion is that this is a reasonable option.”

 

Other Cancer Types – “In patients with melanoma and oesophageal cancer, follow-up outside specialist care appears to be acceptable to patients, but without clinical outcomes data, no model of care recommendations can be made.”

Maybe some savings and reduced radiation in more careful consideration of follow up of bladder cancer cystoscopy, imaging (often with high radiation dose CT)

 

14b     Risk Reduction and increasing value in cancer and other forms of follow up that are going to happen anyway

If the follow up is going to happen there is a (currently) untapped opportunity for risk reduction / lifestyle IN cancer follow up pathways……

 

Tuning the standard model of cancer follow up

so we tune down the standard model of routine follow up for cancer follow up

 

standard pathway is:

turn up….. you don’t have cancer see you in six months …..repeat forever

 

should move to one of:

you don’t have cancer…. here’s the information you need to know, we may test you again, depending on underlying risks and we are now going to invite you to back to a group lifestyle clinic

 

will achieve more value out of the same spend

might even be non hospital model…..(In fact should be)

again – need to work through the practicalities and refine it… but…

 

then, specific to breast cancer follow up, was that issue that the surgeon raised – “if you loose x% of weight you probably wont need that tamoxifen and we can stop it

 

This has the effect of turning the whole process of follow up into a broader one of managing current risk and reducing future risk.

Given that survival from breast cancer now ever increasing…… this becomes more important at population level.

 

Cancer early diagnosis and opportunity for risk management

This is going to lead to lots of OP diagnostic stuff.

It is going to happen, regardless of whether anyone thinks it’s a good idea – politics.

millions will see the adverts about symptoms….hundreds of thousands will go see their GP….thousands will be referred for diagnostics…..a tiny number of whom will be helped… so largely wasted or low value stuff.

 

but (given that it’s going to happen anyway…..largely on account of the politics)…. an approach to improving value would be to embed a brief intervention and or brief advice or referral to lifestyle police into this

“you know the test was negative…. but Id like to talk to you about your smoking…. we can help you stop … and will reduce your risk etc”….

 

And from a local comms perspective the whole initiative becomes not just a testing initiative …. but also risk factor raising and risk reduction strategy. Increasing routes into lifestyle support. From a clinical activity perspective it becomes one of risk management not testing

 

 

  • non GP referrals to OP

Some CCGs considering restricting non-medical referrals to consultants – in some areas constitutes some 40% of outpatient activity.

Some of it is predictable – eg. orthoptists to ophthalmology,

Maybe some scope to consider this in detail.

Some non GP referral may be warranted and desirable – for instance ESP to O&T or pain medicine – as it may be part of a streamlined system.

 

13        Reducing Do Not Attends

Hallsworth et al tested a strategy of three different messages to reduce the 11% of DNAs for OP appointments. The project led to a 25% reduction in missed appointments (from 11.1% to 8.5%) for no extra cost by using SMS messages to people with a reminder of the costs of the appointment. The trial tested the differential impact of different forms of wording on the SMS.

 

Hallsworth et al PLoS ONE 10(9): e0137306

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0137306

 

 

 

 

 

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