Results

1. NEW:FOLLOW-UP RATIOS: DOGMA OR DESIGN? Andrew Bamji Queen Mary's Hospital, Sidcup, Kent DA14 6LT Introduction Local imposition of a new:follow-up (N:FU) ratio for outpatients of 1.88 was deemed impossible to achieve. Previous work (1,2) has shown that ratios are dependent on casemix and staff numbers. A formal audit in one geographical area suggests that a ratio of at least 1:4 may be reasonable (3). I set out to predict the likely ratio de novo from an audit of consecutive new patients. Conclusions have been summarised elsewhere (4). Results 279 new patients were seen (annualised at 523; the equivalent for a full-time rheumatologist of 697). 6 were inappropriate. PCT of origin and obligate referrals are shown below. (Note: increased percentage from Greenwich (23 vs 15%) with concomitant reduction from Bromley, due to waiting list/Choose & Book differences) 37% of the cohort had IJD equivalent to 200 patients annually, broken down below: Of the remainder, 63 (23%) were “one-stop) and 114 had NI conditions who were given further appointments. I have assumed they will have 2 FU appointments before discharge. Real data suggests IJD patients will average 4 FU appointments in year 1. This is shown in table 1. Table 1 Table 2 shows the effect of following guideline recommendations of monthly appointments for RA (and by implication for other IJD) to stability. Table 2 The result is a first year ratio between 1:2.28 and 1:4.11. In the following year, assuming the same new patient profile, one must add in to the table the residual IJD patients undischarged from the previous year. Using the real data figures (table 1 above) and data on average time to next appointment (6 months) and clinic discharges from the database (approx 60 patients discharged/died/lost to FU yearly) the second year numbers are as follows: This results in a ratio of 1:2.8 and continuing the projection you obtain Year 3 1:3.33 Year 4 1:3.85 Year 5 1:4.37 Discussion Is such a casemix typical? There are differences in referral patterns if broken down by PCT: There are several explanations for these differences, including waiting times at other units, special reasons for referral, development of referral protocols (e.g. for back pain in Bexley, which diverts such patients to other services – if correctly followed the % of patients should have been 4.29 rather than 7.14%) and the presence of a referral management system (which might screen out NI patients). Finance To achieve a ratio of 1:2 requires all IJD patients to be discharged after their second follow-up appointment. In some areas (including ours) PCTs have refused to pay for more FU appointments than the expected ratio. For 279 new appointments 525 FU appointments are paid for (total annualised cost £220,600) Using the figures above all the IJD patients (seen initially 2 monthly) would have to be discharged after 4 months and given current data on remission induction all would require re-referral. The cost profile then looks like this: This represents an annualised extra charge to the PCT of a single consultant of £65,600 (£83,000 if RA guidelines are followed for all IJD patients). • Continuing pressure on GPs to reduce referrals, alongside clear guidelines for the specialist management of IJD, will lead inevitably to an increase in proportion of IJD patients seen in rheumatology clinics. Using the simple methods above, anyone can calculate their likely N:FU ratio. This will deteriorate but may be improved by increasing the number of “one-stop” patients, e.g. for osteoporosis assessment or DEXA scanning. However it is likely that commissioners will get wise to gaming strategies. • We have used these data to agree a change to the acceptable N:FU ratio locally. The basis for negotiation should be • Casemix variation and patient accumulation will distort new:follow-up ratios and it is not reasonable to compare units whose casemix is substantially different. • Discharging unstable IJD patients is the only way to maintain a new:follow-up ratio of 1:2 or less. This breaches NICE/BSR guidelines and would be considered clinically inappropriate by the rheumatology community • Discharging new patients would cause PCTs to incur a substantial increase in PbR costs, annualised at around £70,000 per consultant (there are 8 rheumatology consultants currently working in SLHT) Map showing local PCT areas. The two outpatient departments within Bexley PCT are shown in red (QMS) & black (EH) Data collection All new patients referred to one of the two Queen Mary’s Hospital consultants (AB) between May & October 2010 were recorded by disease type, together with data on PCT of origin. Information on expected/obligate referrals (e.g. internal referrals, old patient re-referrals) was also collected. This was entered on my patient database (Excel spreadsheet). Method From the spreadsheet, numbers and percentages of new patients from each PCT were calculated. “One stop” patients were recorded. Data on disease type allowed breakdown into IJD and non-inflammatory (NI) conditions (e.g. osteoarthritis, back pain and soft tissue lesions). Review of long-term follow-up data allowed a prediction of likely time to next appointment for both IJD and NI groups and from this I calculated the numbers of FU appointments generated. In addition I recalculated numbers assuming a FU pattern as recommended in rheumatoid arthritis management guidelines. I have made the assumption that all patients with IJD (including seronegative arthritis, ankylosing spondylitis (AS), juvenile arthritis (JIA) and PMR/GCA) will need to be managed identically in the early stages • Conclusions • Prediction of new:follow-up ratios can be made from simple data • Casemix variation distorts ratios and makes inter-unit comparisons unreasonable • Discharging unstable IJD patients can maintain an artificially low ratio at the cost of breaching management guidelines • Early discharge may significantly increase costs • References • Litwic A, Bamji AN. Follow-up or discharge? A new patient outcome analysis. BSR Annual Meeting, 2008 (Abstract 417 ii121) • Bamji AN, Lane J. Impact of a community-based rheumatology clinic on a hospital department . BSR Annual Meeting, 2010 (Abstract 96 i68) • Baskar S, Obrenovic K, Hirsch G, Paul A, Lanyon P, Erb N, Rowe IF. West and East Midlands Rheumatology case-mix survey. BSR Annual Meeting, 2010 (Abstract i24: OP55) • 4. Bamji AN. We should scrap targets for outpatient follow-up ratios. BMJ 2011; 342: c7373