Providing Access to BNP for GPs in Primary Care is cost efficient and improves the patient journey

1. Providing Access to BNP for GPs in Primary Care is cost efficient and improves the patient journey Chris Johnstone, Carol Kemp, Sylvia Kamya, Neil McConnell , Clare Murphy, Scottish Cardiac Society Autumn Meeting 30 September 2016

2. Background • Diagnosing Heart Failure requires an echocardiogram. • In NHS GG&C prior to 2011, outpatients being investigated for a diagnosis of Heart Failure (HF) were referred to an open access echo pathway. • Original Heart Failure Diagnostic Pathway (HFDP) introduced across GG&C in 2011. Echo numbers were reduced by 50% compared to open access echo pathway. • The HFDP is a a technician led pathway.

3. Current GG&C HFDP Suspected HF in primary care Refer to HF diagnostic pathway service Recommended by SIGN/ NICE/ ESC ECG / BNP If both normal, HF unlikely Return to GP without cardiological review If abnormal proceed to echo. Cardiology review (aetiology, investigation and management plan)

4. Background • If the Echo is abnormal an appointment is made to see a cardiologist. • A patient with heart failure may then have to make 3 visits, 1 for a ECG/BNP, 1 for an echo and 1 for a consultant. This may take an average of 19 weeks. • 2014/15 audit of the GG&C HFDP: approximately 50% of patients had a normal ECG and BNP thus did not require echo. Could these referrals be avoided?

5. Background • BNP is a sensitive, specific test for HF. • A normal BNP and ECG virtually excludes the diagnosis of HF. • BNP is available in primary care in many Western world countries and has been available in England since 2008. • At present in NHS GG&C, BNP is only available via the secondary care HFDP.

6. Aims • To investigate whether providing GPs with access to BNP in Primary Care would cost effectively improve the patient journey by reducing:- • Referrals to the HFDP • The number of times a patient had to attend hospital • Waiting times for echo, cardiology clinic and obtaining a diagnosis

7. Methods • Introduce a pilot scheme for 29 Renfrewshire GP practices allowing GPs to request BNP from primary care. • Continue to run old pathway at same time. • Measure the impact of the pilot scheme against usual care. • Give presentation at Scottish Cardiac Society. • Change practice across GG&C and Scotland

8. Methods • Funding: Local healthboard scheme to improve patient flow. • Collaboration: Primary care, Royal Alexandra Hospital Cardiology and Biochemistry teams. • Buy-in from GPs: Working with inflexible IT systems caused problems, eg BNP couldn’t be added to order comms and we had to use the old referral pathway on SCI Referrals, but GPs had to write ‘Renfrewshire HFDP Pilot’ on the referral form. • Education: We publicisedthe pilot study at GP meetings and by emails to all Renfrewshire practices. • Audit: Baseline data analysis for one year prior to introduction of the pilot pathway in Renfrewshire was compared to six month and 10 month pilot study data.

9. Old pathway flow chart

10. Old pathway flow chart

11. New pathway flow chart

12. Results • BNP made available as an option for Renfrewshire GPs in October 2015. It was not compulsory • Population size: 172,000 • No of BNPs measured Oct 2015 - July16 (inc) = 227 • No of patients referred to pilot pathway Oct 15-July16 = 64 No. of BNP tests ordered per month

13. Results Total Renfrewshire GP Referrals Crude Data • As always nothing is simple. Not all Renfrewshire referrals are seen in the RAH and the RAH sees patients from outside of Renfrewshire. • Prior to Pilot • 16 referrals per month • Ratio old to new pathway 100:0 • Post Pilot Introduction 6 month data collection • 15 referrals per month • Ratio old to new pathway 89:11 • Post Pilot Introduction 10 month data collection • 12 referrals per month • Ratio old to new pathway 66:34

14. Results % of patients seen at RAH Old HFDP not from Renfrewshire • Prior to Pilot • 4% • Pilot 6 month data collection point • 7% • Pilot 10 month data collection point • 10%

15. Results Waiting time until 1stappt(weeks)

16. Results % of referred patients who received an Echo Prior to Pilot • Old pathway 57% (47% ECG, 53% BNP) Post Pilot Introduction 6 month data collection • Old Pathway 49% (47% ECG, 53% BNP) • Pilot pathway 100% Post Pilot Introduction 10 month data collection • Old Pathway 50% (33% ECG, 67% BNP) • Pilot pathway 100%

17. Results Waiting time from GP referral to Echo (weeks)

18. Results Waiting time from GP referral to appt with Cardiologist (weeks)

19. Results Efficiency of Diagnosis Pilot pathway n=64 • Old Pathway n= 152

20. Results Costs • No of referrals to pilot pathway: 64 • No of referrals avoided: 163 • BNP cost is £6.70 x 227 = £1520 over 10 months • Savings on physiologist time: approx £1600 • Anticipated costs: 40 BNPs/month = £3216 per annum. However:- • 70% of new pathway referrals lead to a positive cardiac diagnosis Vs 16% of old pathway referrals. • We should be able to reduce referrals by about 50%. • HFDP Echo appts should be reduced by approx 23%.

21. Conclusions Cost efficiently providing BNP to primary care:- • Improves the patient journey • Reduces number of referrals to a heart failure diagnostic pathway • Reduces number of secondary care attendances for patients • Reduces waiting times for ECHO, cardiology review and thus diagnosis • BNP should be made available in primary care throughout Scotland

22. Thank Youespecially to Dr Clare Murphy, Mrs Carol Kemp, Dr Sylvia Kamya and Dr Neil McConnell

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