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Delivering improvements in diagnostic services 31st March 2010

Delivering improvements in diagnostic services 31st March 2010. Survive and Thrive. Direct primary care access to imaging. Plain films, ultrasound, bariums CT – CT brain – All CT MRI – MRI lumbar spine. Aim of direct access. Improve patient pathways Improve patient experience

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Delivering improvements in diagnostic services 31st March 2010

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  1. Delivering improvements in diagnostic services31st March 2010

  2. Survive and Thrive

  3. Direct primary care access to imaging • Plain films, ultrasound, bariums • CT – CT brain – All CT • MRI – MRI lumbar spine

  4. Aim of direct access • Improve patient pathways • Improve patient experience • Enhance doctor-patient relationship • Reduce whole journey waiting times

  5. “ There is still a lingering perception among patients that their journey remains littered with barriers, pitfalls, duplication and delay”. Kerr Report, 2005

  6. Imaging in patient journey • Imaging is one part of the journey • Imaging interfaces with other steps • Redesigning interface processes can improve the whole patient journey

  7. Effect of access restrictions Consultation in primary care Referral to secondary care Imaging arranged Review in secondary care Primary care ongoing management

  8. Effect of access restrictions Consultation in primary care Referral to secondary care Imaging arranged Review in secondary care Primary care ongoing management ? WASTE ? WASTE

  9. Effect of opening access Consultation in primary care Imaging arranged Primary care ongoing management

  10. Referral should be based on clinical criteria not referral source

  11. Process to open direct access to CT and MRI • Context of formalising co-operative radiology/primary care working in 2004 • Established regular radiology and primary care meetings

  12. Radiology/primary care liaison group • CHP leads, GP sub-committee secretary, GP care fellow • Radiology clinical and managerial staff • Developed open team culture - honest - supportive - challenging

  13. CT brain direct access pilot • Referral criteria agreed for chronic headache • Educational events arranged • Information packs distributed • Pilot from April 2005 – April 2006

  14. Chronic headache • Commonest GP referral to neurology • 4.4 consultations per 100 patients per year • 18,700 headache consultations in Tayside per year

  15. Outcome from 1 year CT brain direct access pilot • 82% of practices referred • 45% of individual GPs referred • 215 patients had CT brain scans • 1.2% referral rate from headache consultations

  16. Questionnaires returned from 189 referrals Initial Outcome • 88% of scans stopped a secondary care referral Longer term (1-2 years post-scan) • 18 (8%) from 215 patients were referred to neurology

  17. Effect of access restrictions Consultation in primary care Referral to secondary care Imaging arranged Review in secondary care Primary care ongoing management ? WASTE ? WASTE

  18. Conclusion from CT brain direct access pilot • Good primary care utilisation • Adherence to referral guidance • Improved patient pathway • 88% of scans stopped secondary care referral Adopted into routine practice in 2006

  19. Process to open access to all CT Referral criteria agreed during 2006 Patients with a non-acute condition that CT may assist in diagnosing with CT being indicated on currently accepted Royal College of Radiologists imaging guidance

  20. Primary care direct access to all CT • Educational events arranged • Information packs distributed • Pilot started February 2007 • First 6 months – 28 non brain referrals Adopted into routine practice in 2007

  21. CT referrals in 2009 Total CT – 23,272 referrals GP CT – 1,375 (6%) referrals

  22. Process to open direct access to MRI • Discussions at radiology/primary care liaison group • Agreed to consider MRI lumbar spine pilot • Orthopaedic and neurosurgery input

  23. Referral criteria agreed Indications • Sciatica • Spinal claudication • Developing motor deficit – simultaneous clinical and MRI referral Exclusions • acute cauda equina syndrome • mechanical back pain

  24. Implementation process • Educational event, EPASS accredited • Referral criteria and flowchart sent to practices • Advice to radiologists on reporting format • Questionnaires sent to referrer with report

  25. Data from 6 months pilot April to September 2009 on primary care direct access to lumbar spine MRI

  26. 179 Referrals • Number of GPs referring 107 - 107/309 GPs (35%) • Number of practices referring 59 - 59/72 practices (82%)

  27. Referrals by practiceApril – September 2009

  28. Referrals by practice October – December 2009

  29. Impact on MRIMRI lumbar spine referrals

  30. Monthly total GP/out-patientMRI lumbar spine referrals

  31. Monthly % GP referrals of total out-patient/GP MRI referrals

  32. MRI waits from receipt of referral to verified report April 2009 – 6 weeks October 2009 – 6 weeks

  33. Data summary • Good GP utilisation • Impact on total referrals uncertain • MRI waiting times unaltered

  34. Responses to distributed questionnaires 173 questionnaires distributed 146 questionnaires returned (84%) 134 questionnaires analyzed (77%)

  35. Did access to MRI lumbar spine stop a referral to secondary care? Yes - 46 (34%) No - 88 (66%)

  36. Was the patient referred to secondary care after the result of the MRI was known? Yes - 68 (51%)

  37. Was the patient referred to secondary care at the same timeas the referral for the MRI? Yes - 20 (15%) Did you mention MRI in the referral letter? Yes - 20 (100%)

  38. Was the report useful to you in managing the patient? Yes - 132 (98%) No - 2

  39. Questionnaire summary • 34% stopped a secondary care referral • When patients were referred, MRI was always noted

  40. Would secondary care have arranged an MRI on these patients? Clinical details on 134 request cards were reviewed by Mr. Eric Ballantyne, consultant neurosurgeon 125 (93%) would have had MRI 9 (7%) would not have had MRI

  41. Patient journey Before direct access GP OP MRI OP After direct access GP MRI 34% GP MRI OP 66%

  42. Patient journey times in weeks Before direct access GP OP MRI OP 1248 = 24 After direct access GP MRI 4= 4 GP MRI OP 4 8 = 12

  43. Outpatient clinic attendances Before direct access GP OP MRI OP 134 134 268 After direct access GP MRI GP MRI OP 88 88

  44. Outpatient clinic attendances • Reduction in referrals equivalent to 1.5 weeks off neurosurgical departmental W/T for all new patients • Reduction in reviews equivalent to 2.5 weeks off neurosurgical departmental W/T for all review patients

  45. Whole year impact 1,400 MRI lumbar spines per year 40% (560 patients) use direct GP access Annual reduction in OP visits 750

  46. Primary care perspective • General practitioners views • Patient experience

  47. Overall summary • Good primary care utilisation • Adherence to referral criteria essential • MRI waiting times maintained • 34% stopped a secondary care referral • Improves patient journey - improves patient experience - shorter journey times - fewer outpatient attendances

  48. Effect of access restrictions Consultation in primary care Referral to secondary care Imaging arranged Review in secondary care Primary care ongoing management ? WASTE ? WASTE

  49. Discussion on pilot interpretation to determine future direction • GP/Radiology liaison group • Diagnostics, radiology and neurosciences group • Open evening meeting for GPs Adopted into routine practice in 2009

  50. Next steps • Direct primary care access to knee MRI • Similar process, but add physiotherapy input • Aim to commence pilot in mid-2010

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