innovations conference 2014 dr peter pockney and donna gillies fast track colonoscopy for positive...

Fast Track Colonoscopy for +FOBTin a public hospital setting

Ms Donna GilliesDr Peter PockneyDr Jon GaniDr Rob FosterConjoint Professor Anne Duggan

Duet Presentation

Definitions

• Fast track (FT)

• Direct access colonoscopy (DA)

• Positive faecal occult blood test (+FOBT)

• National bowel cancer screening program (NBCSP)• 5 yearly 50, 55, 60, 65, 70 (changing to 2nd yearly 50-74)

• NHMRC Guidelines• FOBT Testing 2nd yearly 50-74

• Greater Newcastle Sector (GNS) • John Hunter, Calvary Mater and Belmont Hospital

Background Information

• HNEH has the highest incidence of CRC in the state

• Surgical Cancer Patients: BDH and JHH Cancer Services Report 2013– Inadequate GP referrals– Median (Mean) time from symptoms to definitive treatment

130 (168) days for CRC

• Student projects– 20% of colonoscopies do not meet NHMRC guidelines– Waiting list categories exceeded recommended waiting

periods by 60%

MAJOR issues

• Increased demand – iFOBT – changing to 2nd yearly– Aging population– Increased community awareness

• Variations between – Clinic appointments– Colonoscopy lists

Aim

• To reduce the median / mean time from GP referral to colonoscopy for public patients referred to the GNS following a +FOBT

Method

1. Data analysis Data collection pre and post change for public patients

referred to the GNS following a +FOBT Date of GP referral Type of FOBT test (NBCSP or GP initiated)

• Comparison between groups Date of colonoscopy Quality of bowel preparation Outcome of colonoscopy Post change data included

• “Red Flag” CRC symptoms• Medical history as per +FOBT referral form• Date of last colonoscopy

Methods

2. Change Process Colorectal coordinator / project officer / project team Develop a process for fast track colonoscopy

Direct fax number to dedicated wait list for +FOBT Standard referral form for +FOBT referrals (public and private) Agreement of the process by ALL endoscopists

Screening tool for assessment for direct access colonoscopy following +FOBT

Key decision points for process Standard phone conversation when screening

Results: Project team

Dr Peter PockneyMs Donna Gillies

Dr Jon GaniDr Rob Foster

A/P Anne Duggan

Peri operative staff

Bookings

Referral Management

Facility Managers

Endoscopists

Application Development

Information technology

Theatre / Endoscopy Suite NUM

Medicare LocalsHealth Pathways

Cancer Services

Results: Referral Form

• Internet• Medicare locals GPs

– Integrates into their software

• Endoscopists• Dedicated fax

number for +FOBTs

+FOBT Referral Received in Fast Track Outpatient Waiting List

1st Assessment of Referral• All information i.e. histo / NBCSP ID, bloods

• Review referral for pt Hx• Review CAP for pt Hx

• Review for exclusion criteria for DA colonoscopy

2nd Assessment (Phone Consult)• Check for CRC symptoms

• Check Medical History• Check for exclusion criteria

Direct Access ColonoscopyBooking processed (30 day triage)

Allocated on rotational basis between hospital and endoscopistsFeedback letter to GP

Fast Track Colonoscopy (Clinic Prior to Colonoscopy)

CMH rotational allocation in public or private clinic / roomsSignificant RFS – organise appointment public or private rooms

Feedback letter to GP

Clinic(triage 30 days)

Rotational allocation in public or private clinic / rooms Feedback letter to GP advising

• <50 or >75 • no red flag symptoms

• Normal colonoscopy < 2 years prior

• Complex Medical History (CMH)• Significant Red Flag Symptoms (RFS)– consultant contacted and

appointment booked

• All other patients

DatabaseRecord

Monitor outcomeFollow-up

Audit process

< 7 days from date referral

received

Key Decision Points

Phone Consult

In House• Outpatient booking• Outpatient notes in

medical record• Information provided to

– Endoscopist – Peri-op– NUM

Patient• +FOBT meaning• CRC red flag symptoms• Relevant medical

history• Risks of colonoscopy• Booking process• Bowel preparation

Criteria: Medical Exclusion

• < 50 or >75 years• Iron deficient anaemia• Complex medical history• Stoma• GFR <60• Cirrhosis • Unstable ischaemic heart disease (regular angina or angina on

minimal exertion• Recent Stroke or MI < 3 months• Dual platelet therapy• Exercise tolerance < 1 flight of stairs.• Methadone patient

+FOBT Referrals

Reason for FOBT

Fast Track Direct AccessTriaged out of

FT / DATotal

NBCSP 0 55 13 68

GP Initiated 12 56 41 109

Total 12 111 54 177

FAST TRACK & DIRECT ACCESS

FT: n=12 DA n=111

Time from GP referral to colonoscopy

Pre (Days)N=71

Fast Track (Days)N=11^

Direct Access(Days)N=90*

Median 82 33 41

Mean 103 37 45

Range 28-435 14-63 11-143

CI 99% 21-53 39 to 51

^ 1 patient no date allocated for colonoscopy *21 patients no date allocated all waiting < 28 days, with the exception of 2

Diagnosis: fast track and direct access

Fast Track Direct Access

GP initiated GP initiated NBCSP Total

Adenocarcinoma 4 (57%) 5 (12.5%) 2 (6%) 11 (13.5%)

Adenoma 1 (14%) 12 (30%) 12 (34%) 25 (30.5%)

Normal 2 (29%) 23 (57.5%) 21 (60%) 46 (56%)

Total 7 40 35 82

TRIAGED OUT OF DIRECT ACCESS PREP

N=54

Not fast track / direct access colonoscopy

GP Initiated n= 41*^ NBCSP n = 13*^

Age< 50 years>75 years

109

00

Complex Medical 10 5

Colonoscopy < 2 year previous 4 3

Alternative appointment Total 10• Private 4

• Maitland 5• Other area 1

Total 6• Private 4

• Maitland 2

Symptomatic 6(Upper and lower GI)

1 (last colonoscopy < 1 yr)

Patient avoiding 1

* Could have more than one reason^ No patients in this group had a cancer diagnosis

Diagnosis: triaged out of direct access

GP initiated NBCSP Total

Adenocarcinoma 0 0 0

Adenoma 8 0 8 (50%)

Normal 6 2 8 (50%)

Total 14 2 16

SUMMARY OF DIAGNOSIS+FOBT REFERRALS

Diagnosis all +FOBT

GP initiated NBCSP Total

Adenocarcinoma 9 (15%) 2 (5.5%) 11 (11%)

Adenoma 21 (34.5%) 12 (32.5%) 33 (34%)

Normal 31 (50.5%) 23 (62%) 54 (55%)

Total 61 37 98

Conclusion

• Fast track process removes delays for patients with colonic neoplasia

• Only 50-60% of patients have a normal colonoscopy

• A co-ordinator ensures patients are appropriately triaged (pt who do not meet NHMRC guidelines are still getting appropriate rapid access)

• There are differences between GP initiated and NBCSP cancer rates on our preliminary data