innovations conference 2014 dr peter pockney and donna gillies fast track colonoscopy for positive...
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Dr Peter Pockney and Donna Gillies - Fast-track Colonoscopy for Positive Faecal Occult Blood Testing (+FOBT) in a Public Hospital SettingTRANSCRIPT
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Fast Track Colonoscopy for +FOBTin a public hospital setting
Ms Donna GilliesDr Peter PockneyDr Jon GaniDr Rob FosterConjoint Professor Anne Duggan
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Duet Presentation
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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
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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%
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MAJOR issues
• Increased demand – iFOBT – changing to 2nd yearly– Aging population– Increased community awareness
• Variations between – Clinic appointments– Colonoscopy lists
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Aim
• To reduce the median / mean time from GP referral to colonoscopy for public patients referred to the GNS following a +FOBT
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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
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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
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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
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Results: Referral Form
• Internet• Medicare locals GPs
– Integrates into their software
• Endoscopists• Dedicated fax
number for +FOBTs
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+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
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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
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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
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+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
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FAST TRACK & DIRECT ACCESS
FT: n=12 DA n=111
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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
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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
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TRIAGED OUT OF DIRECT ACCESS PREP
N=54
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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
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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
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SUMMARY OF DIAGNOSIS+FOBT REFERRALS
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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
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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