The cost effectiveness of the Public Direct Access Colonoscopy Service implemented at John Hunter hospital Hunter New England Local Health District and Newcastle University: Presenter(s): Dr Elizabeth Tracey, Research Fellow University of Newcastle Consultant Epidemiologist,HNE Cancer Network Directorate The Lodge John Hunter Hospital Campus HRT 1520 Innovations Workshops and Awards 19-20 November 2015, Sydney
2 Presenters Summary Slide Please complete key messages from your PPT Key problem Colorectal cancer incidence in the Hunter New England Local Health District (HNELHD) is statistically significantly higher than the state average SIR 1.05 (95% 1.02-1.07). 1 Positive FOBT patients in the Greater Hunter Area are routinely referred to an outpatient clinic visit prior to their colonoscopy procedure. At this appointment patient history and other relevant information is recorded and a colonoscopy scheduled. However, patients often reschedule their outpatient clinic visit, new patients have difficulty accessing outpatient visits and tracking of patients does not occur for both the outpatient attendance and colonoscopy visit. 4 5 Aim of Innovation 1. Investigate factors associated with reducing time-to-colonoscopy for people with a positive FOBT in particular for people attending the Public Direct Access Colonoscopy Clinic (PDACC) relative, to the normal service. 2. To investigate the proportion of patients who meet the current recommended triage category of 30 days from GP referral to colonoscopy. 3. To investigate whether there is a difference between: a. the date on the GP referral letter to the date of the colonoscopy (days) b. Clinical factors - Date of the GP referral letter to the RFA date c. Health Service factors - the date on the RFA date to the date of the colonoscopy (days) d. The type of referral service (Direct Access versus normal) and the hospital of colonoscopy (John Hunter, Belmont or Calvary Mater). 4.To examine the cost components of a colonoscopy as part of a cost effectiveness analysis of the PDACC versus the normal service 5. To provide recommendations to HNELHD of findings to improve timeliness, cost, monitoring and reporting Baseline data/ Current situation Data linkage study of Direct Access Colonoscopy service: All patients referred by GPs to the service in 2014. Patients were triaged by a specialist nurse based on recommended guidelines MDT patient - Normal service Patients who underwent a colonoscopy between 1 st January 2012 and 31 st December 2014 at John Hunter, Belmont, or Calvary Mater Hospitals Changes implemented Of the 548 patients included with complete times who underwent a colonoscopy in 2014, 48.2% were triaged via the PDACC and 52.8% via the normal service There was an equal breakdown of male and female patients. The mean age was 61 years in males and 63 years in females. Approximately 44.2 % of all patients were treated at John Hunter Hospital. 32.1% at Belmont and 19.5% at Calvary Mater and 4.2% at other hospitals (Maitland, Private, Out of Area). The cost of a colonoscopy Table 1Means and Medians of time to colonoscopy by type of service and hospital of colonoscopy Ranged from $1,099 at Belmont to $1509.30 at John Hunter for an outpatient procedure. Whereas the cost of a same day colonoscopy for outpatients varied From $2,632.83 for John Hunter and Belmont to $2,495.42 at Calvary Mater Hospital. The biggest cost driver Presenter name Elizabeth Tracey Contact email elizabeth.tracey@hnehealth.nsw.gov.au Health Service Hunter New England Local Health District
3 Key Problem Colorectal cancer incidence in the Hunter New England Local Health District (HNELHD) is statistically significantly higher than the state average SIR 1.05 (95% 1.02-1.07). 1 Positive FOBT patients in the Greater Hunter Area are routinely referred to an outpatient clinic visit prior to their colonoscopy procedure. At this appointment patient history and other relevant information is recorded and a colonoscopy scheduled. However, patients often reschedule their outpatient clinic visit, new patients have difficulty accessing outpatient visits and tracking of patients does not occur for both the outpatient attendance and colonoscopy visit. 4 5
Aim of this innovation 1. Investigate factors associated with reducing time-to-colonoscopy for people with a positive FOBT in particular for people attending the Public Direct Access Colonoscopy Clinic (PDACC) relative, to the normal service. 2. To investigate the proportion of patients who meet the current recommended triage category of 30 days from GP referral to colonoscopy. 3. To investigate whether there is a difference between: a. the date on the GP referral letter to the date of the colonoscopy (days) b. Clinical factors - Date of the GP referral letter to the RFA date c. Health Service factors - the date on the RFA date to the date of the colonoscopy (days) d. The type of referral service (Direct Access versus normal) and the hospital of colonoscopy (John Hunter, Belmont or Calvary Mater). 4.To examine the cost components of a colonoscopy as part of a cost effectiveness analysis of the PDACC versus the normal service 5. To provide recommendations to HNELHD of findings to improve timeliness, cost, monitoring and reporting 4
5 Baseline Data / Current Situation Data linkage study: A protocol was developed and ethical approval was obtained from the Hunter New England Ethics Committee (LNR/14/HNE/525). Direct Access Colonoscopy service: All patients referred by GPs to the service in 2014. Patients were triaged by a specialist nurse based on recommended guidelines into the following categories: 1. Direct Access Service 2. Expedited colonoscopy 3. Positive FOBT but not recommended for colonoscopy and 4. Negative FOBT The data source was the Direct Access Database. Normal service Patients who underwent a colonoscopy between 1 st January 2012 and 31 st December 2014 at John Hunter, Belmont, or Calvary Mater Hospitals. 5. Patients who had a positive FOBT and a colonoscopy in 2014 only were included in this analysis.
6 Key Changes Implemented Open access endoscopy (those in which an endoscopy is performed without prior gastroenterology consultation and who are referred to Direct Access Colonoscopy Clinic) is becoming much more common. 7 The Public Direct Access Colonoscopy Clinic was introduced on the 21 st December 2013 at John Hunter Hospital. As part of the HealthPathways initiative GPs are encouraged to refer patients with a positive FOBT to the Public Direct Access Colonoscopy Clinic. This service is an alternative service where the initial inpatient visit of doctor consultation is instead provided by specialist nurse. The service involves a scripted telephone consultation with patients to obtain information about symptoms, high-risk status, other comorbidities, as well as a history of previous colonoscopies performed. Patients are triaged and if deemed suitable for Direct Access are booked for their colonoscopy, the patient survey is completed, patient consent is obtained and the request for admission (RFA) form is completed and signed by the specialist nurse. A report is provided to the Endoscopist, and bowel preparation is sent to the patient. An earlier audit of time from GP referral to colonoscopy has found that the median time from GP referral to colonoscopy was 82 days, 103 days (mean) with a range of between 28 and 435 days. 6
Outcomes so far 1. Of the 548 patients included with complete times who underwent a colonoscopy in 2014, 48.2% were triaged via the PDACC and 52.8% via the normal service 2. There was an equal breakdown of male and female patients. The mean age was 61 years in males and 63 years in females. 3. Approximately 44.2 % of all patients were treated at John Hunter Hospital. 32.1% at Belmont and 19.5% at Calvary Mater and 4.2% at other hospitals (Maitland, Private, Out of Area). 4. On average 441 (12.7%) of the 3,462 colonoscopies in 2014 were because there was a positive FOBT 7
8 Outcomes so far Table 2 Means and Medians of time to colonoscopy by type of service and hospital of colonoscopy The cost of a colonoscopy Ranged from $1,099 at Belmont to $1509.30 at John Hunter for an outpatient procedure. Whereas the cost of a same day colonoscopy for outpatients varied From $2,632.83 for John Hunter and Belmont to $2,495.42 at Calvary Mater Hospital. The biggest cost driver was the theatre cost. However, direct comparison of component costs for inpatient and outpatient procedures was not possible.
9 Lessons Learnt Aim 1 Investigate factors associated with reducing time-to-colonoscopy for people with a positive FOBT in particular for people attending the Direct Access patients relative, to the normal service. Time from GP referral to colonoscopy Direct Access - the median time 42-44 days compared to 98-68 depending on the hospital. There is only one other study a retrospective audit of the case notes of 433 NBCSP patients (Bobridge 2013) that the median time to colonoscopy was 52 days. Aim 2.To investigate the proportion of patients who meet the current recommended triage category of 30 days from GP referral to colonoscopy. It is clear that regardless of service type (Direct Access or Normal outpatients) 16.4% of PDACC and 6.6% of Normal service patients were seen within 30 days from GP letter to the date on the colonoscopy. Does this matter? Is this benchmark meaningful? The National Bowel Screening pilot is the source of the benchmark figure it has not been reported in subsequent monitoring reports. There is only one other study a retrospective audit of the case notes of 433 NBCSP patients (Bobridge 2013) that found that 23% of patients had their colonoscopy with 30 days. From the health service perspective time from RFA to colonoscopy is probably more meaningful. However, if to benchmark with monitoring reports then we should perhaps measure from the date on the pathology report to the date of the colonoscopy
10 Lessons Learnt Aim 3.To investigate whether there is a difference between the time from GP referral to the time when the patient is booked on the waiting list to the time that the colonoscopy is provided by the type of service (Direct Access versus outpatients). Time from GP referral to RFA Direct Access the median time ranged 6-8 days compared to 42-29 depending on the hospital Bobridge median time 31 days Time from RFA to colonoscopy There is no significant difference in time to colonoscopy for patients regardless of source of referral (Direct Access or normal service) with median times ranging from 34-36 days with the exception of John Hunter normal service which had a median of 48 days. Bobridge median time 25 days Recommendations to improve monitoring and reporting Time to colonoscopy - Waiting times are not consistently recorded in IPM across hospitals. Manual abstraction by staff of the GP date is not feasible but it is very necessary if we are to truly understand the factors impacting on waiting times. 1. Ensure that all hospitals have access to a referral information management system data base to obtain the date on the waiting list by extracting the date stamp that the referral is received. Currently, Calvary Mater does not have access to this system. 2. Investigate whether the GP letter can be converted into a text document and the date searched and parsed into an electronic database. 3. Patients once referred to the service and triaged need to be referred back to the GP a date that the patient care was handed back to a clinician needs to be recorded. 4.Reasons why patients were considered not suitable for the Direct Access Service need to be recorded. Indications and symptoms need to be recorded for all people triaged regardless of suitability for Direct Access.
11 Lessons Learnt recommendations to improve monitoring and reporting 5. The date of the GP letter and an actual copy of the GP letter need to scanned and included in the patients records. Most John Hunter outpatients had a copy of the GP letter but only 10 patients out of 125 Belmont hospital patients had an electronic copy of the GP letter. 6. There is inconsistency across the board in where documents are stored and whether the RFA is signed or not Reasons for the colonoscopy: these are in a free text format in Provation which makes analysis and reporting difficult. 7. An agreed drop down menu should be applied to this field with defined categories for example. 1. Positive FOBT, 2 Symptomatic, 3. Monitoring. This would enable easier extraction and monitoring of time to colonoscopy Reporting Extract data items from existing information systems and put in a reporting database to enable time to colonoscopy to be routinely monitored. Data base specification were developed by Phillip Collards team that abstract information from existing information systems that would allow reporting and monitoring of patients eligible for colonoscopy. To date this reporting system has not been implemented. 8. Perhaps this could be implemented and a number of reports developed? Adjusting for comorbidities and risk factor information These factors may impact on suitability for colonoscopy and therefore time to colonoscopy and were not included in this analysis because information was not routinely completed in the Direct Access Database or 9.Investigate whether information can be obtained consistently from Provation or completed for all patients that access the Direct Access Service regardless of suitability.
Contact for this Innovation For more information Contact: Names Elizabeth Tracey Tel:+61 (02)49223453 Email elizabeth.tracey@hnehealth.nsw.gov.au 12