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

• Enhance doctor-patient relationship

• Reduce whole journey waiting times

“ There is still a lingering perception

among patients that their journey

remains littered with barriers, pitfalls,

duplication and delay”.

Kerr Report, 2005

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

Effect of access restrictions

Consultation in primary care

Referral to secondary care

Imaging arranged

Review in secondary care

Primary care ongoing management




Imaging arranged



Effect of opening access


Imaging arranged


Referral should be based on

clinical criteria

not

referral source

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

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

CT brain direct access pilot

• Referral criteria agreed for chronic headache

• Educational events arranged

• Information packs distributed

• Pilot from April 2005 – April 2006

Chronic headache

• Commonest GP referral to neurology

• 4.4 consultations per 100 patients per

year

• 18,700 headache consultations in

Tayside per year

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

Questionnaires returned from

189 referralsInitial 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




Imaging arranged



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

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

Primary care direct access to all CT

• Educational events arranged

• Information packs distributed

• Pilot started February 2007

• First 6 months – 28 non brain referrals


CT referrals in 2009

Total CT – 23,272 referrals

GP CT – 1,375 (6%) referrals

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

Referral criteria agreedIndications

• Sciatica

• Spinal claudication

• Developing motor deficit

– simultaneous clinical and MRI referral

Exclusions

• acute cauda equina syndrome

• mechanical back pain

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

Data from 6 months pilot

April to September 2009

on primary care direct access

to lumbar spine MRI

179 Referrals

• Number of GPs referring 107

- 107/309 GPs (35%)

• Number of practices referring 59

- 59/72 practices (82%)

Referrals by practiceApril – September 2009

20

177

4

322

100

000

01

0 5 10 15 20 25

1

3

5

7

9

11

13

15

Nu

mb

er o

f re

ferr

als

Number of GP Practices making these referrals

Referrals by practice October – December 2009

Number of Referrals made by each practice Oct to Dec 09

0 2 4 6 8 10 12 14

1

2

3

4

5

6

7

8

9

10

Nu

mb

er

of

refe

rra

ls

Number of GP's practices making these referrals

Impact on MRIMRI lumbar spine referrals

Year

Sept-Sept

Out patient MRI

lumbar spine

2006/2007 1049

2007/2008 1215

2008/2009 1385

Monthly total GP/out-patientMRI lumbar spine referrals

MRI LV Referrals

0

20

40

60

80

100

120

140

160

180

200

Feb-09

Mar-09

Apr-09 May-09

Jun-09

Jul-09 Aug-09

Sep-09

Oct-09 Nov-09

Dec-09

Jan-10

Feb-10

Out Pt GP Pt

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

referralsMRI LV % Referrals

0

20

40

60

80

100

120

Feb-09

Mar-09

Apr-09 May-09

Jun-09

Jul-09 Aug-09

Sep-09

Oct-09 Nov-09

Dec-09

Jan-10

Feb-10

Out Pt GP Pt

MRI waits from receipt of referral

to verified report

April 2009 – 6 weeks

October 2009 – 6 weeks

Data summary

• Good GP utilisation

• Impact on total referrals uncertain

• MRI waiting times unaltered

Responses to distributed questionnaires

173 questionnaires distributed

146 questionnaires returned (84%)

134 questionnaires analyzed (77%)

Did access to MRI lumbar spine stop a referral to

secondary care?

Yes - 46 (34%)

No - 88 (66%)

Was the patient referred to secondary care after the result

of the MRI was known?

Yes - 68 (51%)

Was the patient referred to secondary care at the same

time as the referral for the MRI?

Yes - 20 (15%)

Did you mention MRI in the referral letter?

Yes - 20 (100%)

Was the report useful to you in managing the patient?

Yes - 132 (98%)

No - 2

Questionnaire summary

• 34% stopped a secondary care referral

• When patients were referred, MRI was

always noted

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

Patient journey

Before direct access

GP OP MRI OP

After direct access

GP MRI 34%

GP MRI OP 66%

Patient journey times in weeks


GP OP MRI OP 12 4 8 = 24

After direct access

GP MRI4 = 4

GP MRI OP4 8 = 12

Outpatient clinic attendances


GP OP MRI OP 134 134 268

After direct access

GP MRI

GP MRI OP 88 88

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

Whole year impact

1,400 MRI lumbar spines per year40% (560 patients) use direct GP access

Annual reduction in OP visits 750

Without direct access 1,120With direct access34% (190) 0 visits68% (370) 1 visit

370

Primary care perspective

• General practitioners views

• Patient experience

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




Imaging arranged



Discussion on pilot interpretation to determine

future direction• GP/Radiology liaison group

• Diagnostics, radiology and neurosciences

group

• Open evening meeting for GPs


Next steps

• Direct primary care access to knee MRI

• Similar process, but add physiotherapy

input

• Aim to commence pilot in mid-2010

Direct primary care access to imaging

• Improves patient experience

• Reduces whole journey waiting times

• Releases resource through reducing waste

• Requires to be developed in close collaboration between primary care, imaging and secondary care staff

Delivering improvements in diagnostic services 31st March 2010.

Documents

open access

open direct access

bariumsct ct brain

ct brain scans1

ct referrals

referralsgp ct

total ct

primary carereferral