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Case Studies

 

The Innovation Case Studies section provides a comprehensive list of exemplar innovation projects from across the NHS. These innovations have been carefully selected to represent a range of ideas from medical technologies through to service and pathway re design. Each case study provides a background to the innovation and a contact for further information.

 Click on the Case Study Browse area on the right to find examples by clinical area.

If you have an innovation case study you would like us to publish on the portal please contact the Innovation team at england.innovation@nhs.net

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June 2016 Case Studies

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GCA Fast track pathway

Case study arrowGiant Cell Arthritis (GCA) is a condition which affects the medium and large arteries of the head and neck. The arteries become inflamed leading to potentially life threatening and disabling consequences. This new pathway developed at Southend Hospital demonstrates how patients with this difficult to diagnose condition can be identified and treated quickly.

1.0 Background and clinical need

The incidence of GCA in England is 22 patients per 100,000 and is mainly found in patients over 70 years old. Irreversible vision loss can occur in 15-25% of GCA cases. Patients presenting with ischemic symptoms such as diplopia (double vision), transient visual loss and jaw/tongue claudication are classed as high risk.

The key to improving the outcomes of GCA patients is rapid diagnosis and treatment. However diagnosis is often difficult as the symptoms are similar to many common conditions routinely seen by GP’s and Healthcare professionals.  Common symptoms include:

  • Headache
  • Pain in the temple region
  • Fatigue
  • Fever
  • Flu like symptoms
  • Sudden partial sight loss

Rapid diagnosis without a GCA pathway in place combined with the multiplicity of referral routes leads to major delays in treating patients. In a recent study, the mean time from symptom onset to diagnosis was 35 days. Without rapid treatment visual impairment is permanent leading to loss of independence, increased morbidity (e.g. risk of hip fracture), persistent pain and depression. Patients with GCA also have increased mortality within the first 5 years following diagnosis. Patients with vision loss have reduced survival when compared with GCA patients with unchanged vision.

Developing the pathway

In 2011 the Fast Track Pathway (FTP) for suspected GCA was initiated by Professor Bhaskar Dasgupta Head of Rheumatology at Southend University Hospital.

The pathway centred on a formal agreement between GP’s and other specialist physicians in South Essex through the Joint Service Development Board. The agreement sought to address speedy patient identification and a reduction in the number of referral routes into secondary care. Once the pathway was agreed and all stakeholders were identified and engaged the team set out a phase 1 study to evaluate the new pathway.

 

Figure 1.0 illustrates the patient pathway and clinical decision making points - click on the blue stages for more information. The pathway is backed up by a GP education programme.

GTA suspision and diagnosis link GTA initial treatment link
Referral Options Link
FTP GTA Assessment link
Temporal Artery Ultrasound linkGCA Clinic linkTemporal Artery Biopsy link
 

2.0 Background research

A recent longitudinal observational cohort study was undertaken to look at the effectiveness of the new pathway. The main objective of the study was to investigate the effectiveness of a fast track pathway on sight loss in patients with suspected GCA.

The study looked at 56 newly referred suspected GCA patients seen via the fast track pathway (January – December 2012) as compared to 81 patients seen through the conventional referral and review system (January 2009- Dec 2011) at single centre.

 

Results

The fast track pathway resulted in significant reduction in irreversible sight loss from 37.0% (as seen in the historical cohort 2009-2011) to 9.1% (2012 onwards, OR 0.17, p=0.009). Adjustment for clinical and demographic parameters including known risk factors for GCA associated blindness did not significantly change the primary result (OR 0.03, p=0.007). Fast track pathway resulted in a reduction of time from symptom onset to diagnosis, particularly by reduction of time from GPs’ referral to the rheumatology review (59.1% of fast track pathway patients were seen within one working compared to 33.3% in the conventional pathway, p=0.105).
 

Study Conclusions

Implementation of a GCA fast track pathway led to a reduction of permanent sight loss in newly referred GCA patients. The effect is attributable to reduction in delayed diagnosis and therapy; however, other difficult to measure factors including increased awareness of general practitioners, the public and direct referrals to the rheumatology clinic might have contributed to this result.
 

3.0 Improved patient outcomes

The evaluation for the Fast Track Pathway (FTP) demonstrated some very encouraging results illustrating the potential for major improvements in patient outcomes.

  • Significant reduction in irreversible sight loss from 37.0% to 9.1%
  • A major reduction in the time from symptom onset to diagnosis, particularly by reduction of time from GPs’ referral to the rheumatology review
  • 59.1% of FTP patients were seen within one working day compared to 33.3% in the conventional pathway.

 

The study also showed some significant cost effectiveness results when compared with the standard approaches. The pathway reduced cost by £400 per patient with 2.6 QALYs gained for patients without sight loss and Incremental Cost-Effectiveness Ratio (ICER) of -£840 per QALY. This is mainly related to reduction in multiple referral routes, inpatient stays and re-admissions. The analysis doesn’t take into account the social impact and cost savings which will be considerably greater. Figures 1.1 and 1.2 summarise the key improvements and cost savings identified during the evaluation.

Figure 1.1 Summary of the key improvements in the management and treatment of GCA following implementation of the fast track pathway

Target Improvement Measure(s)
Faster diagnosis Symptom to diagnosis time –time from symptom onset to GP diagnosis
Faster referral Referral to review time – time to GP referral to rheumatology review
Faster assessment Review to biopsy time – rheumatology review to temporal artery biopsy Review to ultrasound time – rheumatology review to temporal artery ultrasound
Reduced incidence of GCA related disease GCA disease control, cardiovascular and other co-morbidities, ischemic complications such as sight loss, strokes, resolution of inflammatory markers
Reductions in GCA related sight loss Percentage of sight loss
Improved cost effectiveness in GCA treatment Reductions achieved in total healthcare cost of GCA care versus baseline cost
Improved patient safety Adverse events related to disease – ischemic complications, large vessel involvement

Improved patient safety

Adverse events related to steroids e.g fractures, diabetes, glaucoma, cataracts

Improved patient satisfaction

Better social care with reduced use of benefits and social services

Improved patient quality of life

HRQOL and EQ5D scores (EQ5D measures ability in 5 domains – pain/discomfort, anxiety/depression, mobility, self-care, usual activities) , sleep disturbance and vision deficit questionnaires

 

Figure 1.2 Costs associated with treating a patient with suspected GCA before and after implementation of the fast-track pathway (NHS England report)

Treatment / Interaction

Before

After

Medication

£190

£190

Investigations

£330

£290

GP Attendances

£55

£50

Outpatient Appointments

£665

£620

Inpatient

 £0

 £0

Inpatient stays

£1,100

£475

Emergency presentations

£70

£50

Readmissions

£190

£0

Training of GP’s

£0

£525

Total Per Patient

£2,600

£2,200

Funding source Logo

Small arrow PROJECT CONTACT

Contact Name Professor Bhaskar Dasgupta Email address Bhaskar.Dasgupta@southend.nhs.uk

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