PRIMARY CARE CONFERENCE Livinghealth17/11/2011

Dr David Molony

Mallow Primary Healthcare Centre (MPHC) Co. Cork

DISCUSS

• Innovation

• Research

• Standards in Primary Care

• Barriers to development

INNOVATION

WARFARIN CLINIC • 200 PATIENTS—13 STEPS • Computerised Solution(CompleteGP)-4 STEPS• Highly satisfied patient group• Fast efficient model, 3 min ap., TTR >65%• Printed dosage instructions-safer.• HSE lab saved 3,700 tests pa.

POSTER PRESENTATION

RESEARCH—EARLI STUDY

In conjunction with Local HSE services

• QUESTIONAIRE to all > 70 yrs old (1,056)• 86% Response Rate• 69 Patients Identified as at “HIGH RISK”• Intervene and cut overall admissions 30-50%• Primary Care Teams show value.• Real Value to Hospitals.

POSTER PRESENTATION

• Building—UK Technical Memorandum standards

• MPHC Developed Standard for Primary Healthcare Centres includes the fundamental principals of international standards:– ISO 9001:2008 Quality Standard– ISO 14001:2004 Environmental Standard– ISO 18001:2007 Health & Safety Standard– JCI Primary Care Standard

MPHC is EQA (INAP) Accredited 2010,2011 to ISO 18001:2007

STANDARDS IN PRIMARY CARE

Resource of Primary Care

• GP four year training – specialty skills not being used—2,700 GPs (& 1,700 PNs)

• Many services can be provided in PC at 30% of hospital cost

• IT available in PC with complete patient record • Every community serviced / same day• Underestimated utilisation & overestimation

of cost in PC by the state bodies –article Dr W Behan IMT today.

BARRIERS to DEVELOPMENT of PRIMARY CARE MODEL

• Money NOT following the patient• No competition allowed for services• No flexibility in Hospitals systems• HSE poorly committed to PC service

development—control issues?• “PPARS Syndrome”– afraid of technology

development

The Future Uncertain

but Primary Care can save the day.

The Future Uncertain

but Primary Care can save the day.

Procedures that could be done in 4TH Practice• Excision - Pigmented Naevi, Sebaceous cysts, Simple cysts, Lipomata, Skin lesions BCC, SCC• Biopsy - skin lesions• Skin abscess - evacuation and packing under LA• Cryotherapy/Electrocautery - Keratoses solar actinic, Warts single multiple, Verucca single

multiple, Skin lesions single multiple• Toe/Hand - Nails-- Wedge resection, Removal of• Suturing lacerations - < and > 4cms, single multiple, Face, Scalp, Body• Haemorrhage - Nasal haemorrhage plugging/cauterisation• Cardiac - ECG, SINGLE, 24 HRLY, Holter, WEEKLY. Stress testing, 24 Hr Blood Pressure Monitoring• Phlebotomy - Hospital and private sector• Warfarin - near patient testing• Haemochromatosis - venesection• Eyes - Adherent FB eyes-removal, Ophthalmic Assessment, Chalazion removal• Hydrocoele - Drainage• Joint Injections - Major , Medium, Minor joints Injection and/or Aspiration of joints.• Gynaecology - Mirena / Implanon / Hysteroscopy • Vasectomy• STD Clinic• GIT - Gastroscopy / Colonoscopy / Sigmoidoscopy / Proctoscopy• Nose - Nasenoscopy, Cauterisations• Infusion Therapy - Cancer, Osteoporosis, Bowel and Joint disease, infection • Health Screening – Well Man/Woman• Diagnostics – Xray, Ultascound, Dexa Scan

Same Service

Hospital Primary CareDoctor higher fee >> Doctor lesser feeEquipment cost == Equipment costCapital/facility cost pd. >> NO capital/facility All capable procedures >> Limited proceduresPoor flexibility >> Very flexibleHigh rigid costings >> ? 60% less costly

Simple mole excision can cost company 3 to 5 times more in hospital than in PC.

Public Patients

•GMS –small number of procedures covered Pressure on GP not to provide service as no returnFor Example:

Suturing laceration PC cost €23.50 – pay €28.60

Public Patients

•GMS –small number of procedures covered Pressure on GP not to provide service as no returnFor Example:

Suturing laceration PC cost €23.50 – pay €28.60

Mirena CostingHospital costs

Out Patient Department visits (OPD) required

Waiting time Cost

Consultant OPD --Mirena assessment. 1 3-12 Weeks €260

Procedure Cost --hosp bed+OT+Nurse+Anaes+Gynae1 3-12 weeks €500

(Conservative estimate)

Facilities payment made to Public Hostipals-HSE paid €700

(Conservative estimate--lump sums to cover all hospital costs)

Consultant OPD--review visit 1 3-12 weeks €260

Totals Waiting time and cost for Merina in Hospital 2 OPD+1 Hosp night 9-24 weeks Waiting time €1,720

(Conservative estimate)

Mirena in Primary Care Centre

Out Patient Department visits (OPD)

required

Waiting time Cost

GMS Mirena No OPD No waiting time €79

Facilities payment Fee (currently not paid for by GMS) €0

Total NO OPD's No waiting time €79

(Not sustainable---no incentive to do in PC.)

Total saving for Carrying out Mirena insertion in Primary care:

2 OPD Visits6-24 weeks Waiting time

€1641

Current Hospital based : Consultant check for Retinopathy

Out Patient Department visits (OPD)

requiredWaiting time Cost Total Cost

Consultant outpatient visit required for a Retinopathy test that can be sent to NCSS for Screening. 500 OPDs 3-12 Weeks €260 €130,000

Primary Care based Retinopathy screeningOut Patient

Department visits (OPD)

requiredWaiting time Cost Total cost

500 Retinopathy test with Retinal Camera were Carried out in house in Mallow Primary Healthcare Centre MPHC and sent to NCSS for Screening.

500 In House (NO OPDs) no waiting time €44 €22,000

Retinopathy Screening Costings

Total saving by carrying out Retinopathy testing in Mallow

Primary Healthcare centre (MPHC):500 OPD Visits

9 – 36 Weeks Waiting€108,000

Diagnostics CostingsCurrent Hospital based ultrasound

Out Patient Department visits (OPD)

requiredWaiting time Cost

Patient requires an ultra sound as determined by a GP and sends Patient to Hospital consultant.

1 3-12 Weeks €260

Ultrasound Done and report sent to the Consultant 3-12 weeks €100

2nd OPD required: the consultant sees the Ultrasound and sends report to the GP

1 3-12 Weeks €260

Totals Waiting time and cost for Ultra sound in Hospital 2 OPDs 9-36 weeks Waiting time €620

Ultrasound done in Primary Care CentreOut Patient

Department visits (OPD)

requiredWaiting time Cost

Patient visits GP and GP determined that an Ultrasound is required. Ultrasound Done within 7 days

The Ultrasound is Done in the primary Care centre within 7 days and report sent to the GP within 24 hours 24 Hours €110

Total NO OPD's Ultra sound report in 2-8 Days €110

Total saving per Ultrasound examination carried out in Primary

Care Centre:2 OPD Visits

8-35 Weeks Waiting Time€520

(100 US saves €52,000; 200 OPD Visits)

IT and Clinical Delivery

• Warfarin Clinic –costly (274pa 2009)• 60+ patients averaging 12pa.• Communication problems.• Too many steps.• Too many hands involved.• Solution –near pt testing, same day, cost

containment, one patient contact, clear written instructions, IT decision support using Rosendaal Method (British Committee for Standards in Haematology)

Introduction• 778,973 prescriptions for warfarin in Ireland (2008)

Atrial fibrillation Pulmonary embolism / Deep vein thrombosis Post-valve replacement

• AF associated stroke increases progressively with age RR reduction of stroke with warfarin over aspirin

39%

• North Dublin Population Stroke Study 2010: <25% of those with known AF anticoagulated with

warfarin prior to stroke onset

Models of care

• Primary care, secondary care, patient self-testing

• Strict control to target INR essential

• Time in therapeutic range (TTR) assessment

Rosendaal linear interpolation method or % time spent in range

Study Setting• General Practice urban/rural mix• Complete GP ® software• Primary care anti-coagulant model adopted in 2002• Patient care pathways and proactive audit assessments

Clinical audit of the management of patients in an anticoagulant primary care clinic in IrelandSarah Molony1, Dr. David Molony2 , Dr. Aisling O’Leary1.1. School of Pharmacy, Royal College of Surgeons Ireland. 2. The Red House Family Practice, Mallow Primary Healthcare Centre.

Aim of studyAudit to assess standard of care provided to patients as determined by TTR

Rosendaal and point prevalence method Secondary objective to undertake an economic assessment of the

model of care

Audit standards BCSH recommendation - 60% TTR (+/- 0.5 units target) 4 weekly testing for those stabilised (Ansell et al) Rosendaal 69%, Point Prevalence 86%, – Oppenkowski et al, 2007.

Methods• Protocol development and ICGP Ethical Approval (Nov ’09)

• Patient identification - 1mg warfarin Rx

• Inclusion of Rosendaal’s method of linear interpolation Complete GP®

• Data collection and analysis

• Re-audit 2010

• Microcosting analysis

Clinical audit of the management of patients in an anticoagulant primary care clinic in IrelandSarah Molony1, Dr. David Molony2 , Dr. Aisling O’Leary1.1. School of Pharmacy, Royal College of Surgeons Ireland. 2. The Red House Family Practice, Mallow Primary Healthcare Centre.

Results 166 patients treated with warfarin 2002-2009

n=143 in practice 2009 n=57 (audit population)

2010 n=64 (audit population)

Patient demographics Median age 77 years

Gender 57% male:43% female

AF 61%, DVT/PE 13%, Post-valve replacement 14.5%

Cost to practice of managing one GMS AF patient on warfarin per year, €276.35

Time in Therapeutic Range

Clinical outcomes

Haemorrhagic events 2009 n=8 (1 major) 2010 n=6

Thromboembolic events 2009 n=4 2010 n=0

Haemorrhagic EventsHaemorrhagic Event on at least one occassionNo event recorded

Ro

se

nd

aal fo

r la

st

12

mo

nth

s o

f tx

100

80

60

40

20

0

2009 n=57

2010 n=64

TTR (12 months) 54% 61%

Point prevalence 60.5% 75%

INR tests 12 15

Conclusion

Simple adjustment to software allowed incorporation of TTR (Rosendaal method)

TTR in re-audit increased to 61% from 54% (12 months)

Adverse events decreased

Study outcomes On-going audit to maintain standard of care

Flagging system for warfarin patients and at risk patients

Point of care testing imminent

Dosage adjustment software now incorporated into software Dec 2010

Kelly et al. Stroke Associated with Atrial Fibrillation- Incidence and Early Outcomes in the North Dublin Population Stroke Study. Cerebrovasc Dis 2010;29;43-49Hart et al. Adjusted-dose warfarin verus aspirin for preventing stroke in patients with atrial fibrillation. Ann Intern med. 2007;147;590-2Baglin TP, Keeling DM, Watson HG; British Committee for Standards in Haematology. Guidelines on oral anticoagulation (warfarin): third edition--2005 update. Br J Haematol. 2006 Feb;132(3):277-85.Baglin TP, Cousins D, Keeling DM, Perry DJ, Watson HG. British Committee for Standards in Haematology and National Patient Safety Agency. Br J Haematol. 2007 Feb;136(4):681.Ansell J et al (2004). The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference Antithrombotic and Thrombolytic Therapy. Chest 126(suppl),204S-233S. Oppenkowski TP, Murray ET, Sandhar H, Fitzmaurice DA. External quality assessment for warfarin dosing using computerised decision support software. J Clin Pathol. 2003;56:605-607.

Ardfert Medical Centre Co. Kerry

Living Health Mitchelstown, Co. Cork

Vista Primary Care Centre, Naas

Waterford Health Park

Wherlands Lane Medical Centre, Cork City

Killarney Primary Care Centre

Mallow Primary Healthcare Centre (MPHC) Co. Cork

Primary Care can make the difference.

Who else can see that ????