Low referral rates by GP’s for SeHCAT scans to diagnose ... · Low referral rates by GP’s for...
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Low referral rates by GP’s for SeHCAT scans to diagnose Bile Acid Malabsorption (BAM) Dr Dhruba J Dasgupta, Guy’s and St Thomas’ Hospital NHS Foundation Trust
BACKGROUND • Bile acid malabsorption (BAM) is a condition which is not very well known even amongst doctors, yet is prevalent in up to 1/3 of people mistakenly diagnosed as having diarrhoea-predominant Irritable Bowel Syndrome (IBS-D).
• SeHCAT scans are the gold standard for diagnosing BAM. It is performed in the hospital’s Nuclear Medicine department.
• BAM has an estimated population prevalence of 1% in the UK. It is treated with bile acid sequestrants such as cholestyramine and may be managed easily by GP’s.
• BAM is therefore significantly under-diagnosed, and many patients in the community are suffering unnecessarily when effective treatments exist. • IBS is predominantly managed by GP’s, so it is logical to firstly target GP’s to raise awareness about BAM.
CURRENT CONDITIONS • GP’s referred a total of just 3 patients for SeHCAT scans to our department in 2014, and 2 in 2015.
• Gastroenterologists refer approx. 2-3 per week.
• It costs GP’s £218-270 for a 1st Gastro referral, followed by £94-116 for a 2nd (follow up) appointment.
• It would cost GP’s only £200 to refer a patient for a SeHCAT scan instead of referring the patient to Gastroenterology.
• Therefore saving of £18-186 for diagnosis per patient for a condition affecting 500,000 adults in the UK.
• Nuclear Medicine is underused, especially by GP’s, and we have lots of free camera time.
TOHETI(Trustprogrammeto
improveefficiencyofimaging)
↑SeHCATreferrals
GPEducaBondays(2studydayssinceJan2016)
Kevin and Justine have had diarrhoea for years.
Their doctors told them they have IBS, and they continue to suffer.
Their doctors are wrong…
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SeHCAT referrals - from GP's
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SeHCAT referrals - from Gastroenterology
GOAL 1. Significantly increase GP referrals of SeHCAT scans to Nuclear Medicine whilst raising awareness of BAM. 2. Increase Gastroenterology referrals of SeHCAT scans.
PLAN/ COUNTERMEASURES
EFFECT CONFIRMATION
(Jan-April)
FOLLOW UP If local primary care IBS management pathways can be changed to include SeHCAT scans, this will lead to a potential surge of referrals and diagnosis of BAM. I have just persuaded the main writer of this pathway to implement this change, and look forward to even more referrals in upcoming months.
LEARNING POINTS • The effective use of Kotter’s change cycle, particularly with regard to creating a sense of urgency for change, and removing obstacles to change, e.g.
dissenting gastroenterologists, and one of the writers of the IBS management pathway. • Understanding how many stakeholder groups are involved, and involving them appropriately. I didn’t involve patient groups until relatively late in the process. • The importance of using the Dolphin strategy (I win, you win) to resolve conflict, for example when negotiating with gastroenterologists.
GP’s:raisingawareness
Gastroenterology:raisingawareness
PaBents:raisingawareness
PresentaBonatGPPracBces(Oct2015onwards)
GPTrustmagazine(‘Connect’)advert(Sept2015)
BuyinandsupportforGPreferrals,andforpotenBalchangeofprimarycarepathwaysinIBSmanagementtoincludeSeHCATscans
PublishingSeHCATscaninfoonhospitalwebsite,withdetailsaboutwhoandhowtorefer(Feb2016)
SendingSeHCATinfoleafletwitheveryscanreporttoGP,evenifnotreferredbyGP(Jan2016onwards)
Emaildialoguewithconsultants,presentaBonatGastromeeBng(Sept2015)
BAMSupportgroup
ArBclewriUenaboutBAMinIBSnetworkmagazine‘GutReacBon’(Dec2015)
Providingcontacts
GEHealthcare(manufactureSeHCAT)
ExternalGastro/BAMexperts
Providingcontacts
ROOT CAUSE ANALYSIS