Primary Care Pathways APCC/Primary Care Pathways.pdf dyspepsia pathway Yes , no symptoms = DONE Yes...

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Transcript of Primary Care Pathways APCC/Primary Care Pathways.pdf dyspepsia pathway Yes , no symptoms = DONE Yes...

  • November 30, 2018

    Primary Care Pathways

    Julia Carter, MD, FCFP Digestive Health SCN Core Committee member

    Co-chair, Primary Care Pathways Working Group

  • Presenter Disclosure

    • Presenter: Dr. Julia Carter

    • Relationships that may introduce potential bias

    and/or conflict of interest:

    • Grants/Research Support: N/A

    • Speakers Bureau/Honoraria: AHS – Digestive Health SCN

    • Consulting Fees: N/A

    • Other: N/A

  • Disclosure of Commercial

    Support • This program has received financial support from in the form of

    an education grant from:

    • Merck Canada, University of Calgary Department of Medicine, Alberta

    Health Services, Alberta Innovates, Alberta Netcare, College of

    Licensed Practical Nurses of Alberta, BrightSquid,, Health Quality

    Council of Alberta, Boehringer-Ingelheim, and the Institute of Health


    • This program has received NO COMMERCIAL in-kind support.

    • Potential for conflict(s) of interest: – Dr. Julia Carter has not received payment from the APCC planning

    committee. Funds from sponsors are pooled to off-set conference costs.

  • Mitigating Potential Bias

    • The planning committee developed the conference

    objectives which do not include the discussion of our

    sponsor’s products or services.

    • Sponsorship funds are pooled and are evenly distributed

    throughout the conference. They do not fund specific


    • The committee has reviewed the content of the

    presentations and ensured that content presented is

    evidence-based and free of undue influence.

  • Can Enhanced Primary Care

    Pathways Improve Patient Care

    and Referral Processes in Alberta?

  • The problem: Access to

    digestive health care

  • • Untenable wait times

    – 24 months+ in Calgary

    • Appropriateness

    • Frustrating for primary care

    providers, specialists, and


    Calgary Digestive Health

    Pathways background

  • The proposed solution:


  • • Primary care pathways for low-risk,

    high-demand indications

    • Telephone advice (Specialist Link) -

    same-day phone consultation

    • Electronic advice (Advice Request) -

    non-urgent consultation through Netcare

    • QuRE

    Primary-Specialty Care


  • Quality Referral Evolution

  • • Build capacity to manage common,

    low-risk conditions in the Medical

    Home – rather than referring to

    specialty care

    Why pathways?

  • • Agreement on “pathway conditions” – that

    can be managed in the Medical Home

    • Co-development by GI and primary care

    • Knowledge translation

    Pathway development

  • • Evidence-based algorithm to guide

    diagnosis and management of common,

    low-risk health conditions

    • Local resources (e.g. PCN supports,

    Alberta Healthy Living Program)

    • References

    • Patient information resources

    Pathway components

  • • Irritable bowel syndrome

    • Chronic constipation

    • Dyspepsia

    • GERD

    • H. pylori

    • NAFLD

    • Chronic diarrhea

    • More to come…

    GI “pathway conditions”

  • • Endocrinology

    • General Neurology

    • Respirology

    • Rheumatology

    • Others

    Other specialties

  • • Implementation through Central Access


    • Referral “closed” – sent back for further

    investigation/management within

    Medical Home

    • Expedited consultation if no resolution

    after pathway completion

    Calgary Process

  • 1. Who should be tested for H. pylori?

     Patients with dyspepsia symptoms

     Patients with history of peptic ulcer/upper GI bleed who are

    contemplating use of NSAIDs or antiplatelets

     Patients with first degree relative with history of gastric cancer

    2. Alarm features  Dyspepsia symptoms plus VBAD (V =vomiting, B =bleeding or

    anemia, A =abdominal mass, D =dysphagia) or melena

     Dyspepsia symptoms plus first degree relative with history of gastric


    3. Diagnosis  HpSAT or UBT

     Before testing, patient must be off antibiotics x4

    weeks and off PPI at least 3 days

    4. Treatment  Round 1: CLAMET Quad or BMT Quad

     Round 2 (if needed): CLAMET Quad or BMT Quad

     Round 3 (if needed): Levo Amox

     Round 4 (if needed or refer to GI): Rif-Amox

    5. Confirm eradication  HpSAT or UBT at least 4 weeks after finishing


    6. Treatment failure  Proceed to next round of treatment

     Option to refer to GI after 3 failed

    treatment attempts

    Treat according to

    dyspepsia pathway

    Yes, no symptoms = DONE

    Yes, continued


    7. Refer for







  • • For patients

    – Comprehensive, evidence-based care within

    the patient medical home

    – Local resources

    – Patient information sheets

    What do pathways do?

  • • For patients

    – Decrease unnecessary investigations/


    – Decrease time off work/travel for specialist

    consultation that may not change


    What do pathways do?

  • • For primary care providers

    – Enhance supports in diagnosis and


    – Suggest local resources

    – Provide references

    – Minimize unnecessary consultations

    – Facilitate necessary consultations


    What do pathways do?

  • • For specialists

    – Reduce referrals for conditions that can be

    managed within the medical home

    – Create capacity for more timely consultation

    with patients at higher risk

    – Good quality referrals with comprehensive

    work-up (and without unnecessary testing)

    – Alarm features identified

    What do pathways do?

  • – To identify “alarm” features and highlight

    them on the referral letter

    – To reassure patients without “alarm” features

    that they don’t need referral and provide

    them with resources

    – To guide management while awaiting, or

    instead of GI consultation

    – Example: NAFLD

    Pathways can be used


  • Outcomes of pathway


  • • Prospective review (2015-2017)

    • 2,240 referrals returned to primary care

    – 15% re-referred to GI for endoscopy

    – 70% were completely normal

    – Only 2% had a clinically significant finding

    (e.g. esophagitis)

    Outcomes - safety

  • • 98% reduction in non-urgent GI wait list

    (Jan 2016-Dec 2017)

    • August 2017-2018, 86% drop in referrals

    for NAFLD

    Outcomes - access

  • Outcomes - adoption






    329 340












    Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18

    GI/Hepatology Pathway Downloads November 2017-June 2018

    NAFLD pathway


  • • 2018 survey of Calgary family

    physicians (n= 625)

    • 55% were aware of pathways

    • 78% of these reported pathways

    changed their clinical practice

    Outcomes – awareness/impact

  • • 1,722 calls to GI

    • Average system savings of $133/call

    (avoided consultations and ER visits)

    • 89% of family physicians are aware of

    Specialist Link

    • 73% of these report it changed their


    Specialist Link

  • GI Access Challenges -


  • • Edmonton

    12-24 months

    • Central and South

    9-12 months

    • Calgary (CAT)

    24+ months

    Wait times for routine GI


  • • Improve access through spread of GI

    Primary Care Pathways across Alberta

    DHSCN Pathways Goal

  • Clear Adaptable

  • Safe Local

  • • Validation (content & format)

    • – primary care, specialists and allied health

    • Spread

    – Knowledge translation to primary care

    providers and allied health professionals

    – Collaborative implementation between GI

    and primary care

    • Evaluation