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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2014 2015 2016

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SeHCAT referrals - from GP's

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Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Jan 2014 to March 2016

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