November 30, 2018

Primary Care Pathways

Julia Carter, MD, FCFPDigestive 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

Economics.

• 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

speakers.

• 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

PATIENTS

Calgary Digestive Health

Pathways background

The proposed solution:

Pathways

• 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

Integration

Quality Referral Evolutionhttps://albertahealthservices.ca/assets/info/hp/arp/if-hp-arp-qure-digital-checklist.pdf

• 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

Triage

• 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

cancer

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

treatment

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

symptoms

7. Refer for

gastroscopy

No

Positive

No

Negative

Yes

• 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/

endoscopy

– Decrease time off work/travel for specialist

consultation that may not change

outcome/management

What do pathways do?

• For primary care providers

– Enhance supports in diagnosis and

management

– Suggest local resources

– Provide references

– Minimize unnecessary consultations

– Facilitate necessary consultations

(expedited)

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

pre-emptively:

Outcomes of pathway

implementation

• 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

105

128

412

308

355

329340

297

0

50

100

150

200

250

300

350

400

450

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

GI/Hepatology Pathway DownloadsNovember 2017-June 2018

NAFLD pathway

introduced

• 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

practice

Specialist Link

GI Access Challenges -

Alberta

• Edmonton

12-24 months

• Central and South

9-12 months

• Calgary (CAT)

24+ months

Wait times for routine GI

consultation

• 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

How?

• Zonal differences

• Rural/remote

• Varying triage processes

• Variable need for formal phone advice

system

Locally appropriate

ACFP e-panel survey input

87%

2%11%

Do you see a role for using clinical pathways BEFORE you consider a specialist referral?

Yes No Maybe

• “determine if a specialist referral is even

necessary”

• “help assure the patient”

• “prevents wasted time for the physician

and the specialist”

ACFP survey input

0

5

10

15

20

25

30

Co-developedwith familyphysicians

Brief Recommendedas best practice

Very visual Comprehensive Not useful at all

Which factors would increase the likelihood of youusing clinical care pathways?

ACFP survey input

• Central repository

• Easy access at point of care

– EMR?

• Potentially time-consuming

• Need for patient information resources

Primary care input

• Create capacity/more timely care for

higher risk patients

• “Can I/when can I decline a referral?”

• Triage processes vary – challenges for

community specialists

Specialist input

• Quality/timely care is the key

• Self-management resources

• Strong communication between providers

• Satisfaction surveys to come

Patient input

Evaluation plan

• Inappropriate specialty consultations and endoscopy procedures avoided

• Family physician & specialist satisfaction survey

• Improved system integration

• Inpatient admissions and ED visits for pathway conditions

• Improved access to GI for sick/urgent patients

• Patient Experience survey

• Specialty care wait time

• Continuity of care

Enhanced Patient

Experience

Improved Patient

Outcomes

Value for Investment

Improved Provider

Satisfaction

• Primary care and specialist champions

working together

• Primary care teams – dieticians,

pharmacists, CDMs, BHCs

• PCN leadership, improvement facilitators

• PHCIN, AMA, AIM, TOP

Partnerships

• Primary care pathways can improve

patient care and referral processes

– Improved care of pathway conditions in the

patient’s Medical Home

– Proven safety

– Decreased unnecessary referrals &

endoscopy

– Improved triage processes

Summary

Thank you!

November 30, 2018