Patient Pathways

GCA Fast Track Pathway Project

PI: Professor Bhaskar Dasgupta, Head of Rheumatology, Southend University Hospital

This new pathway developed at Southend Hospital demonstrated how patients with GCA can be identified and treated quickly.

The key to improving the outcomes of GCA patients is rapid diagnosis and treatment. However, diagnosis is often difficult as the symptoms are similar to many common conditions routinely seen by GP’s and Healthcare professionals. Rapid diagnosis without a GCA pathway in place, combined with the multiplicity of referral routes, leads to major delays in treating patients. In a recent study, the mean time from symptom onset to diagnosis was 35 days. Without rapid treatment visual impairment is permanent leading to loss of independence, increased morbidity (e.g. risk of hip fracture), persistent pain and depression. Patients with GCA also have increased mortality within the first five years following diagnosis. Patients with vision loss have reduced survival compared with GCA patients with unchanged vision.

The pathway centred on a formal agreement between GP’s and other specialist physicians in South Essex through the Joint Service Development Board. The agreement sought to address speedy patient identification and a reduction in the number of referral routes into secondary care. Once the pathway was agreed and all stakeholders were identified and engaged, the team set out to evaluate the new pathway.

A longitudinal observational cohort study was undertaken to look at the effectiveness of the new pathway. The main objective of the study was to investigate the effectiveness of a fast track pathway on sight loss in patients with suspected GCA. The study looked at 56 newly referred suspected GCA patients seen via the fast track pathway (January – December 2012) compared to 81 patients seen through the conventional referral and review system (January 2009 – December 2011) at single centre.

Results

The fast track pathway resulted in significant reduction in irreversible sight loss from 37.0% (as seen in the historical cohort 2009 – 2011) to 9.1% (2012 onwards, OR 0.17, p=0.009). Adjustment for clinical and demographic parameters including known risk factors for GCA associated blindness did not significantly change the primary result (OR 0.03, p=0.007). Fast track pathway resulted in a reduction of time from symptom onset to diagnosis, particularly by reduction of time from GPs’ referral to the rheumatology review (59.1% of fast track pathway patients were seen within one working compared to 33.3% in the conventional pathway, p=0.105).

Conclusions

Implementation of a GCA fast track pathway led to a reduction of permanent sight loss in newly referred GCA patients. The effect is attributable to reduction in delayed diagnosis and therapy; however, other difficult to measure factors including increased awareness of general practitioners, the public and direct referrals to the rheumatology clinic might have contributed to this result.

Improved patient outcomes

The evaluation for the Fast Track Pathway demonstrated some encouraging results illustrating the potential for major improvements in patient outcomes.

Significant reduction in irreversible sight loss from 37.0% to 9.1%
A major reduction in the time from symptom onset to diagnosis, particularly by reduction of time from GPs’ referral to the rheumatology review
59.1% of FTP patients were seen within one working day compared to 33.3% in the conventional pathway

The study also showed some significant cost effectiveness results when compared with the standard approaches. The pathway reduced cost by £400 per patient with 2.6 QALYs gained for patients without sight loss and Incremental Cost-Effectiveness Ratio (ICER) of -£840 per QALY. This is mainly related to reduction in multiple referral routes, inpatient stays and re-admissions. The analysis did not take into account the social impact and cost savings which will be considerably greater.