Improving evidence-based management of irritable bowel syndrome across Somerset

1. Empower GP's to make a positive diagnosis of IBS and equip them with the skills to manage patients within primary care by providing a ‘Diagnosis of IBS’ algorithm using an innovative pathway app for GP desktops across Somerset, with county-wide teaching sessions led by a gastroenterology consultant and/ or a specialist dietitian.

2. Offer GP's faecal calprotectin testing to exclude inflammatory pathologies to prevent unnecessary secondary care referrals. If FC <50 micrograms then patients would be managed within primary care; if FC 51-150 micrograms refer for a secondary opinion but not necessarily endoscopic investigation and >150 micrograms, refer for investigation in secondary care.

3. Produce second algorithm ‘Management of IBS’ as another pathway app for GP desktops across Somerset to equip GPs with the information to provide symptom-based treatment within primary care and an alternative treatment pathway to dietetic first- and second line intervention.

4. Establish an innovative community-based specialist dietetic-led gastroenterology service for non-red flag IBS patients with intractable symptoms but normal blood tests and FC <50 micrograms. This service would be available to GPs and community-based healthcare professionals use dietary therapies including the low fodmap diet provide effective symptom  self-management for patients.

5. To gear the focus of irritable bowel syndrome management towards reduced medicalisation of the condition. The aim is to move away from secondary care referrals and undertaking unpleasant and unnecessary invasive investigations and towards empowering patients to manage their own condition.

Objectives:

• Reduce referrals to secondary care gastroenterology services for patients between 16 and 45 years of age with a low risk of inflammatory pathology.
• Follow NICE recommendations to provide teaching for GPs to equip them with the knowledge and skills to make a positive diagnosis of IBS using Rome criteria and a pathway to provide baseline lifestyle and dietary management advice.
• Implement faecal calprotectin testing for general practitioners.
• Redistribute the funding from reduction of referrals to secondary care towards providing effective treatment within a community-based specialist dietetic clinic.
• Encourage effective patient self-management of their IBS symptoms with dietary intervention.

Baseline audit data from May 2011 showed that 14% of new outpatient slots in secondary care gastroenterology clinics in Taunton and Yeovil were taken by patients 16-45 years of age with no red flag symptoms. In each case, the likely diagnosis was IBS.

For each patient, we calculated the cost of investigations and outpatient slot, before extrapolating these data to determine the annual cost as £161,000. Nearly 50% of the patients seen in Taunton had been seen within the same gastroenterology department within the last 5 years which is clear evidence of the revolving door nature of IBS, with a cycle of repeated referrals and investigations as symptom relief has not proved effective.

GP education sessions in 2011-2 identified that few GPs had heard of or used the Rome criteria to make a positive diagnosis of IBS or felt confident in managing the condition using diet, lifestyle and basic medication. At the start of this project, research suggested that faecal calprotectin would distinguish between IBS and the main differential diagnoses for this group; inflammatory gut conditions such as ulcerative colitis (UC) and Crohn’s disease (CD). In Somerset, faecal calprotectin was not available to either primary or secondary care prior to this study. The use of faecal calprotectin has been the subject of a NICE Diagnostic Guideline (DG11), published in 2013 after our pilot had been agreed. It is reassuring that their level for a negative result at <50 micrograms is the same as ours.

Evidence from Australia first published in 2008, revealed promising results from use of the specialised low fermentable carbohydrate diet (low FODMAP) to achieve lasting symptom relief from IBS. One specialist community-based dietitian had received low FODMAP training in 2010 from Kings College London and undertook a pilot of patients within South Somerset referred directly by GPs to determine outcome. She was able to achieve symptom reduction in 69% with a high level of patient satisfaction. Patients were able to self-manage their condition after discharge from her community outpatient clinic.

In summary, if we could offer an effective IBS diagnosis and treatment pathway for GPs, including availability of faecal calprotectin testing and the ability for onward referral for specialist dietetic intervention, then this should encourage GPs to avoid costly secondary care referrals for their non-red flag IBS patients of 16-45 years of age.

As this project was a collaboration between secondary care (Taunton & Somerset NHS Foundation Trust and Yeovil District Foundation NHS Trust), primary care, the Somerset Clinical Commissioning Group and Community Dietetics (Somerset Partnership NHS Trust), all stakeholders were included in meetings to ensure that at each stage, any objections and concerns were dealt with. Our business plan identified potential cost savings within primary and secondary care, using these to fund the service developments of implementing faecal calprotectin and funding additional specialist dietetics training and time.

Our project plan was:
1. Teaching for GPs around diagnosis and management of IBS using:

• Development of the ‘Diagnosis of IBS’ algorithm as an innovative pathway app for GP desktops across Somerset to aid diagnosis using the Rome criteria.
• Advice in teaching sessions about when to use faecal calprotectin and blood tests.
• When to refer appropriately to secondary care (especially for those patients with red flag symptoms or those with faecal calprotectin > 150 micrograms/g).
• Increase knowledge by using teaching sessions around diet and lifestyle management along with basic first-line medication advice.
• Increase awareness within teaching sessions of access to community-based dietitians for first line and specialist dietary interventions including the low FODMAP diet for those with more intractable symptoms.

2. Use cost savings from avoiding secondary care referral and investigation to implement faecal calprotectin for GP use. When requesting this test, a pop-up appears as part of the electronic requesting form to ask some basic information to allow us to correlate against results and understand their thoughts and prevent inappropriate use of the test.

3. Use cost savings from avoiding secondary care referral and investigation to fund a new post of whole time equivalent specialist dietitian with additional training in using the low FODMAP diet. This provides additional capacity to manage and treat these patients cost-effectively with the aim of reducing the revolving door of re-referrals and healthcare costs. This additional dietetics capacity allowed clinics to be set up in four locations across Somerset to reduce travel time for patients and increase ease of access.

Audit plan at 1 year:
1. New patient slot utilisation in secondary care gastroenterology clinics and costs incurred to compare with baseline data.

2. Use of faecal calprotectin to establish levels obtained, results from investigations and final diagnoses from patients seen and investigated in secondary care whatever their FC result.

3. Number of patients with IBS seen in the new Community Specialist Dietetic-led Gastroenterology clinic and their outcomes.

Outpatient data: In August 2014, utilisation of secondary care gastroenterology clinics showed 9% of new patient slots in Taunton and Yeovil were taken by patients 16-45 years of age with no red flag symptoms and likely IBS. Investigation and outpatient slots cost £10,036 so extrapolating over 12 months, up to £120,000 could be saved, Compared with baseline data, these proportions are still appreciably reduced. All patients were discharged back to their GP with advice about dietetic review.

Faecal calprotectin: 94 patients fitted the pilot criteria with results of <50 micrograms (64 patients). 51-150 micrograms (19 patients) and >150 micrograms/g (11 patients). Despite levels of FC <50 micrograms 13 patients were still referred into secondary care where they underwent  a variety of endoscopy and radiology investigations with no gastrointestinal inflammation found in any case. For FC 51-150 micrograms, 12 out of 19 cases. After investigations, one had limited mild CD while the other 11 patients had normal findings. For FC >150 micrograms/g, 9 of 11 patients were referred for investigation with 5 patients having UC or CD but 3 having normal colonoscopies and one having a normal CT scan.

Dietetic outcomes: 83 patients completed dietetic treatment with all referred for specific IBS dietary interventions including the low FODMAP diet. Outcomes showed statistically significant reduction of all symptoms. Using the validated global symptom satisfaction questionnaire, 65% of patients had satisfactory relief from their symptoms, while secondary outcome data showed that 74% had an improved quality of life with patient quotes such as, “This diet has turned my life around”. Most successful symptom reductions were for heartburn (86% of patients noted improvement), abdominal pain (73%), borborygmi (72%) and urgency (69%).

It is hoped that the new dietetic treatment pathway will reduce secondary care referral of these low risk patients, reduce the significant investigation costs and stop the ‘revolving door’ by providing a longer term solution.

Since this project began in 2011, we have received over 35 enquiries from other primary and secondary care teams to ask how this project was set up and how funding was agreed. A survey of these teams in late 2014 revealed that only 6 UK Trusts had been able to offer a dietetics-led specialist gastroenterology service. In cases where this has not been successful, 91% cited ‘lack of funding’ and 32% cited ‘lack of secondary care support’ amid concerns about missing underlying pathology or loss of secondary care funding. These figures highlight the need for integrated communication to establish a sustainable and successful pathway.

A GP education programme at many locations across the county has ensured a wide spread of information. Education around red-flags, Rome criteria and faecal calprotectin results has enabled us to prioritise patient treatment and symptom improvement where inflammatory pathology is ruled out with non-invasive tests. Our faecal calprotectin results data from the first year prove that a low FC makes an inflammatory pathology highly unlikely, which we hope will reinforce use of our pathway in future. When we presented early results at a Somerset GP forum of 80 GPs in Nov 2014, feedback was very positive including comments such as “really useful” and “will change practice”.

The predicted cost savings were not fully achieved as some patients were still referred into secondary care and some investigations were still carried out as some GPs are not confident in managing this condition. However, the results from our pilot should allay some of their concerns.

Our outcome figures highlight that there is no single solution to IBS and that it is essential to have the multidisciplinary approaches of reliable faecal markers, effective dietetic intervention and GP education in order to have a successful and cost-effective pathway which delivers not only significant NHS savings but also high levels of patient satisfaction.

Somerset Gastroenterology Flexible Healthcare Team comprises: Taunton & Somerset NHS Foundation Trust - Dr Emma Greig & Dr Rudi Matull (Consultant Gastroenterologists) and Zoe Hamilton (Directorate Manager), Somerset Partnership NHS Foundation Trust – Marianne Williams & Leah Seamark (Specialist Dietitians) and Yvonne Barclay (Dietetic Manager, Somerset Clinical Commissioning Group – Dr Kate Staveley, Dr Iain Phillips & Dr Rosie Benneyworth, (General Practitioners), NHS Somerset – Steve Thole (Programme Director) Yeovil District NHS Foundation Trust - Dr Steve Gore (Consultant Gastroenterologist)and Dumiso Ncube (Directorate Manager).