This project won the RCGP Mersey Faculty Audit Prize (2nd Place) Award 2019.
NICE CG118 guidance recommends using colonoscopy to check for signs of bowel cancer in people aged 18 and over with ulcerative colitis or Crohn’s disease (types of inflammatory bowel disease) or adenomas (also known as polyps).
It aims to prevent cancer and prolong life by offering advice on identifying early bowel cancer in adults most at risk. The guidance recommends that follow-up (ongoing) colonoscopic surveillance should be arranged at regular intervals for people with IBD and tubular adenoma as below:
- Low risk: offer colonoscopy at 5 years
- Intermediate risk: offer colonoscopy at 3 years
- High risk: offer colonoscopy at 1 year
Example
Aims and objectives
Aims of the Audit:
1). To identify and create a register for patients with IBD and those with Tubular Adenoma in the practice.
2). To assess if these patients have had colonoscopic surveillance as per NICE CG118 guidance, review within 18 months by their specialists or exempted from the surveillance because of bowel resection.
3). To arrange appropriate follow up appointments for those ‘lost in the system’.
Reasons for implementing your project
- A patient (from another practice) with inflammatory bowel disease (IBD) was diagnosed with colorectal cancer. The cancer was not detected early as he had not been attending colonic surveillance as per NICE guideline.
- Our patients (including those with IBD and adenoma) are under specialists in hospitals in Warrington or St Helens. There are IBD patients under gastroenterologists in Warrington Hospital whilst others attend Whiston or Fairfield. As a result, there is a potential for them to be ‘lost in the system’.
How did you implement the project
- A search of patients with IBD and Tubular Adenoma in the practice was created on the EMIS system using the appropriate read codes.
- Data was manually extracted for each of the identified patients from their medical records, hospital/ clinical letters, sigmiodoscopy/ colonoscopy reports.
Target for audit:
- 100% compliance with the NICE guidance unless otherwise agreed by the specialist or not indicated (e.g. those who have had pan colectomy)
Key findings
Findings of the first audit cycle:
- 27 patients were identified to have a diagnosis of Crohn’s Disease or Ulcerative Colitis in the practice.
- Only one patient has tubular adenoma Crohn’s Disease and Ulcerative Colitis Surveillance in date or a review by gastroenterologist in the preceding 18 months.
- 20 patients - surveillance not required (either because of bowel resection surgery or as advised by specialist).
- 4 patients - surveillance NOT in date and NOT reviewed by specialist in the preceding 18 months.
- 3 patients were ‘Lost in the system’.
- The 3 patients apparently lost to the system should be re-referred or appropriate follow-up appointment with the specialist should be arranged.
Second Audit Cycle (A Re-audit) Findings:
- A re-audit was carried out 5 months later.
- Compliance to the NICE CG 118 guidance = 89% (24 out of 27)
- All the three patients with IBD apparently ‘lost’ in the system have been re-referred.
- Two of them have been seen by their Gastroenterologists and have had a follow up colonoscopy following the initial audit
- One of them missed their appointment and had to be re-referred again, awaiting a new appointment as at the time of this write up.
- Compliance to the NICE CG 118 guidance = 100%
Key learning points
As a suggestion, each GP practice should create and maintain a register of patients with IBD and tubular adenoma and it would be desirable if this type of audit could be conducted at the practice level every three years (perhaps in conjunction with secondary care centres).
EMIS and other computer system providers in primary care can help in creating this register and alert notifications to the practice.