The New Faecal Calprotectin Care Pathway, developed by Dr James Turvill, Consultant Gastroenterologist at York Teaching Hospitals NHS Foundation Trust, and implemented by the Yorkshire and Humber AHSN, supports the implementation of NICE guidance DG11, for the detection of inflammation in the bowel (i.e. IBS vs IBD). Uptake of this guidance has previously been poor and the specificity of the test has caused an increase in unnecessary referrals to secondary care.
The NICE guidance includes a research recommendation which states: Further research is needed on the impact of faecal calprotectin testing on clinical decision making when added to current practice. This includes research into optimal cut off values for tests and the investigation of repeat testing strategies in people with intermediate levels of faecal calprotectin. Development of a consistent definition for the 'intermediate range' is encouraged.
The pathway increased the recommended cut off level and optimised the patient pathway to identify real savings to the health economy. Risk assessment tools and a pack of resources support GPs to use their clinical judgement on whether a referral is necessary. This has resulted in better patient experience, reduction in the number of unnecessary referrals and a reduction in costs to the health system. More detail on the project is on the AHSN website: http://www.yhahsn.org.uk/service/population-health-service/faecal-calprotectin/
Aims and objectives
The cut off for the faecal calprotectin (FC) assay mentioned in the NICE Guidance (50µg/g) was found to increase the number of referrals to secondary care as the specificity at that cut off was not sufficient to prevent a high number of patients with IBS being unnecessarily referred to secondary care.
This new pathway addressed this issue by increasing the cut off to 100µg/g and placing risk assessment figures to support GPs with their clinical decision on when and how to refer a patient. This aims of the pathway were to 1) reduce the pressures in secondary care for endoscopy services and gastroenterology outpatient appointments (by reducing the number of unnecessary referrals), 2) improve the patient experience by supporting quicker diagnoses and enabling those patients who could be treated in primary care to do so 3) provide cost saving benefits for the health economy.
Using a series of supporting documentation and educational support to primary care, there has been an adherence to the pathway of at least 85% which is significantly more than previously (the pathway previously used in Leeds had an adherence of 11%).
This pathway was rolled out initially in York with the aim to spread to the rest of the Yorkshire and Humber region. To date, it has been implemented in 9 CCGs (240 GP practices) and the AHSN has facilitated the scaling up of implementation to other regions such as South Tees, Oxford, Bristol and Exeter.
The AHSN took part in a national task and finish group for the spread of FC diagnostic tests and this pathway formed the basis of the national algorithm which is planned for launch in 2018. This was working with professionals from around the country and included NHS England, NHS Business Services Authority, Trusts, CCGs, GPs and AHSNs.
This example was a runner up finalist in the 2018 NICE Shared Learning Awards.
Reasons for implementing your project
In 2010, Dr Turvill led a programme to devise and implement a structured care pathway for the use of FC testing in primary care. This was designed to overcome the challenge of the high sensitivity but poor specificity of FC tests and to ensure it focused on delivering an improved patient experience and better use of NHS resources.
In 2014, the pathway was piloted as part of a NICE adoption project in 5 GP practices in York. Evaluation on completion demonstrated its safety and effectiveness and a GP survey confirmed trust and support in the pathway. A patient survey was also completed to confirm the patient experience was improved through the implementation of this pathway.
Following on from the pilot, the AHSN knew there would be benefits to the whole Yorkshire and Humber region and worked with Dr Turvill to create a risk assessment tool (pathway) to support GP clinical decision making when there is diagnostic uncertainty. This built upon the previous research which increased the cut off level to 100µg/g and included placing risk assessment figures to support clinical judgement.
This pathway was rolled out initially in York and has spread to a further 8 CCGs in Yorkshire and Humber as well as other areas of the country. There are a further 8 CCGs who are in the process of implementing the pathway in their area. Some of these areas are more urban than others and the patient demographics are mixed indicating that this pathway works well for any area.
How did you implement the project
Following on from the Pilot in 2014, the Yorkshire & Humber AHSN supported rollout of the pathway and creating an implementation pack for CCGs and GPs including:
- Template business cases for CCGs and Trusts
- Downloadable pathway templates for EMIS and SystmOne
- An educational video and slide deck to explain the FC pathway (https://www.youtube.com/watch?v=ah-EH-q0lys&list=PLw476CR0-KDe45xaS1CKNxD4mFDYImz3n)
- GP leaflet to provide more detail of the pathway and why and when to test
- Patient information leaflet to explain what the test is and why it is being carried out
These were co-created with York Teaching Hospitals NHS FT and Vale of York CCG to ensure they would be fully utilised and relevant to the other organisations in the region - a copy of these can be viewed at http://www.valeofyorkccg.nhs.uk/rss/index.php?id=faecal-calprotectin. By providing these essential resources for primary care, buy in and acceptance to implementation was approved in many CCGs.
Some barriers encountered were reluctance and hesitance of gastroenterologists in the trusts, how this would fit with other pathways and how FIT testing would affect the future of FC testing. Dr Turvill was able to provide the clinical assurance to these questions and support buy in from secondary care to this pathway.
The AHSN also funded an economic impact analysis by the York Health Economic Consortium (YHEC) to provide demonstrable benefits to the health economy and support further roll out. Most of the costs of the implementation were for the development of the above resources and the financial cost of the pathway implementation to CCGs was minimal. The final report is available here.
The project is meeting its initial aims though we are still working on getting the pathway implemented into all CCGs within Yorkshire and Humber.
The health economic evaluation completed by YHEC demonstrated that the improved pathway saves £100 000 to £160 000 per 1000 patients tested; this equated to a saving of £2.5 million in the Yorkshire and Humber region. The evaluation also found that the pathway saves 1 unnecessary colonoscopy and outpatient appointment per 4-6 patients tested (147-262 colonoscopies per 1000 patients). The sensitivity and specificity of the new pathway was found to be 94% and 92% respectively versus 94% and 61% for the other pathway mentioned in the NICE guidance - by increasing the specificity of the test, it has resulted in the above benefits to the health system in terms of capacity and cost savings. Through the modelling used for the evaluation, it calculated that there would be cost and capacity benefits for the new pathway if only 1% of GPs adhere to it and our evidence suggests an adherence of approximately 85%.
When the test was first being rolled out, a patient survey was conducted to verify the results from the pilot work. The results of this survey mirrored the first one and demonstrated that patients perceived a benefit to having the FC. Some patient quotes include: “the test was enough to confirm that is nothing more than IBS”, “I was happy that the calprotectin is enough” and “the calprotectin is better than a colonoscopy”.
The findings were so impactful and we have successfully implemented this pathway, that the NHS Business Services Authority have written a case study on how the AHSN have spread and shared this pathway across our region. They use this as promotional information when presenting on their PACIFIC programme and is accessible here.
Key learning points
One key piece of learning is that when developing an implementation plan with CCGs, that having Dr Turvill (or a clinical champion) speak at GP education events is key. We found that the GP understanding of the pathway and why the pathway was changed caused adherence to be higher if we had the talk before roll out rather than after.
Another challenge was around the FIT pathways being introduced and how this would affect FC testing - we explained that the pathways were currently separate and FC testing should not be used if cancer is suspected. FIT testing for non-cancer diseases still needs a lot of research and so this pathway shouldn’t be delayed because of those questions.
It is important to understand which assay is being used as this work was based on the Buhlman assay. We have performed some compatibility testing with Hull CCG to understand the cut off differences for the Thermofisher assay. We have since agreed that this pathway can remain the same with the different assay but it important that people know which they are using to ensure the optimal pathways.
The AHSN are more than willing to share the resources mentioned above to support other organisations to roll out this pathway - without this pack of resources to provide CCGs with, implementation would have been much more difficult.