Using best practice to create a pathway to improve management of irritable bowel syndrome: aiming for timely diagnosis, effective treatment and equitable care
Williams M, Barclay Y, Benneyworth R et al.
Frontline Gastroenterology 2016;7:323-330
Irritable bowel syndrome (IBS) is a chronic, debilitating condition which places a significant strain on NHS finances and resources. National clinical guidelines recommend management of IBS should take place in primary care, however, a significant proportion of patients continue to be referred to secondary care despite a low probability of pathology.
Frontline Gastroenterology 2016;7:323-330
Irritable bowel syndrome (IBS) is a chronic, debilitating condition which places a significant strain on NHS finances and resources. National clinical guidelines recommend management of IBS should take place in primary care, however, a significant proportion of patients continue to be referred to secondary care despite a low probability of pathology.
Research amongst GPs has shown IBS is still seen as a diagnosis of exclusion and that negative test results are useful. With improved GP education regarding diagnosis, alongside an effective management pathway, direct cost-savings should be realised and secondary care gastroenterology services can more effectively target the care they deliver.
In 2011, a Flexible Healthcare Gastroenterology Clinical Team was created in Somerset, consisting of representatives from primary and secondary settings, with the aim of improving patient care by creating a Somerset-wide IBS pathway with funding from the local clinical commissioning group (CCG). By identifying those patients who, despite symptoms, were at low risk of pathology and utilising specialist dietetic input for symptom control, unnecessary utilisation of healthcare resources was avoided. The cost savings achieved were then used to fund parts of the new IBS pathway.
Initially, baseline data was collected including audits to: i) determine the number of patients (aged between 16-45 years) who were referred from primary care with likely IBS (meeting ROME III criteria) and no alarm symptoms and; ii) investigate the ‘revolving door’ effect of ongoing symptoms leading to repeat referral and investigation. In addition, a pilot project by a community dietitian, where patients with IBS were referred directly from local GPs was undertaken. Outcomes using dietary interventions, including the low FODMAP diet, were assessed in a number of ways including symptom evaluation forms at the start and end of treatment and informal feedback data on quality of life.
Following the collection of this baseline data, the focus of the project was on empowering GPs to make a positive diagnosis of IBS, hence avoiding unnecessary secondary care referrals. This was achieved by:
Overall, the proportion of new patients slots used reduced from 14.3% to 8.7% over a 10 month period, whilst overall associated costs reduced by 25% in patients with no alarm symptoms and likely IBS aged between 16-45 years. The potential revolving door data showed that of the 117 patients fitting the criteria of likely IBS with no alarm symptoms and aged between 16-45 years, 32.5% had been seen in the previous 5 years for secondary care investigations. Analysis of the FC testing undertaken in this study found no gastrointestinal pathology found at levels ≤50µg/g, therefore supporting use of this within the pathway.
The specialist community gastroenterology dietitian-led service found that 63% of patients who reported not having satisfactory symptom relief at their initial appointment, then found they did have following dietetic intervention. The informal feedback on the improvement of quality of life showed 74% noted that dietary intervention had improved this outcome.
The combination of components in this pilot project appeared to be successful in achieving a cost-effective IBS pathway with reduced secondary care involvement and an improvement in patient care.
Original paper
In 2011, a Flexible Healthcare Gastroenterology Clinical Team was created in Somerset, consisting of representatives from primary and secondary settings, with the aim of improving patient care by creating a Somerset-wide IBS pathway with funding from the local clinical commissioning group (CCG). By identifying those patients who, despite symptoms, were at low risk of pathology and utilising specialist dietetic input for symptom control, unnecessary utilisation of healthcare resources was avoided. The cost savings achieved were then used to fund parts of the new IBS pathway.
Initially, baseline data was collected including audits to: i) determine the number of patients (aged between 16-45 years) who were referred from primary care with likely IBS (meeting ROME III criteria) and no alarm symptoms and; ii) investigate the ‘revolving door’ effect of ongoing symptoms leading to repeat referral and investigation. In addition, a pilot project by a community dietitian, where patients with IBS were referred directly from local GPs was undertaken. Outcomes using dietary interventions, including the low FODMAP diet, were assessed in a number of ways including symptom evaluation forms at the start and end of treatment and informal feedback data on quality of life.
Following the collection of this baseline data, the focus of the project was on empowering GPs to make a positive diagnosis of IBS, hence avoiding unnecessary secondary care referrals. This was achieved by:
- ‘Diagnosis of IBS’ & ‘Management of IBS’ algorithms via innovative desktop app
- County-wide GP education sessions delivered by a specialist dietitian and/or gastroenterologist
- Provision of faecal calprotectin (FC) testing to exclude inflammatory pathologies in patients aged between 16-45 years with likely IBS and thus avoiding secondary care referrals in those with FC≤50µg/g
- Provision of an innovative, community-based, dietetic-led gastroenterology service using dietary interventions such as the low FODMAP diet for patients with IBS with no alarm symptoms, normal blood tests and FC results and intractable symptoms (first-line dietary advice was supplied by community dietitians based within GP practices or by the GPs directly)
Overall, the proportion of new patients slots used reduced from 14.3% to 8.7% over a 10 month period, whilst overall associated costs reduced by 25% in patients with no alarm symptoms and likely IBS aged between 16-45 years. The potential revolving door data showed that of the 117 patients fitting the criteria of likely IBS with no alarm symptoms and aged between 16-45 years, 32.5% had been seen in the previous 5 years for secondary care investigations. Analysis of the FC testing undertaken in this study found no gastrointestinal pathology found at levels ≤50µg/g, therefore supporting use of this within the pathway.
The specialist community gastroenterology dietitian-led service found that 63% of patients who reported not having satisfactory symptom relief at their initial appointment, then found they did have following dietetic intervention. The informal feedback on the improvement of quality of life showed 74% noted that dietary intervention had improved this outcome.
The combination of components in this pilot project appeared to be successful in achieving a cost-effective IBS pathway with reduced secondary care involvement and an improvement in patient care.
Original paper
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