Multi-centre Service Evaluation Research Articles

MDB-23. MULTICENTRE EVALUATION OF THE MANAGEMENT OF CHILDREN WITH HIGH RISK MEDULLOBLASTOMA: REAL WORLD PERFORMANCE OF THE SJMB03 AND COG99701 PROTOCOLS

Abstract BACKGROUND Several treatment protocols are used in the treatment of patients with high risk medulloblastoma (HRMB). In 2015 the UK Children’s Cancer and Leukaemia Group issued interim guidance recommending treatment as per the SJMB03 protocol, whilst also recognising that the COG99701 protocol may be used. Patients were defined as high risk, if metastatic at presentation, large cell anaplastic histology, MYC amplification, significant residual disease or MYCN amplification, the latter two, more recently only if other adverse features present. METHODS We present a retrospective multi-centre service evaluation of treatment of patients with HRMB at 5 tertiary paediatric oncology centres in the UK. Patients were included if treated for HRMB with SJMB03, COG-99701. Patients were excluded if treated for HRMB on other protocols, including the SIOP HRMB trial, or if initially treated for standard risk medulloblastoma and subsequently treated with these protocols due to upstaging or disease progression. Event free, and overall (EFS and OS) survival analyses were calculated from date of primary resection. RESULTS 59 patients were included (median age 8 years, range 3-19): 26 treated as per SJMB03, 33 as per COG-99701. 5-year OS was 83% (95% Confidence Interval, 73-94%) and 5-year EFS was 66% (54-80%). For patients treated as per SJMB03 5-year OS and EFS was 79% (65-97%) and 70% (55-92%)respectively. and for patients treated as per COG99701, 5-year OS and EFS was 86% (73-99%) and 60% (44-83%). There was a higher incidence of grade 3 & 4 ototoxicity (44% vs 6%) and a higher rate of admission to paediatric intensive care (36% vs 6%) in patients treated as per SJMB03 compared to those treated with COG97701 (p<0.05). CONCLUSIONS These real-world outcomes of patients treated in the UK for HRMB are consistent with the published literature for their outcomes for high risk medulloblastoma.

Written communication of whole genome sequencing results in the NHS Genomic Medicine Service: a multi-centre service evaluation.

Whole genome sequencing (WGS) is being used in diagnostic testing for certain clinical indications within the NHS Genomic Medicine Service (GMS) in England. Letter writing is an integral part of delivering results. However, no national guidelines for writing results from WGS exist. This multi-centre service evaluation used mixed methods to understand the content and readability of letters returning diagnostic, variant of uncertain significance (VUS), and no-finding results to paediatric rare disease patients. Eight Regional Genetics Services (response rate 47%) in England provided a total of 37 letters returning diagnostic (n = 13), VUS (n = 10), and no-finding (n = 14) results. Diagnostic and VUS results were usually delivered during an appointment; no-finding results were typically delivered by letter only. Letters were diverse in which content topics they covered and level of detail. No-finding letters (14/14) explained the result but were less likely to cover other topics. Diagnostic letters discussed the result (13/13), the condition (13/13), clinical genetics follow-up (13/13), clinical management (10/13), and adapting to the result (9/13). VUS letters explained the result (10/10), diagnostic uncertainty (10/10), and clinical genetics follow-up (10/10). Uncertainty was a common component of letters (33/37), irrespective of the result. Reanalysis or review after one or more years was suggested in 6/13 diagnostic, 7/10 VUS, and 6/14 no-finding letters. The mean reading level of letters corresponded to 15-17 years. Understanding how WGS results are conveyed to families during appointments, as well as how families interpret that information, is needed to provide a more comprehensive overview of results communication and inform best practices.

Relapse after cessation of weekly tocilizumab for giant cell arteritis: a multicentre service evaluation in England.

The National Health Service in England funds 12 months of weekly subcutaneous tocilizumab (qwTCZ) for patients with relapsing or refractory giant cell arteritis (GCA). During the COVID-19 pandemic, some patients were allowed longer treatment. We sought to describe what happened to patients after cessation of qwTCZ. Multicentre service evaluation of relapse after stopping qwTCZ for GCA. The log-rank test was used to identify significant differences in time to relapse. 336 GCA patients were analysed from 40 centres, treated with qwTCZ for a median (interquartile range, IQR) of 12 (12-17) months. At time of stopping qwTCZ, median (IQR) prednisolone dose was 2 (0-5) mg/day. By 6, 12 and 24 months after stopping qwTCZ, 21.4%, 35.4% and 48.6% respectively had relapsed, requiring an increase in prednisolone dose to a median (IQR) of 20 (10-40) mg/day. 33.6% of relapsers had a major relapse as defined by EULAR. Time to relapse was shorter in those that had previously also relapsed during qwTCZ treatment (P = 0.0017); in those not in remission at qwTCZ cessation (P = 0.0036); and in those with large vessel involvement on imaging (P = 0.0296). Age ≥65, gender, GCA-related sight loss, qwTCZ treatment duration, TCZ taper, prednisolone dosing, and conventional synthetic DMARD use were not associated with time to relapse. Up to half our patients with GCA relapsed after stopping qwTCZ, often requiring a substantial increase in prednisolone dose. One third of relapsers had a major relapse. Extended use of TCZ or repeat treatment for relapse should be considered for these patients.

ORthopaedic trauma hospital outcomes - Patient operative delays (ORTHOPOD) Study: The management of day-case orthopaedic trauma in the United Kingdom

IntroductionORTHOPOD: Day Case Trauma is a multicentre prospective service evaluation of day-case trauma surgery across four countries. It is an epidemiological assessment of injury burden, patient pathways, theatre capacity, time to surgery and cancellation. It is the first evaluation of day-case trauma processes and system performance at nationwide scale. MethodsData was prospectively recorded through a collaborative approach. Arm one captured weekly caseload burden and operating theatre capacity. Arm two detailed patient and injury demographics, and time to surgery for specific injury groups. Patients scheduled for surgery between 22/08/22 and 16/10/22 and operated on before 31/10/22, were included. For this analysis, hand and spine injuries were excluded. ResultsData was obtained from 86 Data Access Groups (70 in England, 2 in Wales, 10 in Scotland and 4 in Northern Ireland). After exclusions, 709 weeks worth of data representing 23,138 operative cases were analysed. Day-case trauma patients (DCTP) accounted for 29.1% of overall trauma burden and utilised 25.7% of general trauma list capacity. They were predominantly adults aged 18 to 59 (56.7%) with upper limb Injuries (65.7%). Across the four nations, the median number of day-case trauma lists (DCTL) available per week was 0 (IQR 1). 6 of 84 (7.1%) hospitals had at least five DCTLs per week. Rates of cancellation (13.2% day-case; 11.9% inpatient) and escalation to elective operating lists (9.1% day-case; 3.4% inpatient) were higher in DCTPs. For equivalent injuries, DCTPs waited longer for surgery. Distal radius and ankle fractures had median times to surgery within national recommendations: 3 days and 6 days respectively. Outpatient route to surgery was varied. Dominant pathways (>50% patients listed at that episode) in England and Wales were uncommon but the most frequently seen was listing patients in the emergency department, 16 of 80 hospitals (20%). ConclusionThere is significant mismatch in DCTP management and resource availability. There is also considerable variation in DCTP route to surgery. Suitable DCTL patients are often managed as inpatients. Improving day-case trauma services reduces the burden on general trauma lists and this study demonstrates there is considerable scope for service and pathway development and improved patient experience.

Perioperative blood transfusion in major abdominal cancer surgery: a multi-centre service evaluation and national survey.

Anaemia is associated with complications and death after surgery. Perioperative red-cell transfusion triggers are not well defined in patients having oncological surgery, or with cardiovascular disease. We carried out a prospective multicentre cohort study and a clinician survey of UK transfusion practice in adult patients undergoing surgery for abdominal malignancy. The primary outcome was red cell transfusion. Secondary outcomes were transfusion trigger haemoglobin, incidence of complications, length of hospital stay, and acute hospital mortality. In this prospective cohort study, data were collected on 412 patients undergoing surgery for intrabdominal malignancy in 14 NHS hospitals. Twenty-two (5.2%) patients received preoperative, 42 (10.2%) intraoperative, and 52 (12.2%) postoperative red blood cell transfusion. The mean postoperative transfusion trigger was 75.3 g L-1, and the mean number of units of red blood cells transfused was 1.5 (standard deviation, 1.1). Seventeen (4.0%) patients had a documented postoperative troponin elevation. Five (1.2%) patients died within 30 days of surgery. In the survey, 117 clinicians submitted complete responses, of whom 62 (53%) indicated that a transfusion threshold of 70 g L-1 was appropriate: however, this decreased to six (5.1%) if there was evidence of recent cardiac ischaemia. There were 100 (86%) respondents who indicated equipoise for a trial of restrictive vs liberal transfusion, decreasing to 56% if there was coexisting cardiovascular disease. Many patients having oncological surgery receive red cell transfusion, the majority being given postoperatively. Restrictive transfusion practice is generally followed; however, variability exists especially in cardiovascular disease. Equipoise exists for a study of transfusion thresholds in this group.

PEPtalk 3: oral aciclovir is equivalent to varicella zoster immunoglobulin as postexposure prophylaxis against chickenpox in children with cancer – results of a multicentre UK evaluation

ObjectiveTo compare the occurrence of chickenpox in children with cancer who received varicella immunoglobulin (VZIG) or aciclovir as postexposure prophylaxis (PEP).DesignProspective multicentre service evaluation of children with cancer who received...

Multi-centre prospective cohort study of diaphragmatic defect phenotype and repair in neonates with congenital diaphragmatic hernia: ‘The Defect Study’

Abstract Defect size and closure technique in neonates with congenital diaphragmatic hernia (CDH) has long-term consequences for morbidity in survivors. Although subjective operative reporting of the defect size has been standardized, objective evaluation is lacking. There is no reported optimum closure technique related to the size and position of the diaphragmatic defect. We aim to objectively describe diaphragmatic defects and repair methods, at the time of neonatal CDH repair, through a prospective multi-centre service evaluation project. We will evaluate all neonates born with CDH surviving to diaphragmatic repair. All specialist paediatric surgical centres in the UK, Ireland and New Zealand will be invited to participate. Non-identifiable patient data will be collected over a 24-month period using a REDCap database. Diaphragmatic defects and hemidiaphragm measurements will be recorded intra-operatively alongside standardized defect reporting. Closure technique and 1-year outcomes will be captured. Demographics and peri-operative data will be reported as median (interquartile range), mean (standard deviation) or categorical variables. Defect measurement will be calculated as an ellipse with area displayed as a histogram. Patch usage will be compared to the defect area using univariate logistic regression analysis. Univariate logistic regression analysis will also be used to assess for the association between peri-operative variables and complications. Where possible, a multi-variate regression analysis will be performed. Centres will register the project as service evaluation at each participating hospital site. The results will be submitted to an international peer reviewed journal and will be disseminated via appropriate international forums and through patient support networks (CDH-UK).

North Thames multi-centre service evaluation: Ethical considerations during COVID-19.

During the COVID-19 pandemic, healthcare resources including staff were diverted from paediatric services to support COVID-positive adult patients. Hospital visiting restrictions and reductions in face-to-face paediatric care were also enforced. We investigated the impact of service changes during the first wave of the pandemic on children and young people (CYP), to inform recommendations for maintaining their care during future pandemics. A multi-centre service evaluation was performed through a survey of consultant paediatricians working within the North Thames Paediatric Network, a group of paediatric services in London. We investigated six areas: redeployment, visiting restrictions, patient safety, vulnerable children, virtual care and ethical issues. Survey responses were received from 47 paediatricians across six National Health Service Trusts. Children's right to health was largely believed to be compromised by the prioritisation of adults during the pandemic (81%; n = 33). Sub-optimal paediatric care due to redeployment (61%; n = 28) and the impact of visiting restrictions on CYP's mental health (79%; n = 37) were reported. Decreased hospital attendances of CYP were associated with parental fear of COVID-19 infection-risks (96%; n = 45) and government 'stay at home' advice (89%; n = 42). Reductions in face-to-face care were noted to have disadvantaged those with complex needs, disabilities and safeguarding concerns. Consultant paediatricians perceived that paediatric care was compromised during the first wave of the pandemic, resulting in harm to children. This harm must be minimised in subsequent pandemics. Recommendations for future practice which were developed from our findings are provided, including maintaining face-to-face care for vulnerable children.

RSTNCOVID Burns: A multi-centre service evaluation and stakeholder survey of the impact of COVID-19 on burns care in England, Wales and Northern Ireland

As the UK entered the first wave of the COVID-19 pandemic, the National Health Service published consensus guidance to the UK burns services advising changes to the acute management of burns to allow the continuation of safe care while protecting limited hospital resources. We aimed to describe the demographics of burns service users, changes to clinical pathways and experiences of the burns team during the first wave of the COVID-19 pandemic.All burns services in the UK were invited to participate in a national collaborative, trainee-led study supported by the Reconstructive Surgery Trials Network. The study consisted of (1) a service evaluation of patients receiving burns treatment during the COVID-19 pandemic; (2) a multidisciplinary team survey. Analyses were descriptive and narrative depending on data types.Collaborators from 18 sites contributed data from burns MDT surveys and 512 patients. Patient demographics were consistent with typical burns patterns in the UK. The delayed presentation occurred in 20% of cases, with 24 patients developing complications. MDT surveys indicated substantial adaptations and challenges as a result of the pandemic. Access to theatres and critical care were limited, yet a comprehensive acute burns service was maintained. Telemedicine was utilised heavily to reduce patient footfall.Adaptations in the provision of burns care, including greater outpatient care and telemedicine, have emerged out of necessity with reported success. The impact of reduced scar therapy and psychological interventions for burns patients during the pandemic requires longer-term follow-up. Lessons from the UK experience can be used to strategise for future pandemics.

Multi-centre service evaluation of presentation of newly diagnosed type 1 diabetes in children in the U.K. furing the COVID-19 pandemic

Multi-centre service evaluation of presentation of newly diagnosed type 1 diabetes in children in the U.K. furing the COVID-19 pandemic

Multicentre service evaluation of presentation of newly diagnosed cancers and type 1 diabetes in children in the UK during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic led to changes in patterns of presentation to emergency departments. Child health professionals were concerned that this could contribute to the delayed diagnosis of life-threatening conditions, including...

Patient-reported outcome measure for children and young people with amelogenesis imperfecta.

Background Amelogenesis imperfecta (AI) is a genetic enamel defect that can affect both the primary and permanent dentition. It has a range of clinical phenotypes, and children and young people often present with challenging oral health needs. Patient-reported outcome measures (PROMs) can identify key patient concerns.Methods This was a multi-centre service evaluation across several specialist paediatric dentistry services in the UK. A PROM questionnaire was created with clinician and patient input, through peer review with the national AI Clinical Excellence Network, as well as piloting the PROM with ten children and young people with AI. The final PROM questionnaire was distributed to all patients with AI attending each unit between January and March 2020.Results Sixty children and young people (aged 5-17 years) across four specialist units participated, with 72% reporting that they 'often' or 'sometimes' experienced pain or sensitivity and 76% reporting that they 'often' or 'sometimes' felt unhappy with the way their teeth look. Of the patients who were post-treatment, 81% indicated that they were happy with their teeth, compared to just 41% of patients who were mid-treatment and 33% of patients who were pre-treatment.Conclusion Children and young people with AI experience a range of issues related to their function and psychosocial wellbeing. This simple PROM demonstrates the range of issues this group of patients face, and could be used to monitor an individual's progress to ensure that treatment is planned to address the patient's individual concerns and needs.

Patient reported experiences and treatment outcomes of orthodontic patients treated within secondary care settings in the South West of England during the COVID-19 pandemic.

To assess the impact of the temporary cessation of orthodontic services on patients undergoing treatment during the COVID-19 pandemic. Two-phase multicentre service evaluation. Secondary care orthodontic departments in the South West of England. Phase 1 - Patient-Reported Experience Measure questionnaire (PREM). The questionnaire was distributed to patients who had undergone orthodontic treatment during the COVID-19 pandemic once services had resumed. Phase 2 - assessment of treatment outcomes, specifically with the Peer Assessment Rating (PAR) Index. A total of 280 PAR scores were obtained from a cohort of patients treated before and during the pandemic. A total of 711 PREM questionnaires were completed. Participants generally felt relaxed when visiting secondary care settings, orthodontic departments and whilst wearing orthodontic appliances during the pandemic. Nearly 40% of participants were concerned that the pandemic would impact on their treatment, particularly treatment length. Treatment outcomes revealed that patients treated before and during the pandemic experienced percentage PAR score reductions of 83.9% and 80.6%, respectively. Patients receiving treatment during the pandemic experienced longer treatment durations of 126 days. During the pandemic, low levels of anxiety were reported with respect to receiving orthodontic treatment in secondary care settings. Irrespective of the pandemic, a high standard of orthodontic treatment was provided. However, patient concerns regarding treatment length were justified.

Trends in referrals to liaison psychiatry teams from UK emergency departments for patients over 65

AimsThe number of people over the age of 65 attending Emergency Departments (ED) in the United Kingdom (UK) is increasing. Those who attend with a mental health related problem may be referred to liaison psychiatry for assessment. Improving responsiveness and integration of liaison psychiatry in general hospital settings is a national priority. To do this psychiatry teams must be adequately resourced and organised. However, it is unknown how trends in the number of referrals of older people to liaison psychiatry teams by EDs are changing, making this difficult.MethodWe performed a national multi-centre retrospective service evaluation, analysing existing psychiatry referral data from EDs of people over 65. Sites were selected from a convenience sample of older peoples liaison psychiatry departments. Departments from all regions of the UK were invited to participate via the RCPsych liaison and older peoples faculty email distribution lists. From departments who returned data, we combined the date and described trends in the number and rate of referrals over a 7 year period.ResultReferral data from up to 28 EDs across England and Scotland over a 7 year period were analysed (n = 18828 referrals). There is a general trend towards increasing numbers of older people referred to liaison psychiatry year on year. Rates rose year on year from 1.4 referrals per 1000 ED attenders (>65 years) in 2011 to 4.5 in 2019 . There is inter and intra site variability in referral numbers per 1000 ED attendances between different departments, ranging from 0.1 - 24.3.ConclusionTo plan an effective healthcare system we need to understand the population it serves, and have appropriate structures and processes within it. The overarching message of this study is clear; older peoples mental health emergencies presenting in ED are common and appear to be increasingly so. Without appropriate investment either in EDs or community mental health services, this is unlikely to improve.The data also suggest very variable inter-departmental referral rates. It is not possible to establish why rates from one department to another are so different, or whether outcomes for the population they serve are better or worse. The data does however highlight the importance of asking further questions about why the departments are different, and what impact that has on the patients they serve.

Trends in referrals to liaison psychiatry teams from UK emergency departments for patients over 65.

The number of people over the age of 65 attending Emergency Departments (ED) in the United Kingdom (UK) is increasing. Those who attend with a mental health related problem may be referred to liaison psychiatry for assessment. Improving responsiveness and integration of liaison psychiatry in general hospital settings is a national priority. To do this psychiatry teams must be adequately resourced and organised. However, it is unknown how trends in the number and type referrals of older people to liaison psychiatry teams by EDs are changing, making this difficult. We performed a national multi-centre retrospective service evaluation, analysing existing psychiatry referral data from EDs of people over 65. We described trends in the number, rate, age, mental health presentation, and time taken to assessment over a 7 years period. Referral data from 28 EDs across England and Scotland were analysed (n=18,828 referrals). There was a general trend towards increasing numbers of people referred to liaison psychiatry year on year. Variability in referral numbers between different departments, ranged from 0.1 to 24.3 per 1000 ED attendances. The most common reasons for referral were mood disorders, self-harm and suicidal ideas. The majority of referrals were assessed within 60 min, however there is variability between departments, some recording waits over 11 h. The data suggests great inter-departmental variability in referral numbers. Is not possible to establish the cause of variability. However, the data highlights the importance of asking further questions about why the differences exist, and the impact that has on patient care.

Re-initiation of CT colonography services during the COVID-19 pandemic: Preliminary evaluation of safety.

Objective:The COVID-19 pandemic has led to cancellation and deferral of many cancer investigations, including CT colonography (CTC). In May 2020, BSGAR and SCoR issued guidelines outlining steps for conduct of CTC in the early recovery phase. We evaluated the implementation of these in four English hospital trusts.Methods:Ethical permission was not required for this multicentre service evaluation. We identified patients undergoing CTC over a 2-month period from May to July 2020 at four Trusts. We recorded demographics, scan indications, colonic findings, and incidental lung base changes compatible with COVID-19. A subset of patients were contacted via telephone to document new symptoms 2 weeks following their scan. Staff were contacted to determine if any acquired COVID-19 during the period.Results:224 patients (118 male, 52.7%) were scanned during the period. In 55 patients (24.6%), CTC showed a ≥6 mm polyp. 33 of 224 (14.7%) scans showed incidental lung base changes felt unrelated to COVID-19, and only one patient had changes indeterminate for COVID-19; no classic COVID-19 pulmonary changes were found. Of 169 patients with telephone follow-up, none reported any new symptoms of COVID-19 (cough, fever, anosmia, ageusia) within 14 days of CTC. None of the 86 staff contacted developed COVID-19.Conclusion:We found no cases of patients or staff acquiring COVID-19 infection following CTC; and no evidence of significant asymptomatic COVID-19 patients attending for CTC appointments based on lung base changes.Advances in knowledge:Our findings suggest that current practice is unlikely to contribute significantly to spread of SARS-nCOV2. Cancer and significant polyp detection rates were high, underlining the importance of maintaining service provision.

The burden of dehisced wounds in the community: using early results from a multi-centre service evaluation to propose a standard of care to improve patient outcomes and safeguard woundcare budgets

Non-healing wounds and their associated costs present a significant challenge to wound care services. Dehisced wounds are often overlooked, with a lack of true understanding regarding the additional burden this represents. As a consequence, there is a lack of evidence around what is deemed gold standard care, with no published pathways to support clinical practice. A 34-patient data set was captured and analysed as part of an evaluation of hard-to-heal wounds. Patients with wounds meeting specific criteria followed a hard-to-heal wound pathway that facilitated single use negative pressure wound therapy. Implementation of this pathway helped to achieve healing for 18 out of 34 (52.9%) wounds over a 12-week period, subsequently reducing the overall wound care spend from £76 828 to £60 251 for this group. A notably improved response was seen in patients who had a chronic wound of less than 6 months in duration, indicating the importance of earlier intervention and the positive impact this can have on the patient experience and associated health economic outcomes. This service evaluation supports the use of single use negative pressure wound therapy for non-progressing dehisced surgical wounds as part of an indication-led pathway.

A Rapid Multi-Centre Service Evaluation of Presentations to Children's Emergency Departments During the COVID-19 Pandemic

Background: The COVID-19 Pandemic has resulted in the potential unintended consequence of parents being reluctant to bring their children to hospital for acute and emergency care. While there is evidence of this occurring via case series a prospective evaluation has not be performed. Methods: Seven Emergency Departments (EDs) seeing children less than 16 years old collected data prospectively for two weeks on all presenting patients. Information was collected on age, the presence of red flag symptoms (as defined by the Royal College of Paediatrics and Child Health), presence of, and reasons for, any delay in attending. Findings: There were 1460 entries via the portal with 1349 usable entries. The majority of patients, 1262 (93.5%), were felt not to have had a delay in their presentation and of the 51 (3.8%) patients with a potential concern over delay six were admitted. Red flag symptoms were reported in 81 patients; two of these were felt to be delayed presentations but neither were admitted. Interpretation: In a large prospective cohort of children presenting to a representative group of Children’s Emergency Departments the rate of clinician reported delay in presentation was low. While concerns regarding delayed presentations in the UK due to COVID-19 are valid, the impact may be less than originally thought. Funding Statement: This project received no funding. Declaration of Interests: None of the authors has anything to declare. Ethics Approval Statement: Data collection was approved under the COPI notice issued on the 20th March, 2020. The website was approved by NHSX and no identifiable information were recorded other than date of presentation and age. The project was endorsed by the RCPCH as a national service evaluation and appropriate data protection impact assessments took place. Authors did not receive formal IRB approval.

Greater trochanteric pain syndrome in the UK national health service: a multi-centre service evaluation

Greater trochanteric pain syndrome in the UK national health service: a multi-centre service evaluation

Differing commissioning arrangements may contribute to geographic variation in clinical management of digital ulcers in systemic sclerosis

Phosphodiesterase inhibitors (such as sildenafil) and endothelin receptor antagonist, bosentan, are effective for digital ulcer disease in systemic sclerosis (SSc-DU) and are endorsed in international treatment recommendations. Commissioning of high-cost drugs, such as bosentan, however, differs across devolved nations of the UK. We report a multicentre service evaluation project to examine 'real world' management of SSc-DU before and following the 2015 UK Scleroderma Study Group (UKSSG) guidance, across south-west (SW) England and Wales. Results showed that iloprost and sildenafil use for SSc-DU was higher in patients in Wales prior to 2015. Between 2015-2017, sildenafil use for SSc-DU increased in SW England while remaining stable in Wales. Bosentan use for SSc-DU after 2015 in SW England increased, while remaining stable and proportionately lower in Wales. These findings demonstrate that differing commissioning guidance across devolved nations of the UK seems to contribute to geographic variation in patient care.