Patient Pathway Manager Research Articles

#6884 THE BARRIERS TO TRANSPLANTATION IN OUR DIABETIC HAEMODIALYSIS POPULATION AT THE LEEDS TEACHING HOSPITALS NHS TRUST

Abstract Background and Aims According to the 24th Annual Renal Registry Report, diabetes is the most common identified primary renal disease in patients starting renal replacement therapy (RRT). The prevalence of this underlying disease amounted to 30.5% by the end of 2020, a statistic which increased from 27% in 2015. This highlights the challenges faced by healthcare services in meeting the accrescent demands of this cohort of patients. The Renal Association and British Transplantation Society suggest that patients with a BMI >30 kg/m2 are at a heightened risk of complications and is therefore discouraged. Our local transplant centre at St James's University Hospital accepts recipients with a BMI of up to 35 kg/m2 for kidney alone transplantation should no other medical/ surgical contraindications to transplantation prevail. Despite this threshold, there remains a significant proportion of patients suspended from the deceased donor transplant waiting list due to an unacceptably raised BMI. Method Data was collected through the use of clinic letters or GP records uploaded to Patient Pathway Manager and BHLY (Bradford, Hull, Leeds and York) Renal Patient System. Our patient population consisted of those diabetic patients on home and in-centre haemodialysis (Leeds St James's University Hospital, Pontefract, Seacroft, Beeston, Dewsbury, Calderdale and Huddersfield). The aims of our study are to assess the demographics of the diabetic haemodialysis (HD) population at the Leeds Teaching Hospitals NHS Trust, to determine the reasons for suspension from the renal transplant waiting list, with a particular interest in obesity. We also assessed the commonest treatment modality (insulin vs other) and the use of continuous glucose monitoring. Results The Leeds renal services provide haemodialysis for 631 patients, 248 of these being diabetic patients - 66% of whom are male, with a mean age of 60. Just over 50% of this cohort of patients are Caucasian in ethnicity, while 30% are South Asian. By the end of December 2022, just below 20% (n = 119) of all haemodialysis patients were active on the national deceased transplant waiting list. On the other hand, only 14% (n = 35) of the diabetic haemodialysis subpopulation were active by the end of 2022, while 13% (n = 31) were under assessment, 14% (n = 35) declined and/or disengaged from assessment for transplantation, while the rest were either temporarily or permanently suspended. Almost 10% (n = 24) of all diabetic haemodialysis patients are suspended due to a BMI >35 kg/m2. Conclusion Our audit reveals that only 14% of the haemodialysis diabetic population is presently active on the deceased transplant waiting list. This remains suboptimal, as renal or simultaneous pancreas kidney transplantation is the gold standard for diabetes-induced ESKD. Obesity (BMI >35) was a reason for temporary suspension in 10% of our haemodialysis diabetic population. Therefore we need to target this comorbidity in a timely manner in order to optimise patients for transplantation. NICE recommend pharmacological weight-lowering therapy for people who have failed to achieve a healthy BMI following conservative methods. Such medical therapy (eg. liraglutide) is still yet to be evaluated in depth in the ESKD-haemodialysis obese population. Only one patient in our cohort was being treated with liraglutide, while the rest was either on insulin, linagliptin, gliclazide or non-pharmacological dietary modification. The authors of this study encourage the inclusion of CKD5 patients on liraglutide, before they are started on haemodialysis, in order to pave their way to transplantation before it is too late.

Suspected focal nodular hyperplasia in male adults: 10-year experience from a large liver centre.

Focal nodular hyperplasia (FNH) is commonly found in females of reproductive age. In males, the diagnosis is made more cautiously due to its lower incidence and higher incidence of hepatocellular carcinoma, which can have overlapping imaging features. Follow-up or biopsy is sometimes required. This retrospective study aims to assess management of suspected FNH in male adult patients at our institution over a 10-year period. Male adults (≥ 18years) suspected of having FNH from January 2010-June 2020 were identified using a departmental radiology information system search. Data was collected from radiology reports and patient pathway manager. Of 342 patients with suspected FNH, 62 were male (18.1%; F:M of 4.5:1). We only included patients investigated and followed up by MRI, total of 57 patients. Median age was 40years (range 18-74years). Background liver disease present in 21/57 (36.8%), majority with hepatic steatosis. Average number of lesions per patient 1.7. 22/57 (38.6%) had at least one MRI follow-up using liver-specific contrast with 7 lesions demonstrating variation in size (range growth: -3.27mm/year to + 4mm/year). In 7 cases, MRI was not definitive; 6 required biopsy and 1 resection. Only 2/7 demonstrated malignancy. Of the total 57 patients, 6 have deceased and none due to a misdiagnosed or mismanaged hepatic lesion. FNH is relatively uncommon in males, however, our data suggests that lesions with typical MRI characteristics do not require follow-up and diagnosis can be made confidently, similar to females. Any atypical features should prompt a biopsy.

Value of an Integrated Home Dialysis Model in the United Kingdom: A Cost-Effectiveness Analysis

ObjectivesThis study aimed to determine the lifetime cost-effectiveness of increasing home hemodialysis as a treatment option for patients experiencing peritoneal dialysis technique failure compared with the current standard of care. MethodsA Markov model was developed to assess the lifetime costs, quality-adjusted life-years, and cost-effectiveness of increasing the usage an integrated home dialysis model compared with the current patient pathways in the United Kingdom. A secondary analysis was conducted including only the cost difference in treatments, minimizing the impact of the high cost of dialysis during life-years gained. Sensitivity and scenario analyses were performed, including analyses from a societal rather than a National Health Service perspective. ResultsThe base-case probabilistic analysis was associated with incremental costs of £3413 and a quality-adjusted life-year of 0.09, resulting in an incremental cost-effectiveness ratio of £36 341. The secondary analysis found the integrated home dialysis model to be dominant. Conclusions on cost-effectiveness did not change under the societal perspective in either analysis. ConclusionsThe base-case analysis found that an integrated home dialysis model compared with current patient pathways is likely not cost-effective. These results were primarily driven by the high baseline costs of dialysis during life-years gained by patients receiving home hemodialysis. When excluding baseline dialysis-related treatment costs, the integrated home dialysis model was dominant. New strategies in kidney care patient pathway management should be explored because, under the assumption that dialysis should be funded, the results provide cost-effectiveness evidence for an integrated home dialysis model.

One year with the COVID-19 pandemic − Lessons learnt? Intersectoral collaboration measures established during the crisis could benefit capacity and patient flow management in daily clinical practice

PurposeThe COVID-19 pandemic has changed the way hospitals work. Strategies that were detached from the boundaries of departments and responsibilities in the COVID-19 pandemic have proven themselves under extreme conditions and show a beneficial influence on patient flow and resource management as well as on the communication culture. The continuation of closer interdisciplinary and cross-sectoral co-operation in a “new clinical routine” could have a positive impact on personnel concepts, communication strategies, and the management of acute care capacities and patient pathways.Design/methodology/approachThe aim of the paper is to critically discuss the knowledge gained in the context of the COVID-19 pandemic from the various approaches in patient flow and capacity management as well as interdisciplinary co-operation. More recent research has evaluated patient pathway management, personnel planning and communication measures with regard to their effect and practicability for continuation in everyday clinical practice.FindingsPatient flows and acute care capacities can be more efficiently managed by continuing a culture change towards closer interdisciplinary and intersectoral co-operation and technologies that support this with telemedicine functionalities and regional healthcare data interoperability. Together with a bi-directional, more frequent and open communication and feedback culture, it could form a “new clinical routine”.Originality/valueThis paper discusses a holistic approach on the way away from silo thinking towards cross-departmental collaboration.

Nurse coordinator roles in the management of patients with hepatocellular carcinoma: A French national survey

Hepatocellular carcinoma (HCC) mostly occurs in patients with chronic liver disease (CLD). HCC treatment may have a direct impact on CLD prognosis. HCC management can therefore become complex, involving multiple health care providers, such as oncologists, hepatologists, radiologists, and surgeons. In France, dedicated nurses have been involved in patient care pathways. Their impact is poorly documented. PurposeTo determine the country-wide distribution of HCC nurse coordinators in French health care settings and to describe their roles and responsibilities. Patients and methodsA survey using a multi-item questionnaire (including center characteristics, nurse coordinator characteristics, and quality indicators such as patient care pathway initiation timeline, scheduled length of hospital stay, diagnostic disclosure process) was conducted. All French liver cancer centers planning to participate in a prospective national cohort study for patients with HCC (CHIEF Cohort) were invited to take part in the survey. Bivariate analysis compared centers with a nurse coordinator to those without. ResultsAmong the 42 of 72 centers that replied, 14 treated fewer than 75 HCC patients. Treatment mostly took place in hepatology units (34/42). Sixteen nurse coordinators were part of the health care team in 13 of the 42 centers. Among these 13 centers, 11 were university hospitals and 11 followed more than 75 patients per year. The median number of patients followed in these centers was 300 (min–max 44–600) in 2017. All nurse coordinators were involved in providing patient information and counseling. Other roles included treatment monitoring (13/16), care coordination (12/16), psychological support (12/16) and treatment planning (11/16). Thirteen nurse coordinators conducted diagnostic disclosure nurse consultations; seven conducted initial patient contact consultations; and six held outpatient nurse consultations, with wide heterogeneity between centers. The presence of a nurse coordinator was associated with completion of the full diagnostic disclosure process (p = 0.045). ConclusionIn France, nurse coordinators for HCC patient pathway management are present mainly in university hepatology units with a caseload of more than 75 patients per year. All provide patient information and counseling but their roles in care coordination, patient support and holistic assessment are heterogeneous and not standardized.

Sharing primary percutaneous coronary intervention care: first experiences with South Limburg ST-elevation myocardial infarction network.

BackgroundIn the region of South Limburg, the Netherlands, a shared ST-elevation myocardial infarction (STEMI) networking system (SLIM network) was implemented. During out-of-office hours, two percutaneous coronary intervention (PCI) centres—Maastricht University Medical Centre and Zuyderland Medical Centre—are supported by the same interventional cardiologist. The aim of this study was to analyse performance indicators within this network and to compare them with contemporary European Society of Cardiology guidelines.MethodsKey time indicators for an all-comer STEMI population were registered by the emergency medical service and the PCI centres. The time measurements showed a non-Gaussian distribution; they are presented as median with 25th and 75th percentiles.ResultsBetween 1 February 2018 and 31 March 2019, a total of 570 STEMI patients were admitted to the participating centres. The total system delay (from emergency call to needle time) was 65 min (53–77), with a prehospital system delay of 40 min (34–47) and a door-to-needle time of 22 min (15–34). Compared with in-office hours, out-of-office hours significantly lengthened system delays (55 (47–66) vs 70 min (62–81), p < 0.001), emergency medical service transport times (29 (24–34) vs 35 min (29–40), p < 0.001) and door-to-needle times (17 (14–26) vs 26 min (18–37), p < 0.001).ConclusionsWith its effective patient pathway management, the SLIM network was able to meet the quality criteria set by contemporary European revascularisation guidelines.

Implementation of palliative care consult Service in Hungary \u2013 integration barriers and facilitators

BackgroundThe Palliative Care Consult Service (PCCS) programme was among the first initiations in Hungary to provide palliative care for patients admitted to hospital. The PCCS team provides palliative care for mainly cancer patients and their family members and manages the patient pathway after being discharged from the hospital. The service started in 2014 with 300–400 patient visits per year. The aim of this study is to give a comprehensive overview of the PCCS programme guided by a conceptual framework designed by SELFIE (“Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE”), a Horizon2020 funded EU project and to identify the facilitators and barriers to its wider implementation.MethodsPCCS has been selected by the SELFIE consortium for in-depth evaluation as one of the Hungarian integrated care models for persons with multi-morbidity. The qualitative analysis of the PCCS programme was based on available documents of the care provider and interviews with different stakeholders related to the programme.ResultsThe integrated, multidisciplinary and patient-centred approach was well-received among the patients, family members and clinical departments, as verified by the increasing number of requests for consultations. As a result of the patient pathway management across providers (e.g. from inpatient care to homecare) a higher level of coordination could be achieved in the continuity of care for seriously-ill patients. The regulatory framework has only partially been established, policies to integrate care across organizations and sectors and adequate financial mechanism to support the enhancement and sustainability of the PCCS are still missing.ConclusionsThe service integration of palliative care could be implemented successfully in an academic hospital in Hungary. However, the continuation and enhancement of the programme will require further evidence on the performance of the integrated model of palliative care and a more systematic approach particularly regarding the evaluation, financing and implementation process.

Concept Mapping in developing an indicator framework for coordinated health care

Abstract There are increasing calls for improvement of the coordination of health care services, especially the ones provided to chronically ill patients. Coordinated health care requires a different approach to quality indicators than the one adopted in fragmented health care delivery. Therefore, the objective of this study was to develop an indicator framework that will fit the coordinated health care setting. Concept Mapping was used to cluster the items representing care coordination, position them on a map and analyse their contents. Multidimensional scaling was applied to develop a framework. The elements of coordinated care had been previously identified based on a review of literature. They served as an input to a Delphi procedure applied in the subsequent stage of the research. There were 95 elements identified and grouped into nine clusters. The clusters were labelled as “Organisation of health care delivery”, “Patient support”, “Support for clinical decisions”, “Information integration”, “Focus on the patient”, “Patient pathway management”, “Cross-sectoral cooperation”, “Coordination of activities”, and “Soft elements”. The proposed indicator framework is based on the health care system experts’ perspective and is believed to be suitable for managing quality in coordinated health care practice. The findings suggest that Concept Mapping is a perfect way for generating indicator frameworks.

P2.08-003 An Audit of Concurrent Chemoradiotherapy for Non-Small Cell Lung Cancer at the Leeds Cancer Centre (LCC)

Concurrent chemoradiotherapy is the standard non-surgical management of locally advanced NSCLC. Radiation pneumonitis is a well-recognized complication of lung radiotherapy. This retrospective study examines the clinical outcomes and treatment toxicities of patients treated with chemoradiotherapy (CRT) for NSCLC in 2014 at the LCC in UK. Data was retrospectively collected from patients with locally advanced NSCLC treated with concurrent CRT from 1/1/14-31/12/14 at LCC. Patients received 3-D conformal radiotherapy to a dose of 60-66Gy/30-33# over 6-6.5 weeks. Individual patient’s clinical data was reviewed on Patient Pathway Manager for tumor and patient demographics. Radiotherapy dosimetric data were studied with V20, mean lung dose (MLD) and PTV volume. Treatment associated hematological toxicities and radiation pneumonitis were analyzed. Overall and progression free survival were calculated. In addition, correlations between clinical/dosimetry parameter and clinical diagnosis of radiation pneumonitis were analyzed. 58 patients were included in the study. Median follow up was 18.6 months. 66% of patients received weekly carboplatin/paclitaxel and the rest received 3 weekly cisplatin or carboplatin with etoposide. 78% of patients completed both chemotherapy and radiotherapy. For all radiotherapy plans, median V20 was 20.9Gy (range 3.4-29.8Gy), median MLD was 12.8Gy (range 2.3-16.5Gy) and median PTV was 395cc (range 73-819cc). 34% of patients developed grade 3-4 neutropenia, 64% grade 3-4 lymphopenia and 5% grade 3-4 thrombocytopenia. Neutropenic sepsis occurred in 10% of patients with one grade 5 toxicity. Radiation pneumonitis was diagnosed in 17% of patients, all below grade 3. Median time to pneumonitis was 133 days post radiotherapy. Radiation pneumonitis correlated strongly with V20(r = 0.93). Correlations with MLD and PTV were less. There were no correlations with neutropenia, lymphopenia or thrombocytopenia during treatment. 2/3 of the recurrences were distant metastases. 90 day mortality was 5% (three patients died from oesophageal perforation, colitis and pneumonia). The median progression free survival was 20.1 months. The median overall survival was not reached. At the LCC, chemoradiotherapy has been a safe and effective treatment for locally advanced lung cancer. Consistent with existing evidence, V20 remains the most powerful predictor of radiation pneumonitis following lung radiotherapy.

PTH-297 Does height of the rectal cancer impact on the use of neo-adjuvant therapy and ultimate oncological outcomes?: Abstract PTH-297 Table 1

Introduction The impact of the height of rectal cancer from the anal verge and its ultimate clinical significance is controversial 1 (as debated by Tekkis et al in their published paper). The aim of this study is to assess the influence of rectal cancer height and oncological outcomes treated in a specialised colorectal cancer unit. Method Prospectively collected data on a patient pathway manager (PPM) for patients who underwent primary rectal cancer treatment at our unit from January 2005 till December 2010 were analysed. Low cancer was defined as tumour 2 test was used for statistical analysis. Results There were 226 male and 133 female patients with mean age of 70 years (Range: 21–93). Of the 359 rectal cancer patients, 149 (41.5%) had low and 210 (58.5%) had medium/high cancer. Outcome data of tumour height, neo-adjuvant therapy, CRM status, type and mode of surgery and disease relapse is tabulated in Table 1. Conclusion Height of rectal cancer does influence use of neo-adjuvant therapy and ultimate R0 resection rate. It does not influence loco-regional or systemic recurrent rates. Disclosure of interest None Declared. Reference Bhangu A, Rasheed S, Tekkis P, et al . Does rectal cancer height influence the oncological outcome? Colorectal Dis. 2014;16:801808

A quality management model for integrated healthcare in Poland

The objective of this paper is to identify the indicators of a quality management model for integrated healthcare settings in Poland. In order to elicit the items and clusters of quality management, a three–step methodology has been applied: a literature review, a Delphi study, and concept mapping. The literature study resulted in 91 elements of integrated care. The two Delphi rounds were carried out in order to determine the importance of the identified items. Finally, the concept mapping was used to cluster the elements. Hierarchical cluster analysis and multi–dimensional statistical analysis were applied to design the quality management model. We received nine clusters that were labelled by the expert panel. The identified items and clusters focus on patient pathway management, patient centeredness, inter–organisational and inter–sectoral cooperation. The developed model could serve evaluation and improvement purposes in integrated healthcare settings not only in Poland, but in all countries that face healthcare reforms.

Validation of g-8 screening tool for comprehensive geriatric assessment &amp; post-operative delirium in gynecological cancer patients undergoing robotic surgery

those that had received inpatient chemotherapy at St James' Institute of Oncology in Leeds from January 2010 until February 2013. Details regarding cancer diagnosis, treatment, comorbidities and medication use were obtained from the local prospective electronic database Patient Pathway Manager (PPM) and the hospital discharge database Bluespier. Results: A total of 99 patients were identified, with a median age of 78 years. The most common types of cancer observed were colorectal (34%) and upper gastrointestinal (22%). Sixteen patients had no pre-existing comorbidities. Forty four patients had one or two comorbid conditions, and 39 patients had three or more. The intent of treatment was curative in 34% of patients, and non-curative in 65%. At diagnosis, 35% of patients were taking aspirin, 31% were taking a statin and 21% were taking warfarin. Fifty two patients had information regarding medication use at 6 months after diagnosis (53%). Forty seven (90%) of these had no changes made to their medications after diagnosis. Nine patients (17%) were taking warfarin for atrial fibrillation or valve replacement, with only one patient receiving potentially curative treatment. Seven patients (78%) continued to take warfarin, and there was no documentation of discussion with their clinician regarding the appropriateness of anticoagulation. Of the 21 patients taking aspirin at diagnosis, 17 patients (81%) were taking aspirin six months after diagnosis. Thirteen patients (76%) that continued to take aspirin were receiving non-curative treatment. Twenty six patients were taking a statin at diagnosis, and 17 patients (65%) continued to take this after six months. Fifteen of these (88%) were receiving treatment with non-curative intent. No patient had a documented medication review in the oncology clinic. Conclusion: Older cancer patients frequently present with comorbid conditions at the time of diagnosis. A significant proportion of patients in this study were prescribed medications for secondary prevention at the time of cancer diagnosis that were not subsequently reviewed in the oncology clinic. Many of these patients were receiving non-curative treatment. Review of concomitant medications should be carried out by oncologists as part of a comprehensive geriatric assessment prior to treatment decision making. Discontinuation of non-essential medications should be considered in those patients likely to have a short life-expectancy. Disclosure of Interest: None declared.

PMM.03 The management of patients with primary immune thrombocytopenia during pregnancy in Leeds

Introduction and objectivesPrimary immune thrombocytopenia (ITP) is a rare autoimmune condition that affects women of child bearing age and accounts for around 3% of thrombocytopenias at delivery.1 It can lead...

PTH-160 Straight to test Colonoscopies for Suspected Colorectal Malignancy- 5 Year Followup of Patients with Normal Colonoscopies who were Discharged back to GP

IntroductionStraight To Test (STT)services has been adopted by hospitals throughout the UK to improve the efficiency of pathways for early cancer diagnosis. Our previous results suggest that STT colonoscopies for...

Sunitinib-associated hypothyroidism in patients with metastatic renal cell carcinoma.

443 Background: Sunitinib (sun) treatment for patients (pts) with metastatic renal cancer (mRCC) can often lead to fatigue. The incidence of sun-induced hypothyroidism (HT) in the phase III pivotal study of pts with mRCC was 14% for all grades and 2% for grades 3-4. Subsequent retrospective and prospective studies described incidences of between 30–85%. Elevated TSH alone may be seen in up to 85% of mRCC pts treated with sun. Symptoms of HT, eg: fatigue, constipation, cold intolerance, hair thinning, and dry skin have been reported in the majority of sun-treated pts. Methods: We reviewed of all cases of mRCC pts initiating sun treatment between January 2008 and December 2009 using the electronic record system Patient Pathway Manager. Pts with underlying HT, abnormal TFTs at baseline or those on sun for less than two cycles were excluded. TFTs were performed at baseline and then day 1 of every two cycles. Response was assessed every 2-3 cycles. The aims of the study were to Identify rate of sun-induced HT in St James’s Institute of Oncology and determine whether there is a correlation between HT and disease response. Results: 84 pts were included (median age 62 years). 90% had good or intermediate prognosis disease by Memorial Sloane-Kettering Cancer Centre (MSKCC) criteria. 52 pts had TSH &lt;6mU/L and 32 had TSH of &gt;6mU/L. Progression-free survival was significantly longer in those pts with TSH of &gt;6mU/L (29.6 months) compared to those with TSH &lt;6mU/L (11.3 months). Conclusions: Sun-induced HT occurred in approximately 30% of pts and predicted for improved progression-free survival. Further studies are needed to characterise this and updated data will be presented.

1549PD - Treating Diabetic Patients with Chemotherapy: Single Centre Experience of Toxicity and Outcomes

ABSTRACT Background Diabetes is a common comorbidity in cancer patients, and is associated with poorer survival in colorectal cancer (CRC). However, there is little data to describe the experience of diabetic patients during chemotherapy. We have compared a diabetic population of cancer patients with matched controls receiving chemotherapy in a single centre. Methods We performed a retrospective case note analysis using an electronic patient record database (Patient Pathway Manager) and chemotherapy prescription software (ChemoCare) between 2001 and 2011. Diabetic patients starting first line chemotherapy for advanced CRC and advanced gynaecological cancers (GC) were identified. For each case a non-diabetic control was selected, matched for age ( Results 146 diabetic patients and 146 matched controls were included. Median age was 67 years; 95% of diabetic patients had type 2 diabetes, 18.5% were receiving insulin. Performance status was similar (diabetic 66% PS0-1, 29% PS2-3; non-diabetic 64% PS0-1, 34% PS2-3); more diabetic patients had comorbidity (60% vs 45%). A non-significant difference was observed in dose reductions (upfront 31.5% vs 23.9% p = 0.15; on-treatment 23.3 vs 13.7% p = 0.35). Only 5% of diabetic patients had upfront steroid reduction. Diabetes was independently associated with an increased risk of acute admission (OR = 3.32, 95%CI 1.8-5.8, p Conclusions Diabetic patients experienced more acute complications on chemotherapy possibly limiting further treatment options. A prospective study would clarify the contributing factors and inform planning and monitoring of diabetic patients with cancer. Disclosure All authors have declared no conflicts of interest.

PWE-222 Audit of upper GI cancer diagnosis by endoscopy: are diagnoses being missed?

IntroductionGastric and oesophageal cancers have a high mortality rate, particularly if diagnosed at a late stage. We aimed to determine whether Upper Gastrointestinal (UGI) cancers are being missed either endoscopically...

The development of a SPA pilot for specialist palliative and end of life care referrals

The development of a single point of access (SPA) provides a quality driven (1), efficient system for ensuring that all referrals into the services are managed in a timely and...