Case study - Aintree University Hospital

Treat to target within existing resources

  • - £600k estimated saving  per year from  reduced need for  biologic therapy 
  • - 0% patients seen within three months of symptom onset before the Early Arthritis Clinic
  • - 46% patients now seen within three months of symptom onset

The Aintree treat to target service demonstrates that it is possible to redesign a service within existing NHS resources in order to achieve optimal patient care. At no additional cost, Aintree have implemented best practice treat to target management of rheumatoid arthritis patients, which could lead to an annual saving of £600k from the reduced use of high-cost biologic drugs.

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The challenge

  • - From a clinical audit in 2005, Aintree Hospital recorded sub-optimal results for achievement of quality indicators such as time from referral to first visit for rheumatoid arthritis (RA) patients
  • - Without impacting the budget, Aintree Hospital wanted to improve their quality of care for newly diagnosed RA patients

The solution

  • - The Early Arthritis Clinic at Aintree was designed to see patients with suspected RA within three weeks of referral from their GP and to start diagnosed patients on intensive disease-modifying therapy as soon as possible, within a treat to target framework
  • - The service is based on the literature and is aligned with NICE guidelines and the EULAR 2010 recommendations on treat to target
  • - Access to and use of the multi-disciplinary team is considered crucial in the Aintree Early Arthritis Clinic. On diagnosis, all patients are referred to the occupational therapist and most are referred to the podiatrist. There is also access to physiotherapists and clinical psychologists within the hospital
  • - Patients are ideally seen every four weeks by a specialist nurse to monitor response to therapy (this is achieved for 80% of patients). Treatment escalation is initiated if the patient is not achieving the target of disease remission. Careful medicines management occurs when patients are in sustained remission, as they can have their drug dose de-escalated, which can lower costs while maintaining optimal patient outcomes
  • - Patients are educated and encouraged to self-manage through the use of leaflets about the disease and the service, as well as access to a telephone helpline

Use of technology to guide patient management

  • - Ultrasound measurements are routinely used to help guide clinical decisions. Aintree’s use of ultrasound as a diagnostic, prognostic and monitoring tool is leading the way in the use of technology to guide patient management

Improved patient management

  • - Before the clinic was established in 2005, patients were not seen within three months of symptom onset. This is a critical 'window of opportunity' period during which intensive treatment has a high probability of preventing disease progression and irreversible joint damage
  • - This has now completely changed: of 809 patients referred to the Early Arthritis Clinic between 2006 and 2010, 96 patients had symptom duration of less than three months
  • - Aintree Early Arthritis Clinic has shown that high numbers of patients achieve remission at one year (51%). This is the primary goal for RA patients and translates into prevention of joint damage and avoidance of long-term disability

Financial performance and outcomes

  • - No additional costs: The Aintree Early Arthritis Clinic demonstrates that it is possible to redesign a service within the NHS to achieve optimal patient care despite economic constraints. No additional resource or funding was required to set up the treat to target Early Arthritis Clinic, apart from the purchase of the ultrasound machine, which was funded by a pharmaceutical company
  • - Cost savings: One of the main costs in treating patients with RA is the use of high-cost biologic treatment when patients fail to respond to traditional therapies. It is estimated that the intensive treatment strategy employed by the Aintree Early Arthritis Clinic will prevent 66 patients per year from starting high-cost biologic treatment, which equates to an annual saving of nearly £600,000 per year

Commissioning priorities

The Aintree treat to target model is an excellent example of care optimisation under limited resources. It meets a number of the priorities for commissioners as outlined by the King’s Fund in 2013.
  • - Secondary prevention – the early, intensive treatment strategy used by the one-stop EIA clinic helps to quickly control disease activity and prevent patients’ disease worsening
  • - Improving the management of patients with both mental and physical health needs – the treat to target pathway ensures close management of patients, and those who need it have access on site to occupational therapists, psychologists and physiotherapists
  • - Medicines management – improved long term patient outcomes from the treat to target approach should reduce the requirement for high-cost biologic use
  • - Active support for self-management and care co-ordination – patients are encouraged to self-manage and have access to a care co-ordinator via the telephone hotline

Sponsorship statement

This best practice case study project has been sponsored by UCB and supported by a medical education grant from Pfizer.
UCB and Pfizer have not had any influence over content: editorial control remained with the British Society of Rheumatology.

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We gratefully acknowledge the generous support of our sponsors, which enabled the case study project to take place.