Case study: Guy’s and St Thomas’ Hospital

Evidence-based treat to target

  • - £1million estimated savings per year from a 7% reduction in biologic use

  • - Treat to target patients are nearly six times more likely to reach disease remission compared to routine care

The implementation of treat to target and introduction of an electronic database at Guy’s and St Thomas’ Hospital has resulted in good evidence for improved patient outcomes compared to routine care. Fewer patients have required biologic therapy, through secondary prevention of disease progression, saving an estimated £1 million per year.

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The challenge

  • - Guy’s and St Thomas’ wished to improve outcomes in rheumatoid arthritis (RA) patients, with both early and established disease, and instigated a review of the literature and guidelines to help redesign their service in 2004. This resulted in the establishment of the RA Centre at Guy’s and St Thomas’

The solution

  • - The focus of the RA centre is to provide evidence-based treat to target therapy: all RA patients who are not in disease remission, however long they have had the disease, undergo monthly monitoring and intensive step-up combination therapy accelerations
  • - The service is based on the literature and is aligned with NICE guidelines and the EULAR 2010 recommendations on treat to target
  • - The RA centre incorporates an early RA clinic, which aims to see patients rapidly after first referral and starts patients on treat to target management as quickly as possible
  • - Diagnosis and difficult treatment decisions are informed by the routine use of ultrasound
  • - Guy’s and St Thomas’ RA centre focuses the time of the nurse specialist to activities where their skills can make the most impact, to avoid them performing jobs where other healthcare professionals could substitute. This includes running the intensive therapy escalation clinics with a major emphasis on patient education, running a pre-pregnancy clinic and acting as the care coordinator
  • - The RA centre places an emphasis on routine data monitoring for continuous quality improvement. This has led to the installation of an electronic database system and employment of a data manager
  • - Guy’s and St Thomas’ provides a cost-effective service, where multi-disciplinary team functions can be accessed on site at the hospital as needed

Service performance and outcomes

  • - The proportion of patients in remission or low disease activity increased over a period of three years
  • - Significantly more treat to target patients achieved disease remission compared to routine care patients, and were found to be 5.7 times more likely to reach remission. As disease remission is the key treatment goal in RA, this shows the value of this service in meeting national and international recommendations for management of RA
  • - The number of treat to target patients who changed treatment when not reaching the target of remission has increased over time. This change, which is likely to have driven the improved patient outcomes, is thought to be due to better education from the nurse specialist, as the change coincided with the introduction of specialist nurse clinics in 2006

Financial performance and outcomes

  • - It is estimated that the improved patient outcomes associated with the treat to target pathway at Guy’s and St Thomas’ reduces the need for two specialist nurse visits per patient per year. This equates to an annual saving of approximately £230,360 across all patients
  • - Guy’s and St Thomas’ treat to target pathway was found to have a lower used of biologics (13%) compared to routine care (20%) (2008 figures). This is associated with an estimated saving to commissioners of £1,118,412 per year

Integration with primary care

  • - The RA Centre works closely with primary care to ensure rapid and accurate referrals from GPs. A referral form was developed that can be accessed by GPs on the trust website and a close relationship with local commissioners continues with regular meetings every two months

Commissioning priorities

The Guy’s and St Thomas’ evidence-based, treat to target has excellent evidence of improved patient outcomes and the potential for substantial cost savings. It meets a number of the priorities for commissioners as outlined by the King’s Fund in 2013:
  • - Secondary prevention – treat to target management slows disease progression
  • - 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
  • - Care co-ordination and active support for self-management – due to the focus of the nurse specialist on patient education and case co-ordination
  • - Medicines management – improved long term patient outcomes from the treat to target approach reduced the biologic use compared to routine care
  • - Managing ambulatory conditions – an integrated approach to urgent and managed care, has led to an estimated reduction of two specialist nurse visits a year per patient
  • - Improving referral quality – the close relationship with commissioners and the use of the GP referral form help improve the quality and speed of referrals

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.