Southend University Hospital NHS Trust

Preventing blindness by fast-tracking suspect Giant Cell Arteritis patients to immediate treatment


Summary

The fast-track pathway (FTP) at the Southend University Hospital NHS Trust has significantly reduced the number of patients suffering sight-loss as an avoidable complication of giant cell arteritis (GCA). Furthermore, the service is cost-saving, results in an increased patient quality of life, and successfully reduces the time to diagnosis in line with established clinical guidelines.
  • Proportion of patients suffering from sight loss dropped significantly from 37% to 9% when the FTP was introduced 
  • 79% of patients ultimately diagnosed with GCA seen within one working day 
  • An average cost-saving of £400 per patient is realised with the FTP
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The Challenge

  • Giant cell arteritis (GCA) is one of the most common types of vasculitis and can result in irreversible sight loss in up to 25% of cases. 1 Sight loss can manifest over the course of only a few days, therefore the prompt treatment and referral of suspected cases are essential to prevent such debilitating complications from occurring.
  • However, there are significant barriers to realising fast and effective treatment of GCA in clinical practice due to delayed referrals (resulting from a failure to recognise symptoms or to understand the urgency of making the referral itself) and confusion around the many referral routes available.

The Solution

  • Southend University Hospital NHS Trust have developed and pioneered a Fast-Track Pathway (FTP) to ensure a rapid specialist review and initiation of treatment for suspected GCA cases, and to improve public and professional awareness of GCA.
  • This is well-aligned with BSR GCA guidelines which highlight the importance of prompt assessment, to not only secure the diagnosis, but also to prevent unnecessary long term treatment.2

Service Pathway

  • The FTP is focused on primary care and Accident & Emergency (A&E) as these are the services that regularly receive GCA referrals.
  • Patients with features of GCA without ischaemic symptoms: referrer starts high-dose steroids and contacts the rheumatology team for review in the GCA clinic within one working day. Diagnostic tests typically follow within one week.
  • Patients with features of GCA and ischaemic symptoms: referred to A&E for assessment, receiving advice from both Ophthalmology and Rheumatology specialties. After exclusion of other serious pathology, the patient receives steroidal treatment followed by further diagnostic tests. All patients are then reviewed two weeks following initial assessment.
  • To improve awareness, the FTP is publicised to GPs with reminders every 3 months through regular ‘time-to-learn’ sessions, and to patients via newsletters, meetings and advice lines run by the PMRGCAuk charities.

Service Performance and Outcomes

  • On introduction of the FTP, the proportion of patients suffering from sight loss dropped significantly from 37% to 9% when compared with the conventional pathway.
  • A reduction in the time from referral to rheumatology review was likely a major driving force behind the improved clinical outcomes observed, with 79% of patients ultimately diagnosed with GCA seen within one working day.
  • Patients referred using the FTP were diagnosed 2–3 days sooner than those in the conventional pathway, limiting exposure to precautionary high-dose steroids associated with debilitating side-effects.

Financial Performance and Outcomes

  • Implementation of the FTP was associated with cost-savings to the Trust, with a reduction in the average overall cost of diagnosing and treating a patient with suspected GCA from £2,600 to £2,200 per patient.
  • In a cost-effectiveness analysis to compare the FTP with the conventional pathway, patients gained on average 2.6 quality-adjusted life years (QALYs) by avoiding the complication of sight loss. This, coupled with the reduced financial impact, resulted in FTP dominating the conventional pathway (-£840 per QALY).

Patient Focus and Satisfaction

  • Clearly defined referral pathways and well-coordinated teams ensure that care is patient-centred.
  • Public education initiatives have been undertaken to improve awareness including through PMRGCAuk, Fight for Sight and ARMA.

Commissioning Implications

The Southend University Hospital NHS Trust is an example of commissioning best practice in rheumatology and meets a number of priorities for commissioners, clinicians and patients:

 

  • Secondary prevention – the FTP demonstrates a significant improvement in the number of patients who suffer sight-loss as a result of an avoidable complication of GCA.
  • Care co-ordination through integrated health and social care teams – improved communications between primary and secondary care ensure patients are referred quickly and appropriately.
  • Effective medicines management – through timely referral and diagnosis, patients avoid unnecessary side-effects of high-dose steroids.
  • Managing urgent and emergency activity – through working closely with GPs and committing to advancing the education around GCA, referrals into secondary care are more streamlined and appropriate.

This service is an outstanding best practice model for the diagnosis and treatment of patients with suspected GCA. Implementation of the FTP has demonstrated that outcomes can be improved while reducing costs and adhering to clinical guidelines.


Service diagram