Whipps Cross University Hospital

Streamlining diagnosis and access to treatment for people with inflammatory back pain


Summary

The Early Inflammatory Back Pain Service (EIBPS) at Whipps Cross has improved referral quality and reduced the delay to diagnosis for axial spondyloarthritis (axSpA). A specialist physiotherapist co-ordinates all elements of care and this model has led to high patient satisfaction. A suite of educational materials have been produced, which could be employed elsewhere in the country to raise awareness of inflammatory back pain in the community and primary care.
  • 100% of patients rated the service as ‘Good’ to ‘Outstanding’ 
  • Reduced the time to diagnosis by 64% compared with UK general rheumatology clinics 
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The Challenge

  • 60-80% of adults report lower back pain at some point in their life and approximately 6-9% of UK adults consult their GP about lower back pain each year. Axial spondyloarthritis (axSpA) is a rare but treatable cause of this very common complaint, and therefore it is essential that GPs are able to identify the signs of inflammatory back pain (IBP; the primary symptom of axSpA), as opposed to mechanical back pain. However, there is often a lack of awareness of this condition in primary care and among other health professionals.
  • Effective biologic treatments became available for axSpA around 2010, and therefore it became important to identify and treat patients suffering needlessly.

The Solution

  • The Early Inflammatory Back Pain Service (EIBPS) at Whipps Cross Hospital was established in 2010 to provide a dedicated clinic for patients referred with IBP.
  • The clinic is led by a specialist physiotherapist with a good knowledge of axSpA. The physiotherapist also acts as the care co-ordinator, so patients have their telephone number and the physiotherapist can then liaise with the consultant and multi-disciplinary team (MDT) to decide on appropriate management.
  • Patients are diagnosed, assessed and then treated appropriately, with biologics and physiotherapy where necessary.
  • There is also educational campaign (‘Back on Track’) to raise awareness of IBP and axSpA in the community, GP surgeries, allied healthcare professionals and secondary care colleagues. A suite of promotional and training materials have been developed, which could be used elsewhere.

Service Performance and Outcomes

  • The average delay between onset of back pain and diagnosis of axSpA in the UK is 8.6 years, whereas in the EIBPS at Whipps Cross it is 3.1 years. The EIBPS has therefore reduced the time to diagnosis by 64% compared with UK general rheumatology clinics.
  • This decrease in delay of diagnosis is likely to have had substantial positive benefits in terms of clinical patient outcomes.
  • The number of new axSpA diagnoses made by the EIBPS now far exceeds those made by other rheumatology clinics at Whipps Cross, and those made in 2009 before the EIBPS was established. This indicates that the EIBPS has been effective in increasing the number of axSpA diagnoses, which has allowed more patients to access the treatment that they require.

Financial Performance and Outcomes

  • The additional cost of the EIBPS to the Whipps Cross rheumatology department was a specialist physiotherapist for 2 days per week, at £22,000 per year.
  • It is expected that better management of IBP, and specifically axSpA, would reduce a great deal of resource use elsewhere in the healthcare system. Research has shown that better outcomes lead to reduced resource use.

Patient Focus and Satisfaction

  • The service focuses on patient education as well as treatment. A patient booklet has been developed and there is an app in development.
  • In a survey of EIBPS patients:
    • 100% said they would rate the service as ‘Good’, ‘Very Good’, ‘Excellent’ or ‘Outstanding’
    • 91% of patients would definitely recommend the service to family or friends

Commissioning Priorities


The Whipps Cross EIBPS and education programme is an example of commissioning best practice in rheumatology and meets a number of priorities for commissioners, clinicians and patients:

 

  • Improving referral quality – the GP and patient education programme has helped to increase the awareness of IBP in the community and improved referral quality
  • Care co-ordination – the specialist physiotherapist acts as the care co-ordinator, liaising with the patient through clinics and over the phone, as well as with clinicians
  • Putting patients first – Whipps Cross has developed a suite of materials aimed at educating the patient and places the patient at the centre of the service, leading to high patient satisfaction rates
  • Secondary prevention – the EIBPS aims to detect the early stages of disease and intervenes before the disease progresses too far

The service is an emerging best practice model for the diagnosis and treatment of axSpA.


Service diagram