Audit and Practice Survey Posters 303 – 309
303 National cancer diagnosis audit
GPs have a critical role in early diagnosis of cancer through recognition and prompt referral of people with potential cancer symptoms for further testing or specialist consultation. The English National Cancer Strategy recommends an audit, to provide new insights to diagnose cancers earlier and improve outcomes. The audit is a partnership in England involving the Royal College General Practitioners, Cancer Research UK, Macmillan Cancer Support, Public Health England and NHS England. Cancer is an Royal College General Practitioners enduring clinical priority.
This audit will investigate:1. interval length from patient presentation to diagnosis. 2. use of investigations prior to referral. 3. what the referral pathways for patients with cancer are and how they compare with those recorded by the cancer registry. NICE referral guidelines for suspected cancer and National Cancer Strategy standards will be measured. A sustainable programme of clinical audit cycles will be developed to create a comprehensive picture of cancer diagnosis in the UK and allow clinical guideline impact measurement.
Public Health England developed a bespoke online portal which will uniquely give GPs access cancer registry data from patients diagnosed in 2014. GPs input information from first presentation to diagnosis, including: consultations, key dates, investigations, symptoms, referrals and patient characteristics. Uniquely the audit will be reported national and locally at a practice and CCG level.The audit can help identify patients for significant event analysis, highlight challenges/good practice and feedback can help develop improvement plans, influence commissioning decisions and service improvements. The audit demonstrates quality improvement for GP appraisal, revalidation and support CQC inspection.
304 Late Presentation of HIV (Human Immunodeficiency Virus) Infection at a District General Hospital
Background/introduction: A significant proportion of patients (390/6360 (6.1%) in 2012 nationally) present with an AIDS defining illness yearly despite increasing awareness and recognition of HIV. In 2012 the British HIV Association (BHIVA) suggested newly diagnosed patients should commence Anti-Retroviral Therapy (ART) if their CD4 count <350 cells/mm3, they have an AIDS defining illness or a neurological complication.
Aim(s)/objectives: A re-audit was performed following previous audits in 2006/07 and 2011/2012 to ascertain whether late presentation has improved.
Methods: A retrospective study compiled data from case notes of the newly diagnosed between 01/01/2014 and 31/12/2015. Defining late presenters as a CD4 count <350 cells/mm3 or an AIDS defining illness.
Results: 100 patients were identified, 33 were transfers and excluded. 67 remained of which 82.1% were male and 17.9% female. 52.2% were late presenters and 25.4% had an AIDS defining illness of which 9 had PCP, 6 had oesophageal candidiasis, 1 had cryptococcal meningitis and 1 had OHL. Overall 35.8% had a CD4 <200 cells/mm3 (42.9% in 2011/2012 audit) and 68% of the late presenters.
Discussion/conclusion: An improvement was identified in patients presenting with a CD4 count <350 cells/mm3 (52.2%) compared with 2011/12 audit (55.7%). A high proportion continue to present with AIDS defining illnesses or depleted CD4 levels despite growing awareness of HIV and accessibility to health care. Poor prognosis, increasing morbidity and mortality is associated with late presentation. Atypical and opportunistic infections should prompt HIV testing amongst clinicians in both primary and secondary care along with improving patient education and contact tracing to minimise late presentation.
305 Sulphonylureas and Driving – Does Practice Reflect Guidance?
The Driving and Vehicle Licensing Agency (DVLA) have guidance for diabetic patients in regards to driving, which is dependent on the type of medication and licence held. This audit aims to investigate whether General Practitioners are informing patients of DVLA guidance when initiating sulphonylureas and on review. A retrospective primary care audit looking at 45 patient records from 2000-2015 who are currently prescribed sulphonylureas.
This audit found health care professionals were inadequately documenting the information being delivered to patients. Of 45 patients, 69% had their driving status documented and of 42 patients, only 12% had their licence type documented. It was unclear whether 10 patients had ever experienced hypoglycaemic events as there was no documentation. Blood glucose strips were prescribed to 51% of patients on sulphonylureas, and of these 65% were regularly renewing their prescription implying regular testing but it is unclear whether this relates to periods of driving. Sulphonylureas are a common medication used in the treatment of Type 2 Diabetes Mellitus.
A common side effect of sulphonylureas is hypoglycaemia which can lead to impaired consciousness, this is potentially fatal when driving. Therefore it is paramount that guidance set out by the DVLA is implemented.The data collected demonstrates areas for improvement. Recommendations include updating both the pro forma used to initiate and review patients on sulphonylureas to include advice specific to driving and ensuring episodes of hypoglycaemia are asked about and documented. As well as reviewing whether Group 2 licence holders have access to blood glucose monitoring and are actively checking at times related to driving. Blood glucose monitoring for Group 1 licence holders should be assessed on an individual basis.
306 Facilitating access to unscheduled care for patients with learning disability: initial insights from a practice-level audit and stakeholder exercise
Aims/Objectives This mixed-method project explores how, when and why people with learning disabilities access emergency GP appointments and unscheduled care services, and what could be done to better facilitate access to care for this group.
Content of PresentationThe poster combines information from two types of research enquiry. It presents quantitative data from a record search and in-depth notes review of all patients with learning disabilities (n=34) at a medium sized urban general practice. Qualitative data from interviews (n=6) with local professional and lay stakeholders was used to ratify and expand audit findings.
Relevance/Impact The CIPOLD inquiry into premature deaths of people with learning disabilities found significant differences in life expectancy for people with and without learning disabilities. Improved access to urgent / emergency care is one way in which we might narrow this gap.
Outcomes Data from general practice records indicate there may be some difference in use of out-of-hours services between patients in formal care settings compared to those living alone. Data collection continues but initial results suggest the role of the carer is critical as a “gatekeeper” to services. Parents of people with learning disabilities shared important advice on this issue drawing from their own positive and negative prior experiences.
Discussion Further research is needed to determine exactly how people with learning disabilities interact with urgent and emergency services – and how that service use relates to primary care. This exploratory work suggests it may be possible to proactively plan for this group of patients urgent care needs.
307 Monitoring coeliac disease in primary care
Aims See if the practice were compliant with NICE guidelines 2015 on monitoring coeliac patientsObjectives For all coeliac patients:Establish whether they were being monitored annually and whether this included the relevant annual blood testsEstablish whether we were assessing adherence to a gluten-free diet and osteoporotic risk
Content This audit was done to ensure adherence to NICE’s key recommendations and to highlight potential areas for change in practice. Retrospective analysis of all 75 coeliac patients in a large county practice to see how many were under ongoing follow up, who they were followed up by and whether they were undergoing regular blood tests. Also looked at how patients who DNAed their hospital appointments were followed up.
Relevance According to charity, ‘Coeliac UK’, only 24% of patients with coeliac disease are diagnosed with few patients having regular reviews in primary care.
Outcomes Only 21 out of 75 coeliac patients were under ongoing follow up and out of those 21 patients, only 24% were being seen by a GP. 8 out of 75 coeliac patients had DNAed dietician appointments and were ‘discharged back to the GP’ for monitoring but only 1 out of these 8 ever had any subsequent GP follow up.
Discussion This audit lead to the creation of a ‘Coeliac Disease’ template on SystemOne and the start of an annual recall for all coeliac patients. We plan to re-audit in a year.
308 Patient survey assessing holistic needs of patients during urgent referral process for suspected cancer
Shehrazed Amira Lounis
Introduction Patients on urgent cancer referrals have seen improvements by way of prompt management initiated within national 2 week wait guidance. Support and information giving is an integral aspect of guidelines. Whilst extensive research has focused on clinical success of urgent referrals, the holistic needs and difficulties faced by patients have not been assessed. The majority of patients in the ‘2 week wait’ pathway are non-cancer. In this context, provision of information and support is a central element of care.
Objective To assess whether national guidelines for support and information needs of patients with suspected cancer are being met.
Method All patients urgently referred to gynaecology and urology were offered surveys. This included grading of 24 statements based on guidelines, assessing support needs of patients in both primary and secondary care.
Results 117 surveys were collected. 67.2% and 93.3% of patients in primary and secondary care, respectively, agreed with the statements, indicating the majority of their needs had been met. However, at the time of referral: 31.4% disagreed their GP had reassured them most referrals were found not to be malignant; 34% disagreed the referral had been discussed with them; 59% disagreed they had been explained how to seek further information; 46% felt the needs of their family were not considered.
Conclusion Results showed significant lack of holistic support for all patients. Time constraints in primary care is one reason to explain this. Suggestions for improvement include focused consultation checklists to be used at the time of referral, and improved leaflets addressing specific patient concerns.
309 The appropriate use of anticoagulation in patients with non-valvular Atrial Fibrillation in a primary care setting
Atrial Fibrillation (AF) has an incidence of 1% in the UK and is the commonest sustained cardiac arrhythmia. 20% of Cerebrovascular Accidents (CVAs) are caused by AF and effective anticoagulation (AC) reduces CVA incidence by 67%. This suggests that 6-7000 CVAs per year could be prevented by effective AC (including Warfarin with therapeutic INR and New Oral Anticoagulants (NOAC) In the UK, in 2014, of all patients admitted to hospital with CVA and AF, 60% were on non-therapeutic or no AC. As the majority of AF management is performed in primary care, I decided to audit a large suburban UK Primary Care Centre in order to analyse the number of patients with read codes of AF but were not taking effective AC.
I studied the GP records of these patients, performed CHA2DS2-VASc and HAS-BLED assessments and looked for evidence of previous discussions regarding AC.11.1% of the patients studied had incorrect read codes, 22.2% had low CHA2DS2-VASc and therefore required no AC, 11.1% had high CHA2DS2-VASc and high HAS-BLED scores (guidelines recommend that modifiable risk factors for bleeding should be addressed), but 41.7% of patients had high CHA2DS2-VASc scores and low HAS-BLED scores suggesting that AC should be considered.
This audit highlighted the sub-optimal management of AF in the community, I speculated on the reasons for this and made recommendations to the partners of the Practice. To complete the audit cycle, the process will be repeated prior to conference to assess whether changes have been implemented and the statistics improved.