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Delivering
improvements
in diagnostic services
31st March 2010
Survive
and
Thrive
Direct primary care access to imaging
• Plain films, ultrasound, bariums
• CT – CT brain
– All CT
• MRI – MRI lumbar spine
Aim of direct access
• Improve patient pathways
• Improve patient experience
• Enhance doctor-patient relationship
• Reduce whole journey waiting times
“ There is still a lingering perception
among patients that their journey
remains littered with barriers, pitfalls,
duplication and delay”.
Kerr Report, 2005
Imaging in patient journey
• Imaging is one part of the journey
• Imaging interfaces with other steps
• Redesigning interface processes can
improve the whole patient journey
Effect of access restrictions
Consultation in primary care
Referral to secondary care
Imaging arranged
Review in secondary care
Primary care ongoing management
Effect of access restrictions
Consultation in primary care
Referral to secondary care
Imaging arranged
Review in secondary care
Primary care ongoing management
Effect of opening access
Consultation in primary care
Imaging arranged
Primary care ongoing management
Referral should be based on
clinical criteria
not
referral source
Process to open direct access
to CT and MRI
• Context of formalising co-operative
radiology/primary care working in 2004
• Established regular radiology and
primary care meetings
Radiology/primary care liaison group
• CHP leads, GP sub-committee secretary,
GP care fellow
• Radiology clinical and managerial staff
• Developed open team culture- honest- supportive- challenging
CT brain direct access pilot
• Referral criteria agreed for chronic headache
• Educational events arranged
• Information packs distributed
• Pilot from April 2005 – April 2006
Chronic headache
• Commonest GP referral to neurology
• 4.4 consultations per 100 patients per
year
• 18,700 headache consultations in
Tayside per year
Outcome from 1 year CT brain direct access pilot
• 82% of practices referred
• 45% of individual GPs referred
• 215 patients had CT brain scans
• 1.2% referral rate from headache
consultations
Questionnaires returned from
189 referralsInitial Outcome
• 88% of scans stopped a secondary care referral
Longer term (1-2 years post-scan)
• 18 (8%) from 215 patients were referred to
neurology
Effect of access restrictions
Consultation in primary care
Referral to secondary care
Imaging arranged
Review in secondary care
Primary care ongoing management
Conclusion from CT brain direct access pilot
• Good primary care utilisation
• Adherence to referral guidance
• Improved patient pathway
• 88% of scans stopped secondary care referral
Adopted into routine practice in 2006
Process to open access to all CT
Referral criteria agreed during 2006
Patients with a non-acute condition
that CT may assist in diagnosing with
CT being indicated on currently accepted
Royal College of Radiologists imaging
guidance
Primary care direct access to all CT
• Educational events arranged
• Information packs distributed
• Pilot started February 2007
• First 6 months – 28 non brain referrals
Adopted into routine practice in 2007
CT referrals in 2009
Total CT – 23,272 referrals
GP CT – 1,375 (6%) referrals
Process to open direct access to MRI
• Discussions at radiology/primary care
liaison group
• Agreed to consider MRI lumbar spine pilot
• Orthopaedic and neurosurgery input
Referral criteria agreedIndications
• Sciatica
• Spinal claudication
• Developing motor deficit
– simultaneous clinical and MRI referral
Exclusions
• acute cauda equina syndrome
• mechanical back pain
Implementation process
• Educational event, EPASS accredited
• Referral criteria and flowchart sent to practices
• Advice to radiologists on reporting format
• Questionnaires sent to referrer with report
Data from 6 months pilot
April to September 2009
on primary care direct access
to lumbar spine MRI
179 Referrals
• Number of GPs referring 107
- 107/309 GPs (35%)
• Number of practices referring 59
- 59/72 practices (82%)
Referrals by practiceApril – September 2009
20
177
4
322
100
000
01
0 5 10 15 20 25
1
3
5
7
9
11
13
15
Nu
mb
er o
f re
ferr
als
Number of GP Practices making these referrals
Referrals by practice October – December 2009
Number of Referrals made by each practice Oct to Dec 09
0 2 4 6 8 10 12 14
1
2
3
4
5
6
7
8
9
10
Nu
mb
er
of
refe
rra
ls
Number of GP's practices making these referrals
Impact on MRIMRI lumbar spine referrals
Year
Sept-Sept
Out patient MRI
lumbar spine
2006/2007 1049
2007/2008 1215
2008/2009 1385
Monthly total GP/out-patientMRI lumbar spine referrals
MRI LV Referrals
0
20
40
60
80
100
120
140
160
180
200
Feb-09
Mar-09
Apr-09 May-09
Jun-09
Jul-09 Aug-09
Sep-09
Oct-09 Nov-09
Dec-09
Jan-10
Feb-10
Out Pt GP Pt
Monthly % GP referrals of total out-patient/GP MRI
referralsMRI LV % Referrals
0
20
40
60
80
100
120
Feb-09
Mar-09
Apr-09 May-09
Jun-09
Jul-09 Aug-09
Sep-09
Oct-09 Nov-09
Dec-09
Jan-10
Feb-10
Out Pt GP Pt
MRI waits from receipt of referral
to verified report
April 2009 – 6 weeks
October 2009 – 6 weeks
Data summary
• Good GP utilisation
• Impact on total referrals uncertain
• MRI waiting times unaltered
Responses to distributed questionnaires
173 questionnaires distributed
146 questionnaires returned (84%)
134 questionnaires analyzed (77%)
Did access to MRI lumbar spine stop a referral to
secondary care?
Yes - 46 (34%)
No - 88 (66%)
Was the patient referred to secondary care after the result
of the MRI was known?
Yes - 68 (51%)
Was the patient referred to secondary care at the same
time as the referral for the MRI?
Yes - 20 (15%)
Did you mention MRI in the referral letter?
Yes - 20 (100%)
Was the report useful to you in managing the patient?
Yes - 132 (98%)
No - 2
Questionnaire summary
• 34% stopped a secondary care referral
• When patients were referred, MRI was
always noted
Would secondary care have arranged an MRI on these
patients?Clinical details on 134 request cards were reviewed
by Mr. Eric Ballantyne, consultant neurosurgeon
125 (93%) would have had MRI
9 (7%) would not have had MRI
Patient journey
Before direct access
GP OP MRI OP
After direct access
GP MRI 34%
GP MRI OP 66%
Patient journey times in weeks
Before direct access
GP OP MRI OP 12 4 8 = 24
After direct access
GP MRI4 = 4
GP MRI OP4 8 = 12
Outpatient clinic attendances
Before direct access
GP OP MRI OP 134 134 268
After direct access
GP MRI
GP MRI OP 88 88
Outpatient clinic attendances
• Reduction in referrals equivalent to 1.5 weeks
off neurosurgical departmental W/T for all new
patients
• Reduction in reviews equivalent to 2.5 weeks
off neurosurgical departmental W/T for all
review patients
Whole year impact
1,400 MRI lumbar spines per year40% (560 patients) use direct GP access
Annual reduction in OP visits 750
Without direct access 1,120With direct access34% (190) 0 visits68% (370) 1 visit
370
Primary care perspective
• General practitioners views
• Patient experience
Overall summary
• Good primary care utilisation
• Adherence to referral criteria essential
• MRI waiting times maintained
• 34% stopped a secondary care referral
• Improves patient journey- improves patient experience- shorter journey times- fewer outpatient attendances
Effect of access restrictions
Consultation in primary care
Referral to secondary care
Imaging arranged
Review in secondary care
Primary care ongoing management
Discussion on pilot interpretation to determine
future direction• GP/Radiology liaison group
• Diagnostics, radiology and neurosciences
group
• Open evening meeting for GPs
Adopted into routine practice in 2009
Next steps
• Direct primary care access to knee MRI
• Similar process, but add physiotherapy
input
• Aim to commence pilot in mid-2010
Direct primary care access to imaging
• Improves patient experience
• Reduces whole journey waiting times
• Releases resource through reducing waste
• Requires to be developed in close collaboration between primary care, imaging and secondary care staff
