Post Covid-19 diagnostics Tsanami – how we can flatten the wave and reduce the burden of non-value “catch-up” care
The Covid-19 pandemic has had catastrophic consequences in the UK and around the world and has led to unprecedented changes to health services. In the early stages, due to the pace at which the virus was spreading and the lack of robust data, modelling the impact on health services in the UK was difficult. To mitigate for this and ensure that the health system was able to cope with the demands of caring for infected patients as well as protecting those that were not infected, all non-Covid routine care was halted virtually overnight. In preparation for the expected rise in demand, non-infected patients were discharged from hospitals and planned care procedures (including related diagnostics) in Trusts and community were suspended. Accident and Emergency departments and GP surgeries remained open but with drastically revised protocols. Due to the measures introduced, the NHS was able to cope with the peak of the outbreak without overwhelming the system. Now that the infection peak has passed and restrictions are easing, health services are trying to recommence service in areas that were suspended. The focus has shifted to business as usual and preventing ‘indirect deaths’ that occur as a result of non-attendance at A&E for life-threatening illnesses, or suspended management of long-term conditions at the more local level. Prior to covid-19, the health system was struggling under the strain of planned care, and therefore is a return to ‘business-as-usual’ could result in a tsunami of requests that could just cripple the system once more. Is returning to old ways of working the correct approach? Now is an ideal time for Diagnostics departments to implement change that can support better decision making and flatten the wave of low-value, planned care diagnostics
Determining the appropriate level of planned care has always been a contentious issue in healthcare, especially in the area of Direct Access (DA) diagnostics. There exists a struggle between the desire to continually increase population screening under the rationale that early detection equals a reduction in long term costs, and the need to focus on value-based care. For years, diagnostics imaging departments have been struggling, especially in areas such as ultrasound and endoscopy which were faced with increasing demand, coupled with staff shortages resulting in increasing Referral To Treat (RTT) times. Screening tests which were proposed to reduce the downstream demand have only acted to increase activity. For example, it was proposed that Faecal Immunochemical Testing (FIT) would reduce endoscopy and gastroenterology referrals. However, early analysis has shown that due to inappropriate use it has potentially increased downstream activity. The NHS Long-Term Plan promotes prevention and earlier detection, but it also recognises that NHS Trusts have been struggling to meet this additional demand and therefore has promoted more community-based care, especially for diagnostics. This has only acted to open more capacity without reducing the number of referrals. Additionally, there are many cases where this has led to duplication of diagnostics when the patients were referred on to secondary care and the community results were unavailable or quality not trusted so the test is repeated. The Long-Term Plan offers no solution for removing the activity that did not provide value-based care that only acts to clog up the health services and increase patient anxiety due long wait times. Some efforts have been made to reduce demand at local levels. However, resistance to change from clinicians and patients alike has often led to a ‘soft-touch’ approach. In addition to this, in order to address shortfalls in budgets, many of the interventions that were prioritised were focussed on their ability to provide in-year reductions, rather than assessing the value of the requests.
With the advent of Covid-19, all non-Covid care was virtually abandoned overnight. Planned care procedures in Trusts and community were suspended and it is predicted that attendance at A&E dropped by 78% compared to same period last year (April-June) 1. 2-week-wait referrals were down by 75% and GP appointments are significantly reduced. GPs have rapidly adapted their approach to care and their criteria of what is ‘clinically necessary’. Appointments were being triaged, with only a small number of patients are being seen face-to-face. Technologies such as virtual appointments, whose rollout has been accelerated due to the pandemic, have been embraced by GPs and patients alike. Additionally, onward referrals for DA diagnostics, which almost always require face-to-face interaction, has reduced significantly. Prior to Covid-19, studies have shown that one in four GP visits resulted in a pathology request 2. An analysis of DA pathology requests over a three-month period in 2020 (Feb/March/April) has shown a decrease in activity of 85% (52k requests for the week of 17/02/20 versus 7972 for the week of 13/04/20). Test level analysis allows some insight into the types of GP appointments and the pathology tests which GPs currently consider to be clinically necessary for patient care. Tests such as C-reactive Protein (CRP), Urine MC&S, and Wound cultures have only dropped by 79%, 68% and 51% respectively, which is disproportionate to the overall decrease in requests suggesting that patients are seeking treatment for acute conditions such as UTI and infected wounds rather than for ongoing management of long-term conditions. In contrast to this, many of the monitoring tests for long-term conditions such as HbA1c, urine microalbumin, Lipids, Hepatitis C and PSA have dropped by 90% or more showing that long-term care for existing conditions has virtually been suspended. There have also been above average drops in diagnostic testing such as Specific IgE for allergy testing
Now that the peak of the virus has passed, the focus has shifted to resuming care for all patients. Prof Chris Whitty (UK Chief Medical Advisor) and the Royal College of General Practitioners have issued several press releases warning of the potential serious consequences “indirect deaths” resulting from the lack of management of non-Covid conditions. The long-term impact of abandoning planned care is yet to be fully determined with GPs and Trusts are being urged to continue care. NHSEs Medical Director Steve Powis has been publicly encouraging patients to still seek help for medical conditions with public information campaigns persuading people to use the health service if they require it. The initial emphasis was focused on resuming emergency care, and a stratified approach for restarting other areas has been instigated, with cancer care and long-term conditions being prioritised. The resumption of planned care is being managed at the local level and is entirely dependent on local capacity. Many areas of diagnostics require face-to-face patient contact, and therefore appointment times are restricted to minimise contact between clinicians and patients, and patient-to-patient transmission waiting areas as well as in treatment areas. Whilst it is anticipated that a step-change will organically occur due to patients being reluctant to enter medical settings, over time this impact will lessen and patients and clinicians will be eager to catch up on missed appointments, potentially creating a second wave of pressure on the health system. If we are not careful, return to old practices could cause a tsunami of requests for “catch-up” care which could potentially overload the health system at a time when it is struggling with staff shortages and Covid-related care.
How do we ensure that best use is made of restricted resources? Right now, there exists an opportunity to flatten the wave and reform how healthcare is currently provided. There is a small window of time when clinicians and patients will be more receptive to change, and it is important not to lose this advantage. Before re-opening the floodgates, we need to question whether all the referrals that existed previously were even necessary. If some time is taken to assess existing arrangements and plan ways to improve, departments can ensure that services are offered that provide value-based care.
Value-based healthcare focusses on the patient outcome by allocating resources to interventions that improve their long-term health and reduce the effect and incidence of chronic disease, in turn living healthier lives. Low-value healthcare, in terms of diagnostics, are those that provide little or no benefit to the patient and the risk of harm exceeds the benefit. Minimising low/no-value health care can not only improve health outcomes for patients, it can also reduce the burden on the health system and improve the efficiency. In the resumption of care, two main areas need to be addressed – backlog and future referrals, although the same methodology should be used in assessing both. We need to prioritise investigations that provide value-based care and find ways of addressing unmet needs. Picking up the backlog and trying to re-establish existing appointments is not necessarily the best approach when we are aware that there was a lot of unnecessary noise in the system. For example, many MSK issues resolve with rest over a 6-12-week period and therefore a large proportion of MSK issues may no longer require a scan. Example 2: Low value US scans lumps and bumps. We need to focus on how we prevent the re-emergence of low-value care. How do we change ingrained behaviours?
Small changes to referrals can have a big effect. Building questions into the order comms systems that ask the clinician to select reason for referral has been shown to reduce a large portion of the low value requests. Asking questions that provide more details to the diagnostics departments allows for better triage of requests and therefore more efficiency within the system. Changes to reporting which include pathway information can help guide clinicians on ‘next steps’. By ensuring that only the right tests are requested, which contain all the necessary information, we can help the departments lessen the impact of the catchup care tsunami.
2 The effectiveness of interventions to improve laboratory requesting patterns among primary care physicians: a systematic review. Cadogan et al 2015