Dr Peter Pockney and Donna Gillies - Fast-track Colonoscopy for Positive Faecal Occult Blood Testing (+FOBT) in a Public Hospital Setting

2. Fast Track Colonoscopy for +FOBT
in a public hospital setting
Ms Donna Gillies
Dr Peter Pockney
Dr Jon Gani
Dr Rob Foster
Conjoint Professor Anne Duggan

3. Duet Presentation

4. Definitions
• Fast track (FT)
• Direct access colonoscopy (DA)
• Positive faecal occult blood test (+FOBT)
• National bowel cancer screening program (NBCSP)
• 5 yearly 50, 55, 60, 65, 70 (changing to 2nd yearly 50-74)
• NHMRC Guidelines
• FOBT Testing 2nd yearly 50-74
• Greater Newcastle Sector (GNS)
• John Hunter, Calvary Mater and Belmont Hospital

5. Background Information
• HNEH has the highest incidence of CRC in the state
• Surgical Cancer Patients: BDH and JHH Cancer
Services Report 2013
– Inadequate GP referrals
– Median (Mean) time from symptoms to definitive treatment
130 (168) days for CRC
• Student projects
– 20% of colonoscopies do not meet NHMRC guidelines
– Waiting list categories exceeded recommended waiting
periods by 60%

6. MAJOR issues
• Increased demand
– iFOBT – changing to 2nd yearly
– Aging population
– Increased community awareness
• Variations between
– Clinic appointments
– Colonoscopy lists

7. Aim
• To reduce the median / mean time from GP
referral to colonoscopy for public patients
referred to the GNS following a +FOBT

8. Method
1. Data analysis
 Data collection pre and post change for public patients
referred to the GNS following a +FOBT
 Date of GP referral
 Type of FOBT test (NBCSP or GP initiated)
• Comparison between groups
 Date of colonoscopy
 Quality of bowel preparation
 Outcome of colonoscopy
 Post change data included
• “Red Flag” CRC symptoms
• Medical history as per +FOBT referral form
• Date of last colonoscopy

9. Methods
2. Change Process
 Colorectal coordinator / project officer / project team
 Develop a process for fast track colonoscopy
 Direct fax number to dedicated wait list for +FOBT
 Standard referral form for +FOBT referrals (public and private)
 Agreement of the process by ALL endoscopists
 Screening tool for assessment for direct access
colonoscopy following +FOBT
 Key decision points for process
 Standard phone conversation when screening

10. Results: Project team
Dr Peter Pockney
Ms Donna Gillies
Dr Jon Gani
Dr Rob Foster
A/P Anne Duggan
Peri operative staff
Bookings
Referral
Management
Facility Managers
Cancer Services
Application
Development
Endoscopists
Information
technology
Theatre /
Endoscopy Suite
NUM
Medicare Locals
Health Pathways

11. Results:
Referral Form
• Internet
• Medicare locals GPs
– Integrates into their
software
• Endoscopists
• Dedicated fax
number for +FOBTs

12. +FOBT Referral
Received in Fast Track Outpatient Waiting List
1st Assessment of Referral
• All information i.e. histo / NBCSP ID, bloods
• Review referral for pt Hx
• Review CAP for pt Hx
• Review for exclusion criteria for DA colonoscopy
2nd Assessment (Phone Consult)
• Check for CRC symptoms
• Check Medical History
• Check for exclusion criteria
Clinic
(triage 30 days)
Rotational allocation in public or private clinic / rooms
Feedback letter to GP advising
Fast Track Colonoscopy
(Clinic Prior to Colonoscopy)
CMH rotational allocation in public or private clinic / rooms
< 7 days from
date referral
Significant RFS – organise appointment public or private rooms
Feedback letter to GP
Direct Access Colonoscopy
Booking processed (30 day triage)
Allocated on rotational basis between hospital and endoscopists
Feedback letter to GP
• <50 or >75
• no red flag symptoms
• Normal colonoscopy < 2 years
prior
• Complex Medical History (CMH)
• Significant Red Flag Symptoms
(RFS)– consultant contacted and
appointment booked
• All other patients
Database
Record
Monitor outcome
Follow-up
Audit process
received
Key Decision Points

13. Phone Consult
In House
• Outpatient booking
• Outpatient notes in
medical record
• Information provided to
– Endoscopist
– Peri-op
– NUM
Patient
• +FOBT meaning
• CRC red flag symptoms
• Relevant medical
history
• Risks of colonoscopy
• Booking process
• Bowel preparation

14. Criteria: Medical Exclusion
• < 50 or >75 years
• Iron deficient anaemia
• Complex medical history
• Stoma
• GFR <60
• Cirrhosis
• Unstable ischaemic heart disease (regular angina or angina
on minimal exertion
• Recent Stroke or MI < 3 months
• Dual platelet therapy
• Exercise tolerance < 1 flight of stairs.
• Methadone patient

15. +FOBT Referrals
Reason for
FOBT
Fast Track Direct Access
Triaged out of
FT / DA
Total
NBCSP 0 55 13 68
GP Initiated 12 56 41 109
Total 12 111 54 177

16. FAST TRACK & DIRECT ACCESS
FT: n=12 DA n=111

17. Time from GP referral to colonoscopy
Pre
(Days)
N=71
Fast Track
(Days)
N=11^
Direct Access
(Days)
N=90*
Median 82 33 41
Mean 103 37 45
Range 28-435 14-63 11-143
CI 99% 21-53 39 to 51
^ 1 patient no date allocated for colonoscopy
*21 patients no date allocated all waiting < 28 days, with the exception of 2

18. Diagnosis: fast track and direct access
Fast Track Direct Access
GP initiated GP initiated NBCSP Total
Adenocarcinoma 4 (57%) 5 (12.5%) 2 (6%) 11 (13.5%)
Adenoma 1 (14%) 12 (30%) 12 (34%) 25 (30.5%)
Normal 2 (29%) 23 (57.5%) 21 (60%) 46 (56%)
Total 7 40 35 82

19. TRIAGED OUT OF DIRECT ACCESS
PREP
N=54

20. Not fast track / direct access colonoscopy
GP Initiated n= 41*^ NBCSP n = 13*^
Age
< 50 years
>75 years
10
9
0
0
Complex Medical 10 5
Colonoscopy < 2 year
4 3
previous
Alternative appointment Total 10
• Private 4
• Maitland 5
• Other area 1
Total 6
• Private 4
• Maitland 2
Symptomatic 6
(Upper and lower GI)
1
(last colonoscopy < 1 yr)
Patient avoiding 1
* Could have more than one reason
^ No patients in this group had a cancer diagnosis

21. Diagnosis: triaged out of direct access
GP initiated NBCSP Total
Adenocarcinoma 0 0 0
Adenoma 8 0 8 (50%)
Normal 6 2 8 (50%)
Total 14 2 16

22. SUMMARY OF DIAGNOSIS
+FOBT REFERRALS

23. Diagnosis all +FOBT
GP initiated NBCSP Total
Adenocarcinoma 9 (15%) 2 (5.5%) 11 (11%)
Adenoma 21 (34.5%) 12 (32.5%) 33 (34%)
Normal 31 (50.5%) 23 (62%) 54 (55%)
Total 61 37 98

24. Conclusion
• Fast track process removes delays for patients
with colonic neoplasia
• Only 50-60% of patients have a normal
colonoscopy
• A co-ordinator ensures patients are appropriately
triaged (pt who do not meet NHMRC guidelines
are still getting appropriate rapid access)
• There are differences between GP initiated and
NBCSP cancer rates on our preliminary data