care of patients with gastrointestinal disorders: a strategy for the future 14th march 2006 british...

Care of patients with Gastrointestinal Disorders: A Strategy for the Future

14th March 2006

British Society of Gastroenterology

Professor Elwyn Elias President of the BSG

Welcome

British Society of GastroenterologyLaunch of Strategy Document

Dr Mike HellierChair, BSG Strategy Group

What is Gastroenterology?


4

CANCER

Oesophagus

Stomach

Liver / Pancreas

Bowel

GI Cancer is the commonest cause of cancer death

Gastroenterology is:-

5


JAUNDICE

Hepatitis

Cirrhosis

Alcoholic liver disease

Gallstones

Liver disease kills more women than Ca cervix

6


BLEEDING FROM THE BOWEL

Acute GI bleeding has 10% mortality rate

7


INDIGESTION

Acid reflux

Dyspepsia

Ulcers

20 – 40% of population affected

8


DIARRHOEA

Infective

Ulcerative Colitis

Crohn’s

Irritable BowelSyndrome (IBS)

10 – 20% of population affected by IBS

9

Anatomy of the gastrointestinal tract©

10

Gastrointestinal Disorders

Constitute a huge burden of disease

to society

11

Gastrointestinal Disorders

COST SOCIETY:

£7.18 Billion in non NHS costs

£1.4 Billion in NHS costs

A HUGE EXPENSE

Professor John WilliamsGastroenterology services in the UK

The burden of disease, and the organisation and delivery of services for gastrointestinal and liver disorders

A review of the evidencehttp://www.medicine.swan.ac.uk/giservicesreview


Topics covered

Burden of disease− Incidence; mortality; morbidity; quality of life; geographical

variation; socio-economic factors; costs to society

Current service provision− Organisation; workforce; primary care activity; inpatients;

procedures; voluntary sector; costs

Problems with current provision− Access; inequalities; waiting lists; patient safety; information

to patients and practitioners; complications of care

Other drivers for change− Guidelines; changing incidence; screening and prevention;

genetics; quality assessment

Topics covered

Delivery of services for patients with gastroenterological and hepatic disorders

− Developments in service delivery

− Patient perspectives

− Economic burden of GI disease

− Cost effectiveness of GI services

− Information and IT infrastructure

Methods

Systematic review of the literature, supplemented by additional papers on incidence, mortality and morbidity (997 references examined; 936 used)

Interrogation of routine data sources (Hospital episode statistics; Office of National Statistics; Office of Population Census and Surveys)

Critical analysis of the evidence found

Grading of the evidence as appropriate, based on NICE approach

Discussion of key issues with service users

Wide dissemination to seek feedback, and any additional material

Final revision of the document, with conclusions

A flavour of the findings…

Rising incidence of... − Cancer (oesophageal and colorectal)

− Liver disease (hepatitis C; cirrhosis; alcoholic liver disease; non alcoholic fatty liver disease)

− Barretts oesophagus; pancreatitis; gallstones; upper gastro-intestinal haemorrhage; diverticular disease; coeliac disease; irritable bowel syndrome

Considerable impact on quality of life

Gastrointestinal Disorders in Primary Care

For every 9 patients who consult their GP, one will have a gastrointestinal problem

Source: OPCS 3rd and 4th National Morbidity Surveys

Secondary Care Admissions

Skin, etc4%

Eye, etc4%

Ill defined & other22%

Nervous system3%

Haematological4%

Musceloskeletal7%

External causes8%

Respiratory8%

Circulatory11%

Genitourinary12%

Gastrointestinal17%

Percentage of hospital admissions for major disease groups,England, 1998/99-2001/02: based on Finished Consultant Episodes

Source: Department of Health Hospital Episode Statistics

Hospital bed occupancy for gastrointestinal procedures

0

1

2

3

OPCS-4 chapter

Bed

days (

mil

lio

ns)

Source: Department of Health Hospital Episode Statistics

Total number of bed days for main surgical and endoscopicprocedures by OPCS-4 chapter in England, 2000/01

Mortality rates (per 100,000) for major diseasegroups, England & Wales, 2000: people of all ages

Mortality from gastrointestinal disorders All ages

0

100

200

300

400

Cause of death

Mo

rta

lity

ra

te (

pe

r 1

00

,00

0)

Source: ONS (2001)

Mortality rates (per 100,000) for major disease groups,England & Wales, 2000: people aged 15-64

Source: ONS (2001)

Mortality from gastrointestinal disordersin the potentially working population

Percentage of cancer deaths, according to site of cancer: England & Wales, 2000

Source: ONS (2001)

Gastrointestinal cancer

Ovary 3%

Brain 2%

Kidney2%

Skin1%

Other & unspecified 18%

Bladder3%

Prostate6% Lymphatic tissue,

etc 7%

Breast8%

Lung22%

Gastrointestinal tract28%

Costs to society of gastrointestinal and hepatic disorders in 2004

Workforce− 150,000 person years of working age lost per

annum from premature death (cost £3.2b pa)

− 1.7% of long-term sickness absence (£1.05b pa)

− 20% of short-term sickness absence (£2.9b pa)

Hospital costs in England £1.44b pa

Total NHS costs in England £2.4b pa

Source: Lewison G Gastroenterology in the UK: the burden of disease. Wellcome Trust 1997.

Service provision

There is strong evidence for a shift towards greater self-management by patients with chronic inflammatory bowel disease (level of evidence: 1)

But such patients need support (eg education; rapid access to specialist services when needed)

We found no research into the clinical or cost effectiveness of diagnosis and treatment centres

Nurses can perform diagnostic endoscopy safely and effectively, but are not more cost effective than doctors (1)

Specialisation

In hospital, patients with GI and liver disorders should be looked after by specialists (2+)

Complex surgery for GI and hepatobiliary cancer should be performed by specialists who operate on larger numbers (2+)

There is insufficient evidence to support the greater concentration of services in tertiary centres without further research into the clinical and cost benefits, and disbenefits to other services

Clinical Research

Much data is available on burden of disease

There is a lack of high quality research relating to the organisation and cost effectiveness of services, but plenty of opinion

Much more research is needed, to inform policy, service delivery and organisation

A more strategic approach to the co-ordination and funding of research in gastroenterology is needed (as for cancer, heart disease, elderly etc)

The UK Clinical Research Collaboration is potentially a major opportunity

Gastroenterology Services in the UK

The burden of disease, and the organisation and delivery of services for gastrointestinal and liver disorders: a review of the evidence

http://www.medicine.swan.ac.uk/giservicesreview


Thanks to

Those who did the work: Faiz Ali; Ivy Cheung; David Cohen; Gaynor Demery; Richard Driscoll; Adrian Edwards; Margot Greer; Mike Hellier; Hayley Hutchings; Barry Ip; Mirella Longo; Stephen Roberts; Ian Russell; Helen Snooks; Judy Williams; Giles Croft; Ian Frayling; Alistair McIntyre; Roland Valori; Anne Williams

Many other colleagues who gave us comments and further information, and the service users who discussed our findings

The British Society of Gastroenterology for funding

Professor Alastair WatsonRoyal Liverpool University Hospital

GI Cancer


30

0 10,000 20,000 30,000 40,000

OtherLarynx

LiverCervix

Multiple myelomaOral

Brain and CNS*Body of uterus

KidneyOvary

LeukaemiaPancreas

OesophagusMelanoma

StomachNHL

BladderProstate

Large bowelLung

Breast

Number of new cases

Males

Females

*central nervous system

Cancer Research UK

21% of all new cancers in the UK are gastrointestinal

31

0 10,000 20,000 30,000 40,000

OtherBody of Uterus

CervixMelanoma

MesotheliomaLiver

Multiple myelomaHead and Neck

Brain & CNSKidney

LeukaemiaOvary

NHLBladder

StomachPancreas

OesophagusProstate

BreastBowelLung

Number of deaths

Males

Females

24% of all cancer deaths in the UK

are gastrointestinal

32

Comparison of survival from colon cancer

USA Merseyside Thames

Percentage of patients living for 3 years 69% 52% 44%

Late diagnosis when the disease is incurable.

Gut 2005;54:268-273

Professor Elwyn EliasPresident of the BSG

Liver Disease


34

BSG Strategy: Liver Disease

Overweight and Obesity - Obesity Trends

Prevalence among U.S. Adults of a Metabolic Syndrome Associated with Obesity(Findings from the Third NHANES Survey)

The Centers for Disease Control and Prevention (CDC) estimated that as many as 47 million Americans may exhibit a cluster ofmedical conditions (a "metabolic syndrome") characterised by insulin resistance and the presence of obesity, abdominal fat, high blood sugar and triglycerides, high blood cholesterol, and high blood pressure

35

Hospitalisation for NAFLD

FCE rate of NAFLD of the male population by 10-year age band

0

5

10

15

20

25

30

35

40

45

1994 1995 1996 1997 1998 1999 2000 2001 2002

Year Band

Rat

e (p

er m

illio

n)

15-24 25-34 35-44 45-54 55-64 65-74 75+

Courtesy of Dr P Roderick

Nash & Cryptogenic Cirrhosis

Caldwell SH et al Hepatology 1999; 29 : 664

C.C.NAFLD/NASH

HCVCIRRH.>50YR

PBCCIRRH

N 70 50 39 33

AGE 63 49 60 54

FEMALE 49 (70%) 28 (56%) 15 (36%) 33 (100%)

DM or OB 51 (73%) 35 (70%) 11 (28%) 8 (33%)

DM 37 (53%) 21 (42%) 10 (25%) 5 (15%)

MARK OB 33 (47%) 32 (64%) 1 (3%) 5 (15%)

37

Mortality trends from liver diseasein England Wales 1950-2000

38

Alcohol consumption 1900-2000

39

Mortality from Alcoholic liver disease in males. England & Wales 1960-2000

40

Mortality from Alcoholic liver disease in females. England & Wales 1950-2000

41

Hospitalisation rates for alcoholic liver disease 1988-2002

FCE rate of ALD of the male population by 10-year age band

0

200

400

600

800

1000

1200

1400

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year Band

Rat

e (p

er m

illio

n)

15-24 25-34 35-44 45-54 55-64 65-74 75+

Courtesy of Dr P Roderick

42

Mortality due to viral hepatitis (unspecified)

0

50

100

150

Year

Nu

mb

er o

f d

eath

s (I

CD

9 07

04-0

709)

Males

Females

Total

Mortality from Hepatitis C England & Wales

43

Hepatitis C in EnglandThe First Health Protection Agency Annual Report 2005

44

0

50

100

150

200

250

300

0-4

5 to 24

25-34

35-44

45-54

55-64

>65

Age specific rates of Laboratory notificationsHepatitis C in England & Wales

45


46


47

Hepato-cellular cancer mortality in malesEngland & Wales 1960-2000

48

Alcoholic liver disease 295 (16.4%)

Primary biliary cirrhosis 239 (13.2%)

Hepatitis C cirrhosis 218 (12.1%)

Primary sclerosing cholangitis 149 (8.2%)

NASH/cryptogenic cirrhosis 126 (6.9%)

Hepatitis B 73 (4.0%)

Auto-immune hepatitis 68 (3.8%)Data from UK Transplant

Chronic liver disease: Patients listed for transplantation 2000-2

49

642672 669

692 672 689 714

636

732

606

0

100

200

300

400

500

600

700

800

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

2004-2005

2005-2006

Total number of liver transplants in UK by year

Data from UK Transplant

50

Data from UK Transplant

Percentage of total liver transplants that were less than whole grafts

0

2

4

6

8

10

12

14

16

18

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

2004-2005

2005-2006

split

reduced

51

BSG Strategy: Epidemiology of Liver Disease

Non Alcoholic Fatty Liver Disease

Alcoholic Liver Disease

Hepatitis C

These are examples of liver diseases which:

Are on the increase

Have their highest incidence in the relatively young

Have a latent period of 10-30 years before they are reflected in

− Waiting list for liver transplants

− Cancer development

− Mortality statistics

52

BSG Strategy: Liver Disease

Initial screening in primary care

Defined pathways for referral to secondary care

Endoscopy etc. according to guidelines

Multidisciplinary team work (gastroenterologists, surgeons, interventional radiologists, nurse specialists,nutritionists, pathologists and intensivists)

Networking

Audit data on outcome, efficacy, complications

Professor Tony MorrisPresident Elect BSGImmediate Past Chairman JAG

Endoscopy


54

A variety of gastrointestinal endoscopesused to investigate and treat GI diseases

55

Gastrointestinal EndoscopyPlan of talk

Problems with the endoscopy service

Endoscopic workload

Service improvement programme

Training and the National Programme

Workforce developments

The BSG and endoscopy

56

Problems with endoscopy

Non standardized training Previous poor performance in National Audits

and NCEPOD report Long waiting lists Many Government targets Poor infrastructure and equipment Increasing workload Relative shortage of staff

(endoscopists and support)

57

Past and predicted endoscopic workload% population having an endoscopy

0

0.2

0.4

0.6

0.8

1

1.2

OGD F Sig Colon EUS/ERCP

2003 2008

58


Initiated by Modernisation Agency

Rolled out throughout England

Supported by Strategic Health Authority Endoscopy Leads

Aimed at:− reducing waiting times

− improving quality of patient experience

− preparing for introduction of Bowel Cancer Screening

Introduction of Global Rating Scale

Acknowledged linkage of service delivery and training

59


Apply demand and capacity process mapping Communal waiting lists Reduced room downtime (30%) by backfilling lists Employ non-medical, trained endoscopists (mostly nurses) Validate waiting lists (dead, done, don’t want, don’t need,

moved) Reduce ‘Did Not Attends’ AIM

− all urgent scopes within 2 weeks− all routine scopes within 6 weeks

Remove the ‘endoscopy bottleneck’ to achieve the ‘62 day cancer’ and ‘18 week time to treatment’ targets

60

The Global Rating Scale (GRS) 1www.grs.nhs.uk

Developed as part of service improvement programme

Devised by Dr R Valori (National Endoscopy Lead) and endoscopy colleagues on behalf of the programme

Adopted by the Bowel Cancer Screening Programme as measure of quality for potential screening units

12 items divided into 2 domains, each with 4 levels of achievement

Mandatory on-line data returned twice a year from all English Endoscopy Units

61

GRS Domains (2)

QUALITY AND SAFETY

Appropriateness (Guidelines & Audit)

Consent process & Patient information

Safety

Comfort

Quality of procedure

Communicating results to referrer

CUSTOMER CARE

Equality of access & equity of provision

Timeliness

Choose and book

Privacy and dignity

Aftercare

Ability to provide feedback to the service

62

Global Rating Scale (3)

Only those units scoring in top 2 levels of each part of each domain to be Bowel Cancer Screening Centres (BCSC)

General improvement across the board in all items measured over a 6 month period

Being developed to include Training Rating scale

63

0% 10% 20% 30% 40% 50% 60%

% rate of total results

Consent Process Including PatientInformation

Safety

Comfort

Quality of the Procedure

Appropriateness

Communicating Results to Referrer

Equality of Access and Equity ofProvision

Timeliness

Choose and Book

Privacy and Dignity

Aftercare

Ability to Provide Feedback to theService

Ite

ms

Percentage change in GRS level A&B from April 2005 to October 2005

% A&B in April

% A&B in Oct

64

Training and endoscopyThe Professions response

BSG initiative led to establishment of the Intercollegiate Joint Advisory Group on Gastrointestinal Endoscopy (JAG) www.thejag.org.uk

The JAG Holy Grail “ all endoscopists to be trained to the same standards irrespective of their background”

As a consequence BSG/JAG has Developed core syllabus for endoscopy training Developed suite of Basic Skills Courses in each area of endoscopy Courses now accepted as mandatory for all trainee endoscopists 3 National and 7 Regional Endoscopy Training Centres established

to deliver Basic and Advanced courses Programme funded by National Cancer Plan for England (£10.2M)

over last 5 years, but money runs out in mid 2006-2007 financial year Future uncertain, trainees may have to pay for courses

65

Workforce developments

New training scheme, shift work, European Working Time Directive;

results in reduction of training time by at least 25% Increased workload and targets Increased use of nurse endoscopists to provide

backbone of diagnostic endoscopy services DoH trial of non medical, non nursing endoscopists;

PA, Lab technician! Gastroenterologists with sub-specialization

(advanced endoscopy) being proposed by BSG

66

The BSG and Endoscopy. What does it do?

Largest section of Society, very active Committee Representatives on JAG and Statutory Committees Provides CPD and CME on Gastrointestinal Endoscopic

Subjects for BSG members and Associate members by means of Symposia, Research paper and poster sessions

Produces National Guidelines for the safe, effective practice of endoscopy

− Safe Sedation− Cleaning and Disinfection of Endoscopes− Informed Consent for Endoscopy− Antibiotic Prophylaxis− New Variant CJD− Non medical endoscopists

Etc etc etc

67

Capsule endoscopes, the future has started!

Dr Jeremy Sanderson Chronic Diseases of the Gut


69

You are what you eat !…

70

A

BMajor QOL impairment, occupational impact, even in mild disease

The impact of chronic gut disease…

71

Gut “behaviour”

Diet Lifestyle / Stress

Gut immune system

Genes Bacteria

Normal gut function…

72

Normality

Irritable bowel syndromeIBS

Inflammatory bowel diseaseIBD

Diverticular diseaseCoeliac disease

The spectrum of chronic gut disease

73

Irritable Bowel Syndrome (IBS)

10 -22% of UK population

Incidence rising

Only half consult their GP

40% avoidance activity – work, travel, leisure pursuit etc

20-50% of Gastroenterology clinic workload

Massive cost to society

Causes of IBS poorly understood

74

Concept of functional gut disease

“Functional GI disorders” Chronic symptoms without structural abnormality Functional dyspepsia (indigestion) Non-cardiac chest pain Irritable bowel syndrome

“Motility disorders” (muscular dysfunction) Achalasia, gastroparesis Intestinal pseudo-obstruction Faecal incontinence

75

Cause unknown: interaction between genes and environment

Inflammatory bowel disease (IBD)

¼ million cases in UK

(1 in 1000 Crohn’s, 1 in 500 UC)

Major morbidity and poor QOL in young adults

~ £3000 per annum per patient healthcare cost

Crohn’s disease & Ulcerative colitis

76

High impact but low priority

Cancer focus of targets

Unmentionables

Poorly understood – treatments modest at best

Current issues in service delivery for IBS and IBD

77

Current issues in service delivery for IBS and IBD

Demand a multi-disciplinary approach

Dieticians, nurse specialists, counselling support etc

Need evidence for optimal service delivery

Major need for research funding

78

Provision of optimal service for IBS and IBD

Paradigms for Chronic disease management (CDM)

− move care closer to patient, self-care

− shared care agreements

− agreed patient pathways

Multi-disciplinary team approach essential

Key role for Nurse Specialists

79

Provision of optimal service for IBS and IBD

All patients should have access to dietetic services

Access to other related services also important

− counselling, smoking cessation

Improve specialist training at all levels

Support for clinical and basic research

80

You are what you eat !…

…Depending on your Gastroenterology service?

Professor Elwyn EliasPresident of the BSG

Summary


82

Aims

The aim of this strategy is to provide a robust support for the development and commissioning of Gastroenterology and Hepatology services in the UK. We envisage it will be used in business planning and service improvement in primary care at local Trust level and regional level. We also expect it to be an essential document in negotiations for improvement in service and future planning

83

Care needs to be seamless across boundaries

24/24 and 7/7 provision is essential

Continuity and teamwork are key elements

Standards must be acceptable

Aim 1: To serve to care


84

BSG’s aims:

Planning of services to meet the requirements

for optimal patient care – continuity, expertise,

mutidisciplinary teamwork

Aim 2: Improve Planning


85

Threats and challenges


ISDTC

PBC PBR

86

IDC



PBC PBR

??

??

CHOOSE!

87

IDC



PBC PBR

& BOOK!CHOOSE!

88

Caring for the I.B.D.patient


Nutritionist Nurse specialist(stoma care)

EndoscopistGastroenterologist

(IBD specialist)Radiologist

Histopathologist Gastrointestinal SurgeonMDT

89

Acute Gastrointestinal Haemorrhage

B.S.G. Position Statement

In expert hands emergency interventional endoscopy for patients with upper gastrointestinal haemorrhage had the potential to save lives and by reducing morbidity to prove cost effective

AIM

BSG aims to ensure that all patients admitted to hospital at any time of day or night are treated optimally by those with the necessary expertise to save their lives when the opportunity is presented

90

BSG representation to NICE

To prepare a clinical guideline on the management, up to the point of discharge from hospital, of acute upper gastrointestinal bleeding in adults

This should include:

− the respective roles of primary care and secondary care in managing this condition, and;

− the competencies required by endoscopists performing these operative procedures

91

Care needs to be seamless across boundaries

24/24 and 7/7 provision is essential

Continuity and teamwork are key elements

Standards must be acceptable

Aim 1: To serve to care


92

BSG’s aims:

Planning of services to meet the requirements

for optimal patient care – continuity, expertise,

mutidisciplinary teamwork

Aim 2: Improve Planning


Questions Questions


94


Contacts:


3 St Andrews Place

Regent's Park

London NW1 4LB

email

[email protected]

Web site

http://www.bsg.org.uk

care of patients with gastrointestinal disorders: a strategy for the future 14th march 2006 british...

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