CQ - Efficiency and Value for Money

Introduction: 

Elderly patients are susceptible to opioid-induced constipation (OIC) and often remain constipated despite regular laxative prescription. Naloxegol is a gastrointestinal opioid antagonist licensed for OIC in patients failing laxative therapy. Naloxegol’s higher unit price than standard laxatives may disincentivise hospital pharmacies from stocking and supplying it. We present a quality improvement project and cost-analysis on the use of naloxegol in treating OIC in the real-world setting of a post-operative geriatric ward. 

Methods: 

Initial audit- 

Review of inpatient notes from October-November 2022 identified patients on opioids who failed laxative therapy during admission (bowels not opening for ≥3 days, despite 4 consecutive days of laxatives). Number of bowel motions per week following failure of laxatives and number of laxative doses received were recorded. Total cost of laxatives was calculated for each patient. 

Intervention - 

From December 2022-January 2023, naloxegol was given to patients with OIC failing laxative therapy. Laxatives were stopped on receipt of naloxegol.  

Results: 

Baseline audit identified 63.9% patients on opioids had failed laxative therapy. Following laxative therapy failure, average number of bowel motions/week was 2.65. Accounting for length of admission, average cost of laxatives per patient per day was £0.13. 

During the intervention period 67.2% patients on opioids failed laxative therapy. 13 were prescribed naloxegol. Average number of bowel motions on naloxegol was 5.1/week. Average combined cost of laxatives and naloxegol per patient per day was £0.71. 

Conclusions: 

We demonstrate that naloxegol is effective in treating OIC in those failing laxative therapy, at an average cost of £0.58 per patient per day more than those on standard laxative regimes. While difficult to quantify, constipation is detrimental to patient experience and recovery and incurs indirect costs. On balance, we believe this cost margin to be acceptable, and naloxegol a beneficial treatment for OIC in geriatric patients failing laxative therapy.

Background

West Lothian has 17 care homes with 881 residents. General Practitioners (GP) undertake annual review of all residents, including medication review, with variability between practitioners.

Introduction

Multidisciplinary team (MDT) working is the cornerstone of comprehensive geriatric assessment. MDT meetings are an excellent environment for shared learning and discussion. We applied this principle to a 2-year project delivering structured MDT medication reviews of care home residents.

Methods

Funding was secured for a consultant geriatrician (0.5PA for 2 years, £6500 per year) to join the Lead GP, Integrated Care Pharmacist and care home nursing staff in setting up an MDT for each care home. Complex patients were discussed in monthly MDT meetings, focusing on medication reviews. Shared decisions were documented on primary care clinical notes and amendments made to prescriptions. Where necessary, further GP review assessed subsequent impact of medication changes. Annual cost savings were calculated based on the current Scottish Drug Tariff(1). Qualitative feedback was sought from all members of the MDT.

Results

43 residents from 9 Care Homes were discussed in 11 MDT meetings between Jan-Dec 2022. Average age was 83.3 years (64.9-101.3), 63.4% were females. In total 6 new medications were started, while 87 medications were stopped. The dose was increased in 5 medications but decreased in 37 medications. Total annual savings were estimated at £6657, an average of £155 per resident discussed. Feedback from all members of the MDT was positive, particularly for improving patient care and increasing knowledge and confidence in managing this frail population.

Conclusion

Structured MDT reviews ensured patients were on appropriate medications focusing on improving symptoms and quality of life, in keeping with principles of realistic medicine. The estimated annual savings exceeded the funding invested, making this intervention cost-effective. We plan to scale this up further in Year 2 of this project.

Reference

1.            Public Health Scotland, Scottish Drug Tariff,

Introduction

The Same Day Emergency Care Older Person’s Unit (SDEC OPU) provides urgent holistic care, complementing acute and community services to deliver comprehensive geriatric assessment. In October 2022, we introduced a new clinical coordinator role with the aim of improving patient flow. Prior to this role existing, one clinician per day was assigned to take referrals alongside reviewing their own patients, without having an overview of the processes and outcomes of the day. The new clinical coordinator role included taking referrals, vetting patients in A&E, assigning tasks to clinicians, leading regular ‘huddles’, reviewing results, preparing notes and discharge letters, and requesting specialty referrals. The role was introduced to reduce the waiting time of patients within the unit and to reduce waste through the Leeds Improvement Method.

Method

Data was analysed from a 13 week period both before and after the role was implemented, with the main focus being patient length of stay. 454 patients from before the clinical coordinator role was introduced, and 360 patients following its introduction were included.

Results

Mean length of stay was calculated at 5hr 11minutes before the role introduction and 4hr 45minutes afterwards. This reduction in length of stay was statistically significant (p=0.015), with a 95% confidence interval where length of stay was reduced between 8 and 43 minutes (p=0.0029). The percentage of patients discharged within 4 hours of arrival was 30.4% before the implementation and 36.7% after it. This was not statistically significant (p=0.0593). The percentage of patients discharged over 7 hours after arrival was 19.8% before the implementation and 13.3% after it. This was statistically significant (p=0.0143).

Conclusion

The introduction of a bespoke clinical coordinator role within SDEC OPU significantly reduced patients’ length of stay. It has also provided leadership to the team, increased efficiency, and improved patient experience.

Working in a small district general hospital in Llanelli, West Wales, a weekly hybrid multi-disciplinary team (MDT) meeting is held on the stroke and care of the elderly unit. There are 3 separate geriatric teams covering the ward. Typically, these meetings are attended by physiotherapists, occupational therapists, speech and language therapists, discharge nurses, social workers, nurses and a doctor. The main agenda is to discuss the patients’ current medical issues, rehabilitation needs and likely discharge destination/complexities. Medically, these meetings were attended by a single doctor who often found it difficult to concisely summarise the patient’s medical problems from the notes of patients not under their care. Our aim was to streamline the MDT meeting with regards to quality of content, understanding of patient issues and general efficiency. An initial questionnaire was used to gather prospective data. 90% of MDT members suggested that a doctor from each team should attend to present patients under their care and engage in onward discussions. This was implemented over the period of a month. A follow-up questionnaire collected quantitative data by asking MDT members to retrospectively rate, on a scale of 1 to 10, the efficiency of the meeting and the understanding of patient’s medical conditions before and after implementing the change. The average efficiency was rated at 4.8/10 before the change was implemented and 8.8/10 afterwards, a 40% improvement. Understanding of patient medical issues had a 28% improvement, from an average rating of 6 to 8.8. Qualitative and free text data was also collected highlighting a secondary benefit of reciprocal communication between the therapy MDT and the appropriate medical doctors hopefully improving the timeliness of any required action. Suggestions of further changes include making the meeting fully face-to-face, providing a “proforma” to document what was discussed and introducing other members of community teams.

Introduction

An Acute Medical Unit at Morriston Hospital became geriatrician-led in July 2021. From January 2022 the unit received patients on frailty criteria for Comprehensive Geriatric Assessment (CGA). Clinical Nurse Specialists actively manage patients until discharge.

Methodology

The first phase (November 2020 -January 2021) was acute physician-led. Phase 2(September-November 2021) and Phase 3 (March-July 2022) were geriatrician-led. Phase 3 evaluates a frailty specific intake. Patient age, LOS (length of stay), number of referrals to other medical specialities and overall hospital LOS for patients admitted through the unit were analysed.

Result

The number of patients for the three phases were 496, 566 & 503 respectively. Median unit LOS increased by one day between phase 1 and 3 (p<0.01). Meanwhile, median overall hospital LOS showed a reduction from 7 to 5 days between phase 1 and phase 2 (p<0.01) and between phase 1 and 3 (p<0.05). For patients >80 years old, the median LOS overall has reduced from 12 days in phase 1 to 7 days in phase 3 (p<0.01). There was an observed reduction in number of referrals to other specialities per bed between geriatricans (mean 0.41) and acute care physicians (mean 0.57). 50.1% of the patients who are admitted do not meet the frailty criteria set for the unit.

Conclusion

The unit has shown a LOS benefit for patients >70 years, those >80 years experience a 5-day overall LOS reduction. Identifying frail patients who may benefit from CGA is essential for individuals and overall system efficiency. However, patient selection is difficult to achieve with usual bed management processes. Morriston Hospital has developed a modified electronic screening tool based on the Hospital Frailty Risk Score (HFRS). This is embedded into the digital patient management system. It is hoped that this can be utilised to improve access to CGA for older patients