Integrated diagnostic pathway for patients referred with suspected OSA: a model for collaboration across the primary–secondary care interface

Setting

This new pathway was coordinated by a London-based teaching hospital which provides services to approximately 1.6 million patients principally located within four London boroughs. The specialist sleep and ventilation service at this trust receives in the region of 1500 referrals annually for suspected OSA and also provides care for patients across the spectrum of sleep disordered breathing. Within one of the catchment boroughs, GPs are arranged into collaborative working neighbourhoods based on their geographical location. The new pathway was introduced in one of these neighbourhoods. We used a ‘hub and spoke model’ to establish a monthly community outreach OSA clinic within a centrally located ‘hub’ GP practice. This clinic received referrals for patients with suspected OSA directly from other neighbourhood GP practices (the ‘spokes’). For the purposes of this pilot, this clinic was staffed by a sleep and ventilation clinical fellow and consisted of a half day session with capacity to review eight patients. To refer a patient, GPs based at any of the other ‘spoke’ practices within the neighbourhood were required to complete an electronic referral proforma which collected basic patient data as well as a pre-test probability score (STOP-BANG) and an assessment of somnolence (Epworth Sleepiness Scale, ESS). This form was embedded within the practice electronic healthcare portal (EMIS Web, EMIS group, Leeds, UK) and once completed, was sent via a dedicated confidential NHS mail account to the sleep and ventilation team. Referrals were screened by the sleep and ventilation clinical fellow and those with a STOP-BANG ≥3 were accepted and subsequently allocated to an appropriate clinic appointment at the hub practice. Patients with impaired mobility (who would normally require hospital-provided transport to attend appointments) and those who required externally provided translation services were excluded from this pathway and instead booked into a regular hospital appointment.

At the outreach clinic, the patients underwent a brief consultation and were issued with a portable diagnostic device to allow them to undertake a home sleep study (WatchPAT, Itamar Medical, Keisarya, Israel). Patients were assessed for somnolence and non-respiratory sleep disorders using a comprehensive structured sleep questionnaire (online supplemental file 2). Once the devices and questionnaires had been returned to the hub practice, they were reviewed within a virtual MDT meeting run by the specialist sleep and ventilation team based at the London NHS Foundation Trust. The final diagnosis, suggested management and follow-up arrangements, were then communicated directly to the patient and their registered GP. Those patients requiring treatment or further review were automatically scheduled to attend a secondary care clinic.

Data collection

We initially assessed the demands faced by the hospital-based sleep and ventilation service by retrospectively auditing a random sample of referrals to this service between June 2016 and June 2017. This gave us insight into the waiting times, costs and the diagnoses being made in this conventional hospital-based pathway. Furthermore, we undertook a process-mapping exercise in parallel to determine a typical patient pathway from GP referral through to treatment and help identify areas for streamlining particularly when designing the community outreach pathway (online supplemental file 1).

The design of the new pathway was undertaken in collaboration with local GPs, governing members of the Clinical Commissioning Group and the hospital operations team and followed a series of planning meetings with all stakeholders present. Following introduction of the community outreach pathway, prospective evaluation of the service was undertaken over 13 months (January 2018–February 2019). Process measures such as waiting times (from referral to appointment, investigation, diagnosis and treatment) were collected longitudinally and estimates of costs and the final diagnoses made were compiled at the conclusion of pathway implementation. Patient satisfaction was collected using an established questionnaire comprising standardised numerical rating scale (NRS). Patient satisfaction for those attending hospital clinics along the traditional pathway using a similar questionnaire was also collected to serve as a comparator. More detail regarding this is provided in the Patient and public involvement section below. Clinician satisfaction was collected using an online survey (Survey Monkey, SVMK, San Mateo, California, USA) distributed to all senior partner GPs based within practices participating in the community OSA pathway.

Cost estimates of each pathway were calculated using the tariffs listed within the NHS National Tariff 2017/2018 workbook and the pay scales according to ‘Agenda for Change’ (AfC). In the UK, all healthcare professionals (HCPs) aside from doctors and dentists, are remunerated according to a national pay system called AfC. This system allocates pay according to set ‘bands’ which reflect the knowledge, experience and skills of the staff. There are nine pay bands in the UK and, for example, ‘band 7’ would be representative of a typical advanced clinical practitioner or senior physiotherapist. More detail on cost breakdowns and assumptions made have been provided in the Results section.

Data analysis

All results were summarised with appropriate measures of distribution (mean, median, SD) and a Mann-Whitney U test (GraphPad Prism V.7, San Diego, California, USA) was used to compare outcomes between the conventional hospital pathway and the new community-based pathway.

Accuracy and completeness of data was ensured throughout by cross-checking of data entry during MDT meetings and involvement of expert stakeholders when determining pathway costs and process measures. Data were securely stored on NHS Trust computers and the pathway was registered as a service improvement project locally. The Standards for Quality Improvement Reporting Excellence checklist was used when writing the final report.10

Patient and public involvement

Prior to the design of the new pathway, patients attending a hospital sleep and ventilation clinic were invited to complete a structured questionnaire to capture their experiences of the existing service and understand their priorities and preferences when attending an outpatient appointment. This feedback guided the development of the new pathway and informed our outcome measures. Furthermore, patient feedback collected following each monthly hub clinic allowed for continued refinement of the pathway throughout the pilot period. At the conclusion of the pilot period, we conducted semistructured face-to-face interviews with two patients referred along this community pathway. This allowed us to gather more detailed feedback and understand how we might adapt and improve on this pathway to continue to meet the needs of our patients.

Pathway outcomes were not directly disseminated to patients but were made available to access through notices and communications posted within the local GP practices.

Waiting times and diagnoses

Ninety-one patients were referred to the community outreach pathway between January 2018 and February 2019; and following initial screening using a pre-existing referral proforma, all were deemed suitable to attend. Baseline demographics of these patients compared with those managed along the hospital pathway are provided in table 1.

Of these, 70 patients attended a community clinic review and undertook a home sleep study; 21 patients (23%) did not attend the appointment offered to them. (The average non-attendance rate for the hospital pathway was approximately 33%). When compared with data obtained from the retrospective analysis of referrals to the conventional hospital-based pathway, waiting times were significantly reduced across all domains (table 2).

The final diagnoses reached in the community outreach pathway and conventional hospital pathway are summarised in online supplemental file 3. Twenty-two patients (31.4%) in the community pathway were assessed as having moderate or severe OSA or a hypoventilation syndrome on the basis of their study and required specialist treatment. A further 17 patients (24%) had mild OSA and a proportion of these with a significant symptom burden were offered ongoing follow-up in a secondary care clinic. Thirty patients (42.9%) either had a normal study or one demonstrating only snoring or partial airflow compromise during sleep, and these patients were deemed appropriate for ongoing GP managed care. Similarly, 48% of patients (n=49) within the hospital pathway had a normal sleep study or one demonstrating only snoring or partial airflow compromise. Of the remaining sampled patients referred along the hospital pathway, 35 (34%) were assessed as having moderate or severe OSA or a hypoventilation syndrome and 18 (17.6%) as having mild OSA. All patients referred along the hospital pathway attended on average two clinic appointments and waited over 32 weeks to be told their diagnosis compared with 6 weeks in the community pathway group.

Patient and GP satisfaction

Twenty-seven patients attending the hospital pathway and 61 patients attending the community pathway completed a feedback questionnaire assessing their satisfaction using standardised NRS (ranging from 1 to 5; with 1 reflecting ‘not at all satisfied’ and 5 representing ‘very satisfied’). The results demonstrate significantly higher satisfaction scores across all domains for patients referred to the community pathway compared with a parallel cohort referred along the hospital pathway (table 3). Free text comments reinforced this view and a semistructured interview of one patient (P1) highlighted additional benefits including the notion of a community OSA pathway ‘fostering continuity of care in a familiar environment’ and ‘minimising the need to frequently attend hospital clinics which are often a source of anxiety.’ At the conclusion of the 13-month observation period, a survey of 10 GPs from participating practices affirmed a preference for a community-based diagnostic approach. Specific comments from those clinicians surveyed commended the ‘responsiveness and convenience of the pathway,’ ‘the simple referral and rapid communication between HCPs that it permits’ and ‘the stronger relationships it developed between the hospital trust and primary care providers.’

Cost assessment

From referral to diagnosis made, the community OSA pathway incurred an average estimated overall cost per patient of £442.31 representing a significant cost-saving when compared with £732.81 for the hospital-based pathway. Table 4 provides a breakdown of costs.

We estimated the cost for each pathway using the tariffs listed within the NHS National Tariff 2017/2018 workbook. The listed tariff for a hospital outpatient appointment is a standard figure which encompasses clinician expenses as well as hospital overheads and ancillary staff support (eg, clinic receptionists, nurses, porters). For a new respiratory patient appointment this is £208 and follow-up £94; using our figure of an average of two appointments before diagnosis in the hospital pathway (one new and one follow-up), this totals £302. Within the community pathway, premises overheads and ancillary support were provided free of charge and hence the cost listed only considers the HCP wage. While during this pilot of the pathway, the clinic was run by a clinical fellow; we have modelled costs based on future clinics being run by a band 7 HCP. The cost listed is per patient assuming eight patients seen during a 4-hour clinic with 2 hours of administration time. The HCP wages are based on the 2018 NHS AfC scales (midnodal point) and NHS Employers Pay and Conditions Circular March 2018.

The national tariff for a respiratory sleep study is £40811 —this nominally includes the operating cost of the device and clinician reporting time. The unit cost for each device will vary between trusts and depend on the device and contractual agreement with the device manufacturer. We used the same device, within both the hospital and community pathways—hence this cost has not been included in our final calculations.

MDT costs were calculated based on the clinicians present and their hourly wage according to AfC and are calculated per patient based on six patients discussed per hour. The hospital MDT involves a consultant respiratory physician, two band 7 allied health professionals (AHPs) and band 4 AHP. The community MDT was undertaken with a consultant respiratory physician and band 7 AHP. MDT administrative cost was calculated in a similar manner.

Limitations

The community outreach pathway was instituted within a borough with pre-existing strong collaborative working practices between constituent GPs. This method of working might have contributed to the successful outcomes of this pathway and might not have been observed to the same extent if the pathway was introduced in an alternative borough. However, enhanced collaboration and sharing of services in ‘primary care networks’ represents an important strategy of the NHS Long Term Plan and thus is likely representative of future service delivery and organisation across all of primary care.

When comparing the baseline characteristics between the two patient groups, there are significant differences in age, body mass index, smoking status, presence of hypercholesterolaemia and ESS. However, the groups are matched for sex and other comorbidities. This heterogeneity between the two groups likely reflects the fact that the community pathway, by virtue of it being a pilot, only drew from the population residing in one catchment neighbourhood versus the retrospective sample conducted of hospital outpatients which received referrals from across the entire catchment area. While these differences exist and might well account for some of the differences in final diagnoses between the groups, they are unlikely to affect the pathway process and cost outcomes which we have described in this paper.

For the purposes of this pilot, the community outreach clinic located at the hub practice was run by a sleep and ventilation clinical fellow with experience in secondary care sleep and ventilation medicine clinics. We anticipate that when this model of care is delivered beyond the pilot setting, the hub clinics will be run by an experienced band 7 HCP with adequate training in the provision of sleep medicine care and diagnostics. We have therefore modelled our costs based on this assumption. Further, premises and infrastructure costs were not incurred during our study as these were provided for free by the hub practice. However, we do not envisage that these will represent a significant outlay especially as there is a substantial appetite among primary care physicians to embed and spread this pathway further. Additionally, our cost analysis did not include an assessment of cost effectiveness but we plan to undertake this prospectively following wider dissemination of the pathway.

While our findings are encouraging, we acknowledge that we have only evaluated the diagnostic phase of OSA. We recognise that treatment and follow-up represent a significant workload burden for secondary care and we are therefore working with our local commissioners to establish this pathway across the STP and Integrated Care System footprint with a second phase planned to evaluate feasibility of treatment and follow-up.