Better care leads to savings in Inflammatory Bowel Disease
Ulcerative Colitis and Crohn’s Disease are the two main forms of Inflammatory Bowel Disease (IBD) – a long-term condition affecting more than 300,000 people in the UK. IBD causes inflammation of the gut where symptoms can flare up at any time.
The importance of monitoring
Regular monitoring using a patient-initiated follow-up (PIFU) approach, and the ability to receive prompt treatment at the time of the flare-up is vital for patients – something which the conventional diary-based outpatient model can not always accommodate. However, Surrey and Sussex Healthcare NHS Trust (SASH) introduced PKB to help IBD patients to self-manage their condition and remotely communicate with their clinical team, if and when needed. This allows the clinical team to monitor their care and provide timely access to treatment before symptoms progress.
PKB was rolled out to approximately 4,000 IBD patients across Surrey and Sussex Healthcare NHS Trust (SASH). Dr Azhar Ansari, Project Lead and Consultant Gastroenterologist at SASH said: “Patients often experience distressing flare-ups of the disease which can require urgent hospitalisation. However, through using PKB, the patient can self-manage their condition far more effectively and warn us before problems occur.”
Reducing medication costs
Traditionally, IBD patients would be offered azathioprine – an immunosuppressive medication, the side effects of which can cause up to 50% of patients having to swap to an expensive monoclonal therapy. However, since the introduction of PKB, patients are given a lower dose of azathioprine combined with allopurinol. The effective, low-cost treatment is better tolerated by the majority of patients, compared to azathioprine on its own.
Prior to treatment, a simple and readily available blood test that checks for an enzyme level encoded by the TPMT gene can show how an individual will more accurately process azathioprine. The dose can then be lowered to a level that the patient can tolerate but still, derive clinical benefit from.
PKB has allowed Dr Ansari and his team to undertake mandatory monitoring of azathioprine at scale without the need for face-to-face appointments. Patients can quickly flag side effects via PKB, enabling early intervention for those that need it.
As Dr Ansari explains: “The cost implication is huge, as the next line of treatment for those taking azathioprine only is a monoclonal therapy, which can cost £10-15,000 a year. The combined low- dose azathioprine allopurinol treatment costs £200 a year and is delivered as a daily tablet, rather than an injection or hospital-based infusion. The economic cost to the patient is therefore greatly reduced, as they don’t need to take time off work for their treatment.”
The approach is paying dividends for patients and the hospital. With around 4,000 IBD patients, the national IBD standards published by the British Society of Gastroenterologists recommend a clinic that size would need four full-time IBD consultants and three IBD clinical nurse specialists.
Dr Ansari’s team is half that size and has been able to provide excellent care thanks to the fact that patients with the most severe form of IBD are able to benefit from the combined therapy and PKB. In order to become a resilient service as more patients enrol onto PKB, further clinical nurse specialists and administration staff are required but without the increase in consultant staff. Through consultant supervision, clinical nurse specialists and administrators upskill in IBD enabling the service to develop its out-of-hospital experience.
Dr Ansari explained that as well as representing a shift in the model of care provided, this approach also needs a new strategy when it comes to funding. He said: “What we’re doing at ESH strips out the 12-month follow up system, which is an obsolete way of running a service. But what this means is that rather than funding the service based on activity, Clinical Commissioning Groups need to look at a value-based or outcome- based model of funding.
“Our outpatient clinics will always be at capacity, but this is an opportunity to free up space for patients that need to be seen immediately, and provide an alternative for those with less severe symptoms not needing face-to-face appointments.”
Benefits from a study by the Royal College of Physicians (2018)
- The redesigned IBD service saves around 650 patient hospital attendances per annum, a carbon saving of at least 60 tonnes CO2e.
- At an average patient journey of approximately 23 miles* this equates to around 4.4 tonnes CO2e.
- Patients are empowered to take responsibility for their health.
- By preventing hospital admissions and lengthy outpatient appointments, patients save time and avoid stress and time off work.
- A sample of patients surveyed in 2018 showed that the majority felt that the service had a positive impact on their IBD and improved their quality of life.
- The service saves around £232,320 per annum by avoiding hospital admissions (average stay 5 days) and appointments.
- The introduction of LDAA has reduced the use of expensive monoclonal therapy and led to a 90% reduction in admissions and 80% reduction in operations (28 admissions in 2015, compared with 280 in 2008; 20 operations in 2015, compared with 113 in 2008).
- This equates to potential savings of approximately £1.5 million per annum on operations alone†.
- The service avoids 80 hospital admissions, 136 emergency department attendances and 440 outpatient appointments per annum.
- Patient access to specialist care at the time of a flare-up has reduced from 6 weeks to 1 week.
* based on a random sample of 50 patients
† based on an average of £16,226.23 per operation for ulcerative colitis.