Introduction There is immense pressure on NHS organisations to achieve early diagnosis and rapid treatment of cancer. Nottingham Colorectal Cancer Service introduced a Direct to test (DTT) initiative to shorten the time to diagnosis and improve 62 day target compliance.
Method We amended our 2WW referral form to incorporate ECOG performance status and a Charlson co-morbidity checklist. GPs were asked to provide an up to date eGFR and FBC/Ferritin. All 2WW referrals received between 1/8/14 and 30/11/14 were vetted by a Colorectal Consultant and selected for DTT according to a pre-defined protocol. DTT patients were telephoned by a Nurse Specialist (NS) to confirm suitability and explain the process. Those not deemed suitable for DTT were offered outpatient assessment (OPA). A tariff of £24 was agreed for telephone assessments in place of OPA. All referrals were logged in a database and outcomes of investigation and treatment were analysed. Statistical comparisons were performed on GraphPad Prism software.
Results 553,2WW referrals were vetted and 355 patients (64.1%) were deemed suitable for DTT. 64 (11.6%) failed telephone assessment and underwent OPA. 11 patients (2.0%) failed to complete the pathway.
280 patients successfully completed a DTT pathway (50.6%) and 233 (42.1%) completed OPA/investigation. 40 patients (7.2%) were excluded due to inappropriate referral, patient choice/DNA, or OPA that investigation was not appropriate. The DTT group (mean age 64.9y) was significantly younger (p < 0.0001) than the OPA group (71.0y). No adverse events were reported.
The median time to first test was significantly shorter in the DTT group 12 days vs. 23 days in OPA (Mann Whitney P < 0.0001). Median time to final diagnosis 16 days (DTT) was also significantly lower (Mann Whitney P < 0.0001) than 26 days (OPA).
15 colorectal cancers (CRC) were detected in the DTT group (5.4%) and 22 CRC in the OPA group (9.4%). 11 DTT cancers underwent elective surgery all within 62 days whereas 3 patients in the OPA group (13.6%) required emergency surgery. 5 patients in the OPA group (22.7%) received palliative care only compared to 1 in the DTT group (6.7%).
The DTT pathway obviated the need for outpatient clinic (tariff £193) prior to testing in 280 patients, saving a total of £47320 in 4 months.
Conclusion The DTT initiative in our service has improved time to diagnosis and compliance with 62 day targets. It also saved the cost of 280 outpatients assessments, assuming that all of these patients would have been investigated in the same manner after OPA. However, DTT selects out a younger and fitter group that is less likely to have Colorectal Cancer but may detect CRC at an earlier stage.
Disclosure of interest None Declared.