Introduction The two week wait (2WW) referral leads to significant burden on outpatient clinics. This delays appointments for patients that may not fit the 2WW criteria. Only 5% of patients referred as 2WW will have an upper GI malignancy and it may not be necessary for all these patients to be reviewed urgently in clinic. Previously at our hospital, most upper GI 2WW referrals were booked an OGD (performed by any available endoscopist) in addition to a clinic appointment on receipt of the referral. In order to streamline the service, in January 2013 patients were triaged to either an OGD or a clinic appointment. The index OGD’s are now done on consultant’s list (Gastroenterologist and Upper GI Surgeon) with a clinical assessment at their OGD appointment. Further management is protocol based and dependant upon the assessment and OGD findings. The aim of this study was to determine if this change in practice is effective and safe.
Methods Patients referred as a 2WW in January and February 2012 were compared to those referred in January, February, August and September 2013. Only patients triaged directly to OGD were included (77/143 (54%) in 2012 and 180/291 (62%) in 2013). 14 patients were excluded from further analysis due to non-attendance.
Results Total cancer detection for all referrals was 8% in 2012 and 9% in 2013. In patients selected for a direct OGD referral, 7 upper GI cancers were diagnosed in 2012 and 14 in 2013. After the OGD, 4 (5%) patients in 2012 were immediately discharged back to the GP, compared to 33 (20%) in 2013 (p = 0.003). Of those attending clinic post OGD, 9 patients (13%) were given a routine appointment in 2012 compared to 50 (37%) in 2013 (p = 0.0002). Comparing the two years, there was a 32% reduction in the requirement of urgent outpatient appointments (83% had urgent OPD in 2012 compared to 51% in 2013, p = 0.0001). Of those discharged in 2013, 85% had documentation of the current symptoms at time of OGD and in 94%, treatment advice was provided to the GP. One patient was discharged after an OGD showing grade B oesophagitis and symptom improvement with PPI. Unfortunately, a re-referral 8 weeks later for worsening symptoms found oesophageal cancer on OGD.
Conclusion The introduction of consultant assessment as a first contact for all OGD 2WW referrals has led to a significant reduction in the requirement of urgent outpatient clinic appointments by one third. Waiting times for all clinic referrals have reduced significantly, amounting to 54% reduction in the number of patients waiting more than 9 weeks for a first appointment. Cancer detection is comparable to the previous model of care. Patients with ongoing symptoms at the time of endoscopy need follow up. In hindsight the missed cancer should have had an oesophageal biopsy, but this is clinical judgement and we do not believe the new service accounted for this delay.
Disclosure of Interest None Declared.
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