Case study: Addenbrooke’s Hospital

One-stop early inflammatory service

  • - 62% patients diagnosed within three weeks of referral in the one-stop EIA clinic, compared to 35% in general rheumatology clinics

  • - £45,800 estimated per annum savings due to reduced use of high cost therapies; equivalent to 45% of the total cost of the service

The one-stop early inflammatory service provided by Addenbrooke’s Hospital has cut waiting times for first appointments and substantially increased the number of patients receiving early diagnosis and early treatment. These improvements help prevent long-term disability and reduce the need for high-cost therapies, thus saving an estimated £46k.

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The challenge

  • - Cambridge University Hospitals NHS Foundation Trust (based at Addenbrooke’s Hospital) identified delays in the early diagnosis and treatment of inflammatory arthritis patients, which were leading to poor patient outcomes

The solution

  • - To tackle the challenge, the trust established a one-stop early inflammatory arthritis (EIA) clinic at Newmarket hospital, to focus on fast diagnosis and treatment of patients with suspected EIA
  • - Patients are referred to the service through a one-page proforma completed by GPs that allows direct access to the EIA clinic. The proforma focuses on key symptoms rather than laboratory tests, to ensure that there is minimal delay between the patient seeing the GP and appearing at the clinic
  • - On their first visit to the clinic, patients are initially seen by a consultant rheumatologist who will diagnose the condition and prescribe a treatment regimen based on disease severity
  • - A band 5 clinic nurse is also present in all appointments and acts as a care coordinator for the patient
  • - If the patient is positively diagnosed, they are then taken by the clinic nurse to have X-ray and blood tests as well as to have a steroid injection administered, all on the same corridor as the consultation room
  • - Following the tests, the patient then immediately has an appointment with a rheumatology practitioner who educates the patient regarding their diagnosis and treatment, provides counselling support and referral to the multi-disciplinary team (MDT) as necessary
  • - The patient then enters a standardised, treat to target care pathway involving regular visits to check response to treatment. If patients do not achieve the disease activity target, their treatment is changed regularly
  • - During the periods between visits to the hospital, patients and GPs have access to a telephone hotline run by the rheumatology practitioner to deal with any requests for information

Service performance and outcomes

  • - The one-stop EIA service was launched in 2004. Since the implementation of the service, the mean waiting time for a first appointment has reduced from 12 weeks to five weeks
  • - In 2008, 62% of patients referred to the service received an early diagnosis (within three weeks) compared to 35% in general rheumatology clinics. Furthermore, 61% of one-stop EIA service patients and 44% of general rheumatology patients received intensive therapy at their first appointment
  • - Early diagnosis and early treatment with intensive therapy are key quality indicators for rheumatoid arthritis (RA)1 and help to quickly bring patients’ disease under control, thereby preventing long term joint destruction and disability
  • - Six months after entering the pathway, 37% of patients achieve clinical remission. This is the primary goal for RA patients and translates into prevention of joint damage and avoidance of long-term disability

Patient focus and satisfaction

  • - A key role of the rheumatology practitioner is to provide education and counselling to patients about their disease and their treatments
  • - Depending on the emotional impact of the diagnosis, it is sometimes not appropriate to start treatment and education in the first visit. Such patients are offered to return to the clinic in two weeks, to ensure that they are fully prepared for starting treatment
  • - Occupational therapists offer a four week patient education programme with four sessions lasting 2.5 hours each. The main aims of the programme are to teach patients techniques to manage pain, fatigue and how to protect their joints
  • - In a 2013 patient satisfaction survey, 100% of patients agreed or strongly agreed that they were satisfied with their experience of the one-stop EIA clinic

Financial performance and outcomes

  • - One of the main costs in treating patients with RA is the use of high-cost biologic treatment when patients fail to respond to traditional therapies
  • - Due to the intensive treatment strategy employed by the one-stop EIA clinic, which reduces the number of patients who required high-cost therapy, it is estimated that the pathway offers a saving of £45,800 per annum compared to a typical RA service. This is equivalent to 46% of the cost of the service (£98,900)

Commissioning priorities

  • - The Addenbrooke’s one-stop early arthritis clinic is an example of commissioning best practice in rheumatology and meets a number of the priorities for commissioners as outlined by the King’s Fund in 2013:3
  • - Care co-ordination – the one-stop EIA clinic has a dedicated nurse to act as the care co-ordinator, helping patients to access all the services offered by the clinic
  • - Secondary prevention – the early, intensive treatment strategy used by the one-stop EIA clinic helps to quickly control disease activity and prevent patients’ disease from worsening
  • - Medicines management – through their initial diagnosis and allocation to a disease group, patients receive appropriate therapy at the beginning of the pathway and are regularly reviewed, allowing the modification of medications when needed
  • - Active support for self-management – rheumatology practitioners educate patients about their disease and treatments when first diagnosed and a 1 month education programme, run by the occupational therapist, is also offered to improve self-management

Sponsorship statement

This best practice case study project has been sponsored by UCB and supported by a medical education grant from Pfizer.
UCB and Pfizer have not had any influence over content: editorial control remained with the British Society of Rheumatology.

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We gratefully acknowledge the generous support of our sponsors, which enabled the case study project to take place.