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Delivering a Better Quality of Care in a Primary Care Setting

Delivering a better quality of care in a Primary Care Setting

MEOMED has developed, with support and funding from NHS England, a remote diagnostics service hosted on the N3 network for cardiology which reduces unnecessary referrals by 75% whilst delivering improved patient care in the Primary care setting. We have successfully trialled the service with a number of GP surgeries in London, Liverpool and York. We are currently preparing to roll out our remote cardiology service to surgeries in Greater Manchester. MEO Cardiology MEO Cardiology offers a reporting package made up of a Consultant Cardiologist report on primary care ECGs, and/or an e-Consult report where the Consultant Cardiologists create bespoke patient specific reports covering ECGs and treatment recommendations based on patient history. MEO’s secure IT portal has been configured and connected with the secure N3 network, to enable GPs to send cardiology investigations directly to expert NHS cardiology consultants, who then provide a rapid and effective reporting and “e-Consult” service within a few hours. The e-Consult is designed to save directly into the patient management software. Primary care healthcare professionals capture the ECG data using a standard 12 lead ECG. MEO’s portal is compatible with a range of existing devices used in GP practices to capture ECGs. MEO’s service allows ECGs and patient history to be examined by a Consultant Cardiologist (specifically an Electrophysiologist) remotely. MEO Cardiology Trials and Research MEO was awarded grants from the NHS England Regional Innovation Fund to run trials of its remote cardiology diagnostic service with GP surgeries across the UK. MEO Cardiology has been trialled in a number of GP Surgeries / CCGs in: York CCG, Brent CCG and Liverpool CCG in 2014 – 2015. Our field research has demonstrated that GPs are keen to have ECG tests undertaken ‘in house’, but are concerned that their own skills & experience are insufficient to use just the technical reports for diagnosis and creating a treatment plan. They suspect that this lack of confidence leads to an increase in unnecessary referrals at increased expense to the commissioning body. The ready availability of consultant-reported context-appropriate ECG rightly places the initial management of cardiovascular disease in primary care and allows the GP to retain control of treatment pathways. Dr Neil Hobson, Consultant Cardiologist/ Electrophysiologist and co-inventor of MEO says, “MEO was borne out of frustration with the existing care pathway. My clinics are always bursting and a significant percentage of the patients should either not have been there, or could have very easily been treated at the GP’s surgery. The time is right to utilise cutting edge technology to have specialists support the GPs in the earlier diagnosis and treatment of patients. Having consultants support GPs is no longer an option, but a necessity due to cost constraints and quality improvement expectations.” The MEO ECG e-Consult project has been awarded an Arrhythmia Alliance research grant to better demonstrate the benefits of having experts guide GPs in the early stages of patient management. Trudie Lobban, Chief Executive of Arrhythmia Alliance (The Heart Rhythm Charity) says, “The MEO concept is a great opportunity for the NHS to improve patient care whilst reducing diagnostic costs. The quality of existing ECG interpretation is variable at best across the UK, with telemedicine often being provided by nurses so having a specialist ‘electrical’ Cardiologist on tap to report on the data and create a care plan is the Gold Standard for our patients. The aspirations we have for the MEO project is reflected in this being our first ever research award.” Conclusions from the Trial The surgeries that trialled the MEOMED cardiology service found that it provided appropriate, high-quality care and minimised unnecessary referrals, which saved them money. It also reduced waiting times for cardiac care. MEOMED’s diagnostic service is also much more rapid and convenient for the patient: results are received sooner, patients don’t have to travel to and wait at a hospital and patients that required urgent attention and care were seen far sooner.

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Delivering a better quality of care in a Primary Care Setting

The MEOMED Cardiology service was implemented in LIVERPOOL Medical Centres, Clifton Medical Practice Yorkshire & Brent CCG and piloted on 569 patients as detailed in the table below: Area Brent Liverpool Yorkshire Total

Number of patients Male Female 71 42 134 158 79 85 284 285 569

Average age of patients Male Female 55.9 57.4 48.8 50.9 54.8 55.7

Table 1 - Overview of Patients seen The service has proved to be very popular with patients because they could have the ECG performed at the local GP practice and get the results swiftly, which resulted in very low DNA rates for patients not attending ECG clinics. Thirty-seven percent (212) of patients were able to be managed in primary care as a result of the information provided by NHS Consultant Cardiologists. This would be in the form of other GP-led investigations or medication changes. The target service level for MEO is 48 hours and during the study the average turnaround time for reports from a consultant cardiologist was just over 2 hours, MEO delivers a significant improvement on the average time for a standard patient referral which ranges from 2 â&#x20AC;&#x201C; 18 weeks to have your condition reviewed in a Cardiology Department, often being seen by a technician, or non-consultant cardiologist. The tables below show that as a result of using MEO Cardiology for patients which GPs were considering referral to a hospital, the MEO reports enabled GPs to make better decisions on patient care and referrals to cardiologists were reduced by around 80% across all patients (Figure 1). Outcomes for All ECGs

Figure 1- Overall outcomes for all ECGs

Delivering a better quality of care in a Primary Care Setting

Outcomes of Abnormal ECGs

Figure 9 - Analysis of abnormal ECGs Analysis of Normal ECGs

Figure 10 - Analysis of Normal ECGs by reporter Benefits of Early Diagnoses 16 of 313 (5.1%) referrals were recommended on basis of history alone (red flag symptoms) (see figure 3.). Interestingly, although MEO Cardiology was not designed to be an emergency tool, our NHS Consultant Cardiologists detected 3 patients who required urgent treatment and were directed to go straight to A&E. Had these patients not been assessed by Consultant Cardiologists they would have had delayed treatment if they had been referred via the standard care pathway.

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Delivering a better quality of care in a Primary Care Setting

During the trial, MEO Cardiology evolved to have the ability to automatically collect relevant patient clinical history from the Primary Care patient records. This new feature lets the NHS Consultant Cardiologist know everything needed to make a full consultation. This reduces the time taken to see the patient and significantly improves the quality of report the Cardiologist can write. Knowing the patient’s clinical history and seeing the ECG ALLOWS THE Cardiologist to support and advise the GP in a way that is not possible via normal Telehealth methods. Cost savings MEO Cardiology can deliver to CCGs The results demonstrate clearly that MEO Cardiology offers a very high quality diagnostic service alternative to the status quo. For just the 569 RIF patients drawn from across the UK it can be seen that speed and quality of care is improved while the cost of unnecessary referral is reduced by around 80%. In regions of the UK where ECG patients are sent directly to the technician run secondary care Cardiology Outpatients at a cost of £336.40, MEO Cardiology costs only £82.30 and is exclusively staffed by Consultant Cardiologists. Rapid Access Clinics, designed to reduce waiting times and allow patient’s hospital levels of service cost £184 per ECG patient. Again, these are run and staffed by the technicians, who produce technical reports for the GP offering little expert guidance to the GP and therefore the number of unnecessary referrals remain high at 40%. Given that the information provided by MEO is superior to each of these alternative, the price difference really matters, and since the average practice only receives total funding worth £136 per registered patient in 2013/14 maximises the quality of care a practice can provide for a given amount of funding. But this amount conceals massive variation between practices and illustrates that annual funding for unlimited access to GP practices is less than an annual Sky TV subscription, which costs £238 per year according to Pulse. In this context, the hidden ECG costs matter!

In many regions of the UK CCG’s are increasing looking for alternatives. Companies have responded and offer technician reported telehealth. As these services are nurse reported, they do not provide the GP with comment on the patient or the possible treatment options which can be made unlike MEO. The information provided is similar to the auto interpretation software which come as standard on many of the ECG machines but for which the companies charge in the region of between £11 to £21 depending on the speed of the report. Reports from CCGs indicate that companies frequently escalate the ECG report to ‘urgent’ and bill at the higher price of £21. In summary and taking into account the relatively high referral rates to secondary care of 40%, from technician led services provided by other companies the price per patient is actually nearer to £123.40.

Delivering a better quality of care in a Primary Care Setting

MEO Cardiology offers some clear advantages that lead to reduced costs, increased quality in patient care and education of the GPs. Although MEO cardiology is run by and reported by only senior NHS Consultant Cardiologists the average price per ECG patient is only ÂŁ82.30. This is due to two clear factors, one is the low MEO ECG price due to the skills of our Consultant Cardiologist operatives, but also due to the very low rates of referrals, which is only 20%. Regular Hospital Referral Rapid Access Technician Telehealth MEO Cardiology

Referral Rates 45% 45% 37% - 45% 20%

Table 7- Referral rates The Referral Rates stipulated above are based on literature reviews and research findings from the RIF report. Based on our CCG interviews we know that other companiesâ&#x20AC;&#x2122; technician level services normally find that 45% of ECGs are abnormal in some way or other, indeed our own Cardiologists described 256 of the 569 ECGs as abnormal which is 45%. Despite the findings of the NHS Consultant Cardiologists some Technician Telehealth companies claim that only 37% of their undertaken ECGs were referred, therefore abnormal. As no patient information is analysed with the ECG, it must be inferred that 37% were abnormal. Either they have missed 8% of the abnormal ECGs, or the patient population was different.

Figure 18 - CCG Expenditure for 569 ECG Patients- RIF

Table 8 - CCG Price Per ECG Patient- RIF When we extrapolate the RIF findings to reflect to needs and population of a reasonable sized CCG we can see the dramatic cost impact that MEO Cardiology could have. Taking a 60 practice CCG and extrapolating our RIF findings we make the following assumptions:

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Delivering a better quality of care in a Primary Care Setting

Average CCG Profile CCG Population Population per practice ECGs Taken

255300 4255 7148

Total GP Practices Estimated number of ECGs per 1000 pop Estimated number of ECGs /practice

60 28 145

Table 9 - Average CCG assumptions

Figure 20 -Cost Breakdown for Average CCG with 7148 ECGs By changing the design of the primary care Cardiology diagnostic service, and utilising the skills and time of the NHS Consultant Cardiologists MEOMED believe that CCGs can save hundreds of thousands of pounds each and every year. Indeed, the shift from secondary care provision of diagnostic services to primary care could lead to better quality results and at a fraction of the costs. Below you can see the potential savings realised by using MEO Cardiology. MEO Cardiology compared to: Regular Hospital Referral Rapid Access Technician Telehealth

MEO Savings £1,816,437.03 £729,880.23 £293,827.83

Table 10 - MEOMED cost savings On a per patient basis, the savings per report are clear. MEO Cardiology compared to: Regular Hospital Referral Rapid Access Technician Telehealth

MEO Savings per Patient £254.10 £102.10 £41.10

Table 11 - Cost saving per patient

Delivering a better quality of care in a Primary Care Setting

In summary the MEOMED Ltd RIF project and the trial of MEO Cardiology service have achieved the following outcomes: • An 80% reduction in referrals to secondary care can be achieved versus a standard ECG hospital pathway. Even when compared to so call ‘expert reported’ options (this actually means technical reporting) MEO Cardiology can still offer a 55% reduction in referrals. Regular Hospital Referral Rapid Access Technician Telehealth MEO Cardiology

Hospital Referrals 7148 3217 3217 1451

Referral Reduction 80% 55% 55%

Table 12 - Reduction in referrals • If implemented on a CCG scale the savings realised will be significant. Whether comparing to traditional hospital referrals or the commonly used technician Telehealth services, using NHS Consultant Cardiologists are still the best value due to the additional skills they have and the patient specific reports that they can create. MEO Cardiology compared to: Regular Hospital Referral Rapid Access Technician Telehealth

MEO Savings £1,816,437.03 £729,880.23 £293,827.83

Table 13 - Savings for CCG Other Benefits of using MEO Cardiology • A speedy response results service, which is popular with GPs. An average report turnaround time of 2 hours. Instant options are available, but this means a technical report, not a Consultant Cardiologists. • Over 5% of patients were highlighted for appropriate referral on the basis of the patient history alone. This is a unique MEO Cardiology feature, and classed as red flag symptoms. • A popular educational tool as it enables GPs to upskill by learning from the NHS Consultant Cardiologists and gain confidence in dealing with patients with heart conditions, whilst minimising the risk to them of making a misdiagnoses. • The system puts the GP more in control of the specialist treatment required by their patient. • A service which provides better, faster care for patients, which is more convenient for them and which facilitates the GP to reassure the concerns of the patient’s sooner.

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Delivering a better quality of care in a Primary Care Setting

Testimonials from GPs that used the service

“In my 27 years as a GP, this is the best diagnostic innovation I have used” Dr M C Patel, GP - Brent “After using this service for 10 months we have been delighted with the results. GPs from across the Liverpool area have commented about the speed and quality of the service, along with the reassurance they have with it being run by and delivered by Consultant Cardiologists. SSP Health’s interests in supporting this service stemmed from GPs being over burdened with increasing pressure to justify referrals. Patient expectations remain the same, with a need for immediate and appropriate care and the reassurance of an accurate diagnosis. Simple cost effective service that alleviates the patients concerns, and supports GPs in making safe decisions quickly about the need for referral and treatment with direct input from a Cardiologist. An additional positive outcome of the MEO service pilot is likely to have been reduced need for A&E attendance and unplanned admissions, particularly zero day admissions, as a result of the quality and speed of the returned diagnostics. The impact on these areas is to be evaluated.” Dr Shikha Pitalia, GP Liverpool “Delighted with this service, would be very keen to continue using this now the pilot has finished. I liked the fact that it has resulted in an e-Consult rather than the limited technical reports that we have seen in the past. MEOMED have significantly reduced our secondary care referrals” Dr Adeeko, GP, Everton Road Surgery.

“…amazed with the service… reports returned same day vs. hospital time of 3-6 weeks” Carolyn Matthews, NHS Brent Teaching PCT “The service and speed of MEOMED has enhanced our surgery and the wellbeing of our patients” Daniele Gledhill, Practice Manager - Liverpool “We have sent several ECGs for diagnosis and received reports within 15-20 mins. We have not had to make any outpatient referrals to secondary care” Mrs Vadher Nutan, NHS Brent CCG “…very fast and well informative diagnose given by the MEOMED cardiologist” Dr Thoe, GP Garston Health Clinic -Liverpool “The substantial cost savings and improved quality of service MEOMED delivers will be implemented by a number of Clinical Commissioning Groups across the UK” Dr Paul Hamner, NHS Trustech “Please pass on my thanks to the superb help. I have already shared my appreciation with the cardiology lead, Dr AjitShah. Best wishes Raphael, Dr Raphael Rasooly (NHS BRENT CCG)