PAEDIATRIC COMMUNITY
IBS: SETTING UP A PATIENT SERVICE Rebecca Gasche Registered Dietitian, Countess of Chester Hospital NHS Trust Rebecca has a keen interest and specialises in gastroenterology dietetics. She currently works in the community setting in the Chester area, running clinics and group sessions to manage a wide range of gastroenterology conditions.
REFERENCES Please visit the Subscriber zone at NHDmag.com
The IBS pathway discussed in this article can be viewed at www. NHDmag. com/ibspathway.html
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When I started my post in April 2016, my initial task was to help set up a dietetic-led irritable bowel syndrome (IBS) service. Following on from successful dietetic-led coeliac services, my Trust wanted to create a similar pathway for patients with IBS, to help reduce pressures in secondary care, wait times and improve patient outcomes. IBS is a long-term condition affecting the digestive tract. It can most commonly cause symptoms such as abdominal discomfort, an altered bowel habit and bloating, and can have a huge impact on a patient’s quality of life. It is known that diet and lifestyle factors play a huge role in managing symptoms, hence why NICE guidance on management of IBS suggests the use of avoidance and exclusion diets to only be advised by a healthcare professional with expertise in dietary management.1 When looking at the low-FODMAP diet more specifically, which is used as second-line treatment for IBS, studies have supported dietitians being the healthcare professionals to deliver the dietary guidance, stating that dietitians have an extensive knowledge of nutrition, health and disease and are the leading experts in educating patients on disease-specific dietary management, including IBS.2 One study concluded that dieteticled implementation of the low-FODMAP diet is an effective strategy for the management of IBS and that the trend for non-dietetic-led implementation of the diet is of concern, as there is no evidence of the clinical effectiveness or risks associated with such practices. The study also stressed the importance of dietetic-led management in IBS needing an increased recognition in clinical practice.2 Despite the evidence, it is thought that IBS referrals account for up to 60% of outpatient gastroenterology referrals.3,4 By using a thorough referral system to rule out other potential gastrointestinal causes, a dietetic-led
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clinic with access to a gastroenterologist is suitable to manage this patient group. AIMS OF THE IBS SERVICE
The aim of the IBS service at Chester was to ultimately reduce the pressure from the gastroenterology consultants, who were finding that a large amount of their clinical time was being spent with IBS patients. They would often refer these patients onto the dietitians after seeing them initially. Reducing consultant pressure would lead to a reduction in consultant wait times, as well as patient wait times to be treated, with the aim that patient satisfaction would, therefore, increase. The pathway also hoped to reduce unnecessary investigations, such as colonoscopies. The policy aimed for patients to be seen within four weeks of receiving the referral, and that they would be seen by a dietitian before, or instead of, seeing a consultant. It was made clear that patients must be screened for any ‘red flags’, and that the dietitians had the relevant specialist skill set to be able to identify abnormal results/symptoms and link in with the gastroenterology consultants when needed. If dietary manipulation did not improve a patient’s symptoms, they could be referred directly into secondary care, without delay to their care. LOGISTICS
First and foremost, the policy had to be written and agreed with the gastroenterology team. We knew that if the dietitians were to see these patients
The aim of the IBS service at Chester was to ultimately reduce the pressure from the gastroenterology consultants . . . instead of the consultants, it was crucial that thorough screening methods were in place to ensure that patients weren’t misdiagnosed. The NICE guidance emphasises the importance of excluding other diagnoses in patients presenting with symptoms of IBS.1 Therefore, we requested that those referring into the service had to ensure that all patients presenting with symptoms, such as abdominal pain or discomfort, bloating and/or a change in bowel habit for at least six months, were assessed for the following ‘red flags’: • unintentional and unexplained weight loss; • rectal bleeding; • a family history of bowel or ovarian cancer, or signs and symptoms of cancer in line with the NICE guidance on recognition and referral for suspected cancer; • anaemia; • aged over 50 years. Any patient presenting with IBS symptoms alongside one or more red flags were to be referred directly into secondary care. As well as assessing for red flags, patients would be seen by the dietitian on the basis that the following tests had been ordered and returned within normal range: • FBC • tTGA • ESR • TFTs • CRP • Faecal calprotectin These could be completed by the referrer or the dietitian once the referral had been received. We ensured that our policy allowed the dietitian to order any bloods/stool samples that had not been checked, to avoid having to reject referrals for this reason and allow patients to be seen sooner. Testing for these bloods/stool samples helps to rule out conditions which present similarly to IBS, such as coeliac disease, inflammatory bowel disease or infections.
Once the policy was approved by the gastroenterology and dietetics teams, and had gone through the relevant governance meetings, the next step was to set up the clinics in which these patients would be seen. Logistics of finding clinic rooms, dates, times and admin letters attached to the clinics all takes time! The service began with two clinics per week, 30 minutes for each patient for both an initial or review. A lot of work went into promoting the service in primary care, working closely with the clinical commissioning group (CCG), encouraging GPs to refer to the ‘dietitian first’. The consultants were aware to redirect any referrals they received, with no red flags, to the service, and they were also on hand to support the dietitian if required. GROUP EDUCATION SESSIONS
The IBS clinics ran from 2016-2017 and were proving a success in reducing wait times both for patients and consultants. However, as the service was promoted within the gastroenterology team, GPs and other community settings, the numbers of referrals increased. We opened additional clinics and set up an ‘opt-in’ appointment scheme to reduce the number of ‘did not attends’, but soon found that we were at our capacity and risked patients waiting longer than the four weeks set out in the IBS policy. Our next step was to look at treating patients in a group setting, which has proven to work well for other conditions such as coeliac disease and diabetes. Evidence from a number of studies demonstrates how group education enhances patient acceptability of a treatment through a sharing of experiences with others with similar conditions.5,6 One of the first studies to look at group session delivery of the low-FODMAP diet was conducted in 20137 and a further study in 20178
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COMMUNITY which had similar findings. Both studies found that the low-FODMAP diet group sessions reduced wait times and increased capacity, and that there was significant symptom relief from baseline to follow up. Ultimately, it was seen that dietitian-led FODMAP group education was clinically effective and that the costs associated with a FODMAP group pathway were worthy of further consideration for routine clinical care. The 2013 study did recognise that a significant minority attending the group sessions would have preferred one-onone sessions, but also noted that there are several possible advantages to group sessions including peer-support and sharing of experiences.7 OUTCOMES
A telephone clinic and low-FODMAP group sessions commenced in January 2018 and altered the pathway (visit www.NHDmag.com/ IBSpatientservicepathway for more on the Chester IBS service). In setting up the group sessions, we saw a definite reduction in wait times. However, we have encountered other barriers, for example, some patients don’t want to engage in the group setting; some need that one-on-one appointment to help adapt their diet on an individual basis. This has emphasised the importance of correct triaging of patients for the group setting, and enabling those who are not suited for group education to be seen in a one-on-one appointment. On the other hand, we have had many patients who enjoyed the group setting. A particular quote has been: “It’s nice to meet other people who understand my condition”, and it has been great to hear patients share low-FODMAP recipe ideas and details of local support groups etc. As it stands, the groups will continue and we will continue to adapt them to be as user friendly as possible, given the improvement it has made with the wait times. So far, we have found the following outcomes: • 75% of patients seen in the service report that their symptoms have improved. • Wait times for patients to be seen reduced from ~12 weeks to ~4 weeks. • <7% of patients seen (n=17) required onward referral to a gastroenterologist. • The total number of IBS referrals to the dietitians increased by 142% from 2016-2017. 30
• The number of referrals received from gastro consultants into the dietetic-led IBS service has increased by 103% since 2016, demonstrating that the consultants see the value of the dietetic input. • In 12 months (2017-2018) the dietetic-led IBS service has saved 161 new consultant appointments. • The service has proven to be cost effective and one that reduces pressure in secondary care by freeing up consultant time. THE FUTURE
Moving forward, the option of utilising dietitians as non-medical prescribers may further remove the need for consultant time, by allowing dietitians to manage those patients who are referred onto secondary care and who require more medical management of their condition. There are a number of medications that may be used with IBS patients, including antispasmodic agents, laxatives, linaclotide, loperamide, tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs).1 If the pathway were to introduce a non-medical prescribing dietitian, both skill sets of dietary management and medication can be utilised to optimise patient symptoms without the need for referring onto secondary care. In addition to this, the use of virtual clinics may further improve wait times and capacity, by capturing a large number of patients at one time. In January 2017, Somerset Partnership NHS Trust trialled the use of IBS group webinars to help capture more of their patients, as they found many were getting lost to follow up as a result of low-FODMAP group sessions. Their conclusions showed positive results for using the webinars, with 82% of patients finding that their confidence in managing their IBS had increased after attending the webinar and 100% of patients stating they would recommend the webinar to a friend.9 The use of webinars within dietetic services has the potential to cost-save for the NHS, as printing/room costs are eliminated. They are also able to reach a vast number of patients at one time, providing patients with the tools to manage their symptoms independently and, therefore, preventing referrals into secondary care. Something to consider in not only IBS pathways, but all applicable services within the NHS.
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