Patients referred under UGI 2WW Pilot direct access Standard 2WW UGI Study period 28th January 2016 – 25th May 2016 Number 2WW UGI referrals 122 203 Mean age [95% CI] 61.6 years [58.3, 64.8] 66.4 years [64.3, 68.5] First contact allocated OGD straight to test Clinic first 55% (n = 67) 45% (n = 55) 30% (n = 60) 70% (n = 143)
Time to first contact at NUH: OGD Pilot direct access Standard 2WW UGI Mean days from GP referral to direct-to-test OGD 10.0 [95%CI 9.0, 10.9] 10.6 [95%CI 8.9, 12.2] No difference between pilot direct access and standard 2WW p > 0.05
Time to first contact at NUH: clinic Pilot direct access Standard 2WW UGI Mean days from GP referral to outpatient clinic 10.7 [95%CI 7.1, 14.3] 9.7 [95%CI 8.8, 10.5] No difference between pilot direct access and standard 2WW p > 0.05
Time to first contact at NUH Pilot direct access Standard 2WW UGI Mean days from GP referral to direct-to-test OGD 10.0 [95%CI 9.0, 10.9] 10.6 [95%CI 8.9, 12.2] Mean days from GP referral to outpatient clinic 10.7 [95%CI 7.1, 14.3] 9.7 [95%CI 8.8, 10.5]
Tests requested after clinic: standard UGI 2WW
Time on UGI 2WW pathway Time spent on UGI 2WW pathway Pilot direct access Standard 2WW UGI Mean days from GP referral to ‘exit’ from UGI 2WW pathway
Time on UGI 2WW pathway Exit from UGI 2WW pathway may involve: test(s) undertaken to diagnose patient’s symptoms test(s) performed to exclude oesophago-gastric cancer
Time on UGI 2WW pathway Time spent on UGI 2WW pathway Pilot direct access Standard 2WW UGI Mean days from GP referral to ‘exit’ from UGI 2WW pathway 16.9 [95%CI 14.9, 18.8] 16.8 [95%CI 15.4, 18.2] No difference between pilot direct access and standard 2WW p > 0.05
Time on UGI 2WW pathway Time spent on UGI 2WW pathway Pilot direct access Standard 2WW UGI Exit from UGI 2WW pathway if direct-to-test OGD is 1st contact 11.6 [95%CI 10.3, 12.9] 12.0 [95%CI 9.7, 14.3] Exit from UGI 2WW pathway if clinic is 1st contact 23.8 [95%CI 20.8, 26.9] 19.1 [95%CI 17.4, 20.7] Quicker exit time from UGI 2WW pathway if only contact is straight-to-test OGD -> Caveat: test to exclude OG cancer
Time on UGI 2WW pathway Time spent on UGI 2WW pathway Pilot direct access Standard 2WW UGI Exit from UGI 2WW pathway if direct-to-test OGD is 1st contact 11.6 [95%CI 10.3, 12.9] 12.0 [95%CI 9.7, 14.3] Exit from UGI 2WW pathway if clinic is 1st contact 23.8 [95%CI 20.8, 26.9] 19.1 [95%CI 17.4, 20.7] Quicker exit from UGI 2WW pathway along standard UGI 2WW p < 0.05
Time on UGI 2WW pathway Time spent on UGI 2WW pathway Pilot direct access Standard 2WW UGI Mean days from GP referral to ‘exit’ from UGI 2WW pathway 16.9 [95%CI 14.9, 18.8] 16.8 [95%CI 15.4, 18.2] Exit from UGI 2WW pathway if direct-to-test OGD is 1st contact 11.6 [95%CI 10.3, 12.9] 12.0 [95%CI 9.7, 14.3] Exit from UGI 2WW pathway if clinic is 1st contact 23.8 [95%CI 20.8, 26.9] 19.1 [95%CI 17.4, 20.7]
Cancer diagnoses UGI 2WW pathway First contact Mode of presentation Pilot pathway Direct-to-test OGD Post-prandial vomiting, weight loss Weight loss Dyspepsia Pancreas cancer? Bowel cancer Pancreas cancer Clinic first Known ovarian cancer, known mediastinal disease, dysphagia Metastatic prostate cancer Progressive ovarian cancer
Cancer diagnoses UGI 2WW pathway First contact Mode of presentation Standard 2WW UGI Direct-to-test OGD Dysphagia Localised oesophageal CA Clinic first Dysphagia, bowel cancer surgery 2015 IDA, previous colonic adenoma Dysphagia with N OGD 2015 IDA Post-prandial vomiting, weight loss Weight loss, anorexia Weight loss with N OGD 2016 Dysphagia with SCC mouth 2004 Dysphagia with SCC palate and schizophrenia++ Weight loss with schizophrenia ++ Weight loss, vague abdominal pain IDA, post-prandial vomiting Obstructed metastatic bowel cancer from localised occurrence Localised bowel cancer Metastatic thymoma Metastatic bowel cancer Metastatic duodenal cancer Metastatic pancreas cancer Metastatic SCC ?oeso ?orophar Metastatic SCC ?oeso ?palate Localised pancreas CA Metastatic stomach cancer
Cancer diagnoses post-exit from UGI 2WW pathway First contact at NUH Mode of presentation 1 month post-exit standard 2WW UGI Direct-to-test OGD Dysphagia with N OGD [no chest imaging] Metastatic pancreas CA with lung metastases [emergency admission] Clinic first Abdominal pain with N OGD Iron def anaemia, failed CT colonography Ascending bowel cancer [re-referral C+B Gastro] Obstructed caecal bowel cancer
Complications post-exit from UGI 2WW pathway Days post-UGI 2WW pathway exit Complication 3 Emergency admission with aspiration pneumonia post-OGD, then had acute stroke day 12 of hospitalisation 7 Emergency admission with ARF requiring haemodialysis precipitated by [cardiac] ascites drainage 20 Emergency admission with pancytopenia presenting with symptomatic anaemia 5 Emergency admission with decompensated heart failure following OGD
Death post-exit from UGI 2WW pathway Days post-UGI 2WW pathway exit Diagnosis given at exit from UGI 2WW pathway 48 Metastatic SCC oesophagus with peritoneal disease 39 Metastatic pancreas cancer with liver, peritoneal and skin metastases 30 Metastatic SCC oesophagus with liver infiltration
Emergency presentation resulting in a diagnosis of cancer at NUH in 2014 Number of cancers diagnosed following emergency admission to NUH Postcode
Postcode distribution? Proportion %
Conclusions Vetting at hospital stage is not rate limiting step in exit from pathway
Conclusions Vetting at hospital stage is not rate limiting step in exit from pathway Cancers identified by GP-requested DTT OGD were not oesophago-gastric but required further tests
Conclusions Vetting at hospital stage is not rate limiting step in exit from pathway Cancers identified by GP-requested DTT OGD were not oesophago-gastric but required further tests UGI 2WW pathway more frequently diagnoses cancer outside of oesophago-gastric tract [which cannot be diagnosed by OGD alone]
Conclusions Vetting at hospital stage is not rate limiting step in exit from pathway Cancers identified by GP-requested DTT OGD were not oesophago-gastric but required further tests UGI 2WW pathway more frequently diagnoses cancer outside of oesophago-gastric tract [which cannot be diagnosed by OGD alone] There is a postcode variation in 2WW suspected cancer referrals and emergency cancer diagnoses but this is complex
Conclusions Vetting at hospital stage is not rate limiting step in exit from pathway Cancers identified by GP-requested DTT OGD were not oesophago-gastric but required further tests UGI 2WW pathway more frequently diagnoses cancer outside of oesophago-gastric tract [which cannot be diagnosed by OGD alone] There is a postcode variation in 2WW suspected cancer referrals and emergency cancer diagnoses but this is complex
Nina R Lewis nina. lewis@nuh. nhs Nina R Lewis nina.lewis@nuh.nhs.uk 0115 9691169 Extension 56335 Fax: 0115 8405821