Practice-based commissioning (PBC) provides an opportunity for clinicians to develop improved and less costly pathways of care.
In Sedgefield, PBC Group's locality, we have developed a successful local enhanced service (LES) for patients with uncomplicated DVT.
This is now being offered to all practices within County Durham PCT's area. Patients with suspected DVT can spend days in hospital. They often wait four days for a Doppler ultrasound when, for uncomplicated cases, DVT diagnostic testing and treatment can be safely managed and delivered in the community, given the correct skills, equipment, medication and supervision arrangements.
Our pathway was developed over about 18 months, following consultation between clinicians working in primary and secondary care, using a collaborative approach.
The lead nurse for the project, Penny Campbell is from my practice in Newton Aycliffe and she and I have been demonstrating how it works to other practices.
The potential for savings across the PCT is large. The tariff for a one-day, non-elective in-patient stay for DVT with complications is £2,015. Without complications, it is £1,160.
A first outpatient appointment costs £215 and a follow-up appointment £92. Across the Sedgefield locality of 93,000 patients, the total cost for DVT admissions was more than £70,000 for nine months in 2005/6.
This figure did not include the cohort of patients admitted with 'query DVTs' who turned out not to have DVT. Calculation of these costs was more difficult because they are coded under general medicine.
It soon became clear that there was an opportunity to achieve major cost savings.
The tariff per patient depends on the level of care provided and is paid from the practice's commissioning budget. It ranges from £10 for a pre-test Wells assessment to £100 for a diagnosis of DVT.
An audit of patient satisfaction with the service has been very positive and we can now offer patients a choice of where they would like to have their ultrasound scan. The box on the left gives a definition of uncomplicated DVT. From this we can judge which patients should be excluded from in-surgery testing.
Practices involved in the Sedgefield pathway have seen fewer hospital admissions thanks to accurate clinical assessment using the Wells clinical probability tool.
The Wells score (see table, left) determines whether the patient requires a D-dimer blood test. There are various D-dimer tests available and we use the 'simpli-red' test, which is easy to use and provides a result within two minutes.
Patients with a positive D-dimer or a high clinical probability according to the Wells score are referred for Doppler ultrasound. We can often arrange for this to be done within four hours of the patient attending the surgery. We start such patients on low-molecular-weight heparin (LMWH).
If the ultrasound is negative, the LMWH is withdrawn and other causes for the patients' symptoms are looked for. With a positive result, the patient starts warfarin therapy.
Most patients are able to arrange transport for a scan but we have an arrangement with a taxi service for those who cannot. We have only had to use this twice and a £20 taxi is much cheaper than the £1,160 hospital admission cost for an uncomplicated DVT.
The pathway includes a protocol for dosing of LMWH and also the initiation of warfarin treatment once a DVT is confirmed. Patients are given an information leaflet and follow up-appointments for LMWH and INR blood tests.
In summary, our DVT scheme has a number of benefits including positive feedback from patients; it is an evidence-based pathway and involves a collaborative approach with nurses, managers and primary and secondary care clinicians. It also has the support of County Durham PCTs and in setting it up, we were engaging in PBC.
The pathway is generating cost savings to reinvest in patient care; practices are rewarded for their time and efforts and it frees up hospital beds.
Dr McKinty is a GP in Newton Aycliffe, County Durham. Contact Robert.McKinty@gp-A83037.nhs.uk for more details.
|Wells clinical probability score for DVT|
|Paralysis, paresis, recent plaster cast to lower limb:||1|
|Recently bedridden >3 days, surgery within 4 weeks:||1|
|Tenderness along distribution of deep venous system:||1|
| Calf swelling 3cm greater than on asymptomatic side (measure 10cm below|
|Entire leg swollen:||1|
|Pitting oedema in symptomatic leg only:||1|
|Dilated superficial veins (non varicose) in symptomatic leg:|| 1 |
|Alternative diagnosis more likely than DVT:||-2 |
|Pre-test score|| Probability |
| 3 or more||High|
Sedgefield PBC Group
- Covers a population of 93,000 in County Durham.
- Commissioning the DVT pathway, a local enhanced service, is the group's biggest success so far.
- Other areas the group is working on include medication management with pharmaceutical support for practices; GPSIs in gynaecology; heart failure protocols and access to echocardiograms and brain natriuretic peptide testing. It is also starting to look at pain management and other areas.
- Regular meetings are held at which all local practices are represented.
- The group has a management board, think tank and health improvement group.
Patients suitable for surgery testing
- Patient is not pregnant and has no recent pregnancy.
- Patient can look after himself or herself at home.
- There is no history of haemorrhagic stroke, recent surgery or GI bleed.
- The suspected DVT is not clinically extensive above the knee, and there are no factors suggestive of pulmonary embolus.
- The patient is suitable for low-molecular-weight heparin (LMWH) treatment.