ambulatory lung biopsy: a new model for the...
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Ambulatory lung biopsy: a new model for the NHS
Dr Sam Hare Barnet Hospital
Royal Free London NHS Trust
Lung cancer
• Leading cause of UK cancer mortality
• UK: 2nd lowest European survival rate
• 62-day RTT is worse than other major cancers (78.5%)
• Many advances in non-surgical Rx
• Early diagnosis is key to improving survival rate
Percutaneous CT-guided lung biopsy
• Pivotal in lung cancer diagnosis
• Increasing demand for tissue
• Patients with poor lung function are often delayed/
declined biopsy – a paradoxical practice
• Can’t get treated quicker unless you have a diagnosis
Book bed
Biopsy
Lung function
No PTx Significant PTx
Discharge
Admit for underwater seal drain for 24-48 hours
CXR @ 4-6 hours
Referral
Inpatient bed 4-6 hours
Book bed
Biopsy
Lung function
No PTx Significant PTx
Discharge
Admit for underwater seal drain for 24-48 hours
CXR @ 4-6 hours
Referral
Inpatient bed 4-6 hours
Is there another way?
Can it work in the NHS? Barnet model
• Integrated “in-house” radiology-delivered service
• No bed requirement
• No lung function requirement
• Early 30-60 minute discharge (>99% patients)
• Biopsy performed as standard (no new expensive kit)
• HVCD for lung collapse – patient still goes home
Results
Barnet Model
Discharge
No pneumothorax & well
CXR @ 30 mins
Biopsy
Referral
Heimlich valve chest drain (HVCD)
Improved patient experience at a fraction of the cost
Outcomes - clinical
• 1032 outpatient lung biopsies since 2011 (231 in last 6 months)
• >99% successful early discharge rate
• >98% biopsies diagnostic
• MDT: tissue already available (gold standard)
• Smaller cancers & patients previously not biopsied
• Access new treatments: RFA; SABR; gene therapies
• Lung metastases (colorectal; melanoma; endometrial)
“A game changer”
Outcomes - clinical
• Pathological confirmation rate in lung cancer >92%
• 73% increase in resection rates (2013) – T1a (<2cm) cancers
• No intra-operative frozen section for 5 years – huge efficiency savings in operating theatre time
• 85% lung biopsy referrals performed <7 days
• 38% performed <4 days
• Current service: ~10-12 outpatient lung biopsies/wk
Earlier lung cancer diagnosis with cost savings
Outcomes - financial
• Saving at least 3.5-5.5 bed hours per case in
uncomplicated biopsy
• Saving at least £400/day (inc. a bed) in cases of
significant pneumothorax
• Productivity – allows 10x increased number of
biopsies
• Referral of patients declined biopsy elsewhere
“More for less”
Benefits- Patients
• Improved patient experience
• Avoids hospital admission
• Reduced psychological burden
• Earlier lung cancer diagnosis
• Access to novel treatments
• More tissue gained at 1 biopsy sitting
Case study: TG
“Lung biopsy procedure much quicker”
“All patients should have access to the small drain”
Benefits- respiratory service • Safe biopsy even in more complex patients
• Expeditious, self-sufficient lung biopsy service
• Eliminated bed related delays in biopsy scheduling
• Respiratory inpatient bed day savings
• Respiratory clinical time savings
“Transformed the diagnostic pathway”
“Biopsies done without delay”
Benefits- NHS
• World class lung biopsy practice: early diagnosis
• Frees up beds
• Efficiency savings (QIIP)
• 90% direct cost-saving using ambulatory HVCD (£36)
versus standard inpatient management of PTx (£400)
• Shorter RTTs
• Shorter operating times (45 mins frozen section = 1
lung resection or 2 VATS lung surgeries)
NHS 5-year Forward View “What will the future look like?”
• “Networks of care” -> Scaleable nationally in small and large hospitals (infrastructure already in place; no real barriers)
• “Out of hospital care needs to become a much larger part” -> Ambulatory PTx management at home
• “Integrate services around patient; best experience for patients” -> Patient-centred management reduces psychological burden
• “We should learn much faster from the best examples, not just from within the UK but internationally” -> Pioneered in Ottawa (Canada) but this is a European first
• Best value for money” -> 90% cost savings vs. standard practice
Scaleable
Full MDT discussion of treatment options
Day 1-5
Day 28
Day 33
Day 62
Suitable for potentially curative treatment?+
Fast track lung cancer clinic. Meet LCNS. Diagnostic process plan / diagnostic planning meeting prior to clinic Treatment of co-morbidity and palliation / treatment of symptoms
Curative Intent Management pathway* Test bundle requested at first OPA including at least: PET-CT and as
required: detailed lung function and cardiac assessment / ECHO.
Meet with LCNS and receive information.
Day 0-3
No
No cancer: Manage/discharge
Day 42
Lung cancer unlikely Further management according to
local protocol with options of further management of CT findings by primary care or secondary care (see separate detailed algorithm)
CT within 24 hours if clinically indicated; inpatients seen within 48 hours by acute oncology, respiratory and/or palliative services
Yes
National Optimal Clinical Pathway for suspected and confirmed lung cancer: Referral to treatment
Surgery Specialist palliative care
Chemotherapy Radiotherapy
First Treatment
Other palliative
treatments
TRIAGE (by radiology or respiratory medicine according to local protocol) Lung cancer suspected?
Investigations to yield maximum diagnostic AND staging information with least harm. Results available within 3 days for subtype
and 10 days for molecular markers.
GP
CT abnormal?
CXR (reported before patient leaves dept.)
suspicious of lung cancer?
No
Yes
Yes
No
Yes No
Yes
Maximum times
Maximum times
High clinical suspicion?
No
Yes
Urgent or routine CXR
CT same day / within 72 hours
Further investigation(s)?
Follow-up Lung Cancer Clinic Cancer Confirmed and treatment options
discussed. Research trial considered.
LCNS present
OPA with treating specialist
(within 3 working days)
Further investigation(s)?
No
Yes
No
Yes
Clinical diagnosis or patient preference means biopsy not
required.
Will pathological diagnosis influence treatment and is potential treatment appropriate to patient’s wishes?
Day 21
Direct referral criteria
(NIC
E)
No
Further investigation(s) indicated?
No
Yes
CT suspicious of lung cancer?
No Yes
Manage CT
no
t in
dic
ated
Hospitals referrals (A&E, internal or incidental findings) for suspected lung cancer
NIC
E re
ferr
al
guid
ance
Day -3-0
Further discussion needed?
Yes
No
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*Refer to further pathway detail
$ Some or all diagnosis and staging tests may be in a tertiary centre
+ Low threshold for curative intent pathway; may discuss with wider MDT if unsure
Direct to biopsy variation?
STT plus ALB – National Cancer Diagnostic
Capacity Funding (NC&E London)
Summary
• Current lung biopsy practice:
– contributing to poorer lung cancer outcomes
– failed to evolve alongside new lung cancer treatments
• Early discharge & ambulatory HVCD to treat lung collapse are both safe
• Cost; efficiency; clinical time; and bed savings
• Improved patient experience and patient focused
• Earlier lung cancer diagnosis in more patients
