1. Fast track diagnosis and management of GCA
Bhaskar Dasgupta
Consultant Rheumatologist
Honorary Professor, Essex University
Visiting Professor, Anglia Ruskin University
Southend University Hospital
NHS England Webinar 24 June 2016

2. Case Study Southend University Hospital NHS Trust
Preventing blindness by fast-tracking suspected Giant Cell Arteritis patients to immediate treatment
Outstanding Best Practice Award 2016
What was the process for the Award?
Shortlisting
Visit by the BSR – rheumatologist, CEO, Health Economist,patient
Presentation and report
Award adjudicated by experts within BSR, RCP President,NICE representatives
Distinguishing features – reduce sight loss, collaborative with primary care and other specialists, patient centred, evidence based,financial savings

3. Reduction of sight loss in GCA BSR Best Practice Workshop
The challenge
The solution
Evidence of improved outcomes (clinical, patient experience, financial)
Next steps
What was learned from the experience
What we would do differently/tips
30 minute presentation, 30 minute demo of ultrasound
Royal Botanical Gardens Birmingham June

4. Blood supply of the Optic Nerve
Why is the optic nerve so vulnerable in GCA?
Intimal hyperplasia blocking arterial lumen
Lack of collaterals
Very vulnerable to ischemic injury
Elderly patients with possibly pre-existing atherosclerosis factors

5. Fast track pathway to reduce sight loss in GCA
Permanent vision impairment is seen in 15-25% of GCA some of whom have bilateral involvement.
Irreversible ischemic complications such as sight loss occur early, prior to steroid therapy
This is preventable with steroid therapy
Need fast-track treatment analogous to stroke for GCA with ischemia
Evidence – Reggio Emilia study
Note results from VCRC survey of sight loss done in 2015
Similar results from Yellow card survey of sight loss in the UK

6. A case history 75 year old lady
Figure: 20x16cm Parietal-occipital scalp lesion representing scalp necrosis in 75 year old female patient newly diagnosed Giant Cell Arteritis taking high dose steroids for over 4 weeks. Her temporal artery biopsy taken fourteen days after commencing Prednisolone 60mg demonstrated chronic inflammatory infiltrates and giant cells were noted around the elastic lamina.
Images courtesy of Dr Shyanthi Pattapola (Rheumatology Spr Southend Hospital)

7. Flourescein angiogram showing Choroidal ischemia in GCA
Fluorescein angiogram in a patient with visual loss from GCA. In these early phase pictures note the marked darkness on the left side of the pictures denoting delayed choroidal filling of fluorescein due to severe choroidal ischaemia on the nasal half of the fundus

8. Case 2: the lucky one !! 76y male (independent, very active)
8 weeks - night sweats
3 weeks - constitutional symptoms (malaise, weak, polymyalgia)
headache and neck pain
blurred vision Right eye
Treated for presumed sinusitis
CRP 20, ESR 24

9. The lucky one !! Admitted as possible GCA
Reviewed by Ophthalmology (R optic neuritis)
Commenced immediately IV methylprednisolone
Next day vision returned
US: “halo” sign positive (L common temporal, L parietal, L frontal, R common temporal)
Discharged on oral prednisolone after 3/7 IV methylprednisolone
Biopsy positive

10. Outcomes of acute sight loss
Loss of independence
Loss of confidence
Depression
Loss of mobility
Residential care
Medical complications such as hip fractures, infections
Impact on family

11. Cost of Blindness
Low vision clinic assessment, provision of low vision aids, training in their use
Low vision rehabilitation in activities for daily living
Acute admission to geriatric ward for broken hip, total hip replacement, rehabilitation
Registration as blind or partially sighted
Community care—provision of a home care worker
Social security benefits, in particular attendance allowance
Blind person’s tax allowance
Treatment and support of depression in the elderly
C Meads and C Hyde Br J Ophthalmol :

12. What is to be done? AION in GCA : ‘Stroke in the eye’
Need a campaign analogous to ACT-FAST for stroke?
‘Time is Sight’ instead of ‘Time is Brain’
‘’Symptom to steroid time’ as a performance marker

13. Obstacles to early recognition
Delayed presentation
Delayed referral
- failure to recognize symptoms/urgency
Delayed therapy
- Multiplicity of referral routes

15. Temporal Artery Ultrasound
How long does the examination take?

16. TA ultrasound halo Definition of halo
Homogenous, hypoechoic wall thickening, well delineated towards the luminal side, visible both, in longitudinal and transverse planes, most commonly concentric in transverse scans.
The thickened arterial wall remains visible upon compression, i.e. the echogenicity contrasts hypoechoic due to vasculitic vessel wall thickening in comparison to the mid- to hyperechoic surrounding tissue.

17. Axillary vasculitis (Large-Vessel GCA)
Similar definition for axillary artery halo

18. FTP Awareness Campaign
Pathway was publicised to the sources of patient referral
Reminders every 3 months
Regular time-to-learn sessions arranged for GPs
PMRGCAUK and the groups: newsletters, meetings and to newly diagnosed patients contacting the helpline.

19. Results: Sight loss Year Total number of GCA patient
Number of GCA patients who lost vision (%) 61
19 (29)
2009 17
4 (23.5)
2010 26
7 (26.9)
2011 30
7 (23.3)
2012 33
3 (9)
Note major reduction in the absolute numbers
So it is not better results due to treatment of milder disease
Similar findings have been replicated from Norway

20. Comparisons of Pathways
GCA – conventional
(n=46)
GCA –fast track
(n=33)
p-value
GP Referral to review [days]*
3 (0-71)
1 (0-8)
0.068
Symptom to diagnosis [days]*
21 (1-196)
14 (0-168)
0.85
We also observed a reduction of the median ‘symptom to diagnosis time’ by 1 week (statistically not significant due to low patient numbers and wide range data); and the median time from referral by GP to review in rheumatology clinic, was also reduced.
*median (range)

21. Giant Cell Arteritis – A Cost-Benefit Analysis Study

22. Incremental cost effectiveness ratio
Costs and Savings
EQ-5D
QALYs
ICER is a tool helps us to compare different pathways to determine which is the best use of resources.
Involves calculating: Costs and savings, EQ-5D health questionnaire (looking at health outcomes) , Quality adjusted life years (QALY’s= life years x QOL)
In order to determine to Incremental cost effectiveness ratio (ICER).
This is to be calculated for the FTGCA pathway and the conventional referral route.
Difference in the overall costs between the conventional and FTP per patient
ICER =
Difference in the number of QALY’s gained between conventional and FTP per patient

23. Costs and Savings GP Appointments ↓ Diagnosis and Treatment
Inpatient stay
Readmissions
Drugs ↑
Training and awareness to doctors
QALY’s gained
Cost
Benefit

24. Average cost of diagnosing and treating a patient with suspected GCA
A difference of £400 per patient treated for suspected GCA.
The ICER of implementing the FTP = -£840 per QALY.
‘FTP saves money’
Conventional pathway
£2,600
Fast-Track pathway
£2,200

25. Fast track clinics & non-GCA diagnoses

26. Service Performance and Outcomes
On introduction of the FTP, the proportion of patients suffering from sight loss dropped significantly from 37% to 9% when compared with the conventional pathway.1
A reduction in the time from referral to rheumatology review was likely a major driving force behind the improved clinical outcomes observed, with 79% of patients ultimately diagnosed with GCA seen within one working day.1
Patients referred using the FTP were diagnosed 2–3 days sooner than those in the conventional pathway, limiting exposure to precautionary high-dose steroids associated with debilitating side-effects.1
Patil, P, M. Williams, W. Maw, K. Achilleos, S. Elsideeg, C. Dejaco, F. Borg, S. Gupta, B. Dasgupta (2015) Fast-track pathway reduces sight loss in giant cell arteritis: results of a longitudinal observational cohort study. Clin Exp Rheumatol Mar-Apr;33(2 Suppl 89):S Epub.

27. Financial Performance and Outcomes
Implementation of the FTP was associated with cost-savings to the Trust, with a reduction in the average overall cost of diagnosing and treating a patient with suspected GCA from £2.6k to £2.2k per patient.
In a cost-effectiveness analysis to compare the FTP with the conventional pathway, patients gained on average 2.6 quality-adjusted life years (QALYs) by avoiding the complication of sight loss.
The economic evaluation determined that the FTP dominated the conventional pathway (−£840 per QALY).

28. Patient Focus and Satisfaction
The FTP aims to ensure improved public and professional awareness of GCA, conduct rapid specialist reviews and initiation of treatments, with the aim to improve patient care by preventing visual loss and unnecessary exposure to potential harmful treatment.
Clearly defined referral pathways and well-coordinated teams ensure that care is patient-centred.
Demonstrable close links with patient groups and uniform backing from for the FTP.
Improved recruitment to GCA-related trials including GIACTA and SIRRESTA.
Public education initiatives to improve awareness including through PMRGCAuk, Fight for Sight and ARMA.

29. Commissioning Implications
Secondary prevention (King’s Fund 2013 Commissioning Priority1) – the FTP demonstrates a significant improvement in the number of patients who suffer sight-loss as a result of an avoidable complication of GCA.
Care co-ordination through integrated health and social care teams (King’s Fund 2013 Commissioning Priority1) – improved communications between primary and secondary care ensure patients are referred quickly and appropriately.
Effective medicines management (King’s Fund 2013 Commissioning Priority1) – through timely referral and diagnosis, patients avoid unnecessary side-effects of high-dose steroids.
Managing urgent and emergency activity (King’s Fund 2013 Commissioning Priority1) – through working closely with GPs and committing to advancing the education around GCA, referrals into secondary care are more streamlined and appropriate. Furthermore, the FTP allows early diagnosis of serious non GCA pathology that may mimic GCA
Naylor, C., Imison, C., Addicott, R., Buck, D. and Goodwin, N., Transforming our health care system: ten priorities for commissioners. London: The King’s Fund; 2013.

30. Target Outcomes
Target Improvement
Measure(s)
Faster diagnosis
Symptom to diagnosis time –time from symptom onset to GP diagnosis
Faster initial treatment
Symptom to steroid time – time from symptom onset to start of steroid therapy
Faster referral
Referral to review time – time to GP referral to rheumatology review
Faster assessment
Review to biopsy time – rheumatology review to temporal artery biopsy
Review to ultrasound time – rheumatology review to temporal artery ultrasound
Reduced incidence of GCA related disease
GCA disease control, cardiovascular and other co-morbidities, ischemic complications such as sight loss, strokes, resolution of inflammatory markers,
Reductions in GCA related sight loss
Percentage of sight loss
Improved cost effectiveness in GCA treatment
Reductions achieved in total healthcare cost of GCA care versus baseline cost
Improved patient safety
Adverse events related to disease – ischemic complications, large vessel involvement
Adverse events related to steroids e.g fractures, diabetes, glaucoma, cataracts,
Improved patient satisfaction
Better social care with reduced use of benefits and social services
Improved patient quality of life
HRQOL and EQ5D scores (EQ5D measures ability in 5 domains – pain/discomfort, anxiety/depression, mobility, self-care, usual activities) , sleep disturbance and vision deficit questionnaires

31. Next steps : For patients
A patient-friendly booklet which will be available as a DVD, handout or web link
which educates patients to the nature of GCA
discusses signs and symptoms with need for urgent action to prevent ischaemic complications
explains the assessment process
explains the nature of various tests
Treatment and results to expect
Online Webinar

32. Next Steps : for clinicians
an online package consisting of documents, powerpoint presentations and webinar videos, addressing:
Education and training and questions for subjective evaluation
Signs and symptoms of GCA
Tests and investigations education e.g. temporal and axillary artery ultrasound/ temporal artery biopsy
Advice and education on pathway and referral routes
Treatments and monitoring protocols
Shared-care advice and protocols
Support for co-morbidities that may affect or change management
Latest research and news

33. Thank you Case Study Southend University Hospital NHS Trust
Preventing blindness by fast-tracking suspected Giant Cell Arteritis patients to immediate treatment
Outstanding Best Practice Award 2016
Thank you
Thank you

34. Supra –aortic vascular ultrasound

35. Temporal artery ultrasound
’Halo sign’ - Meta-analysis evaluating 23 studies – sensitivity 87%, specificity 96%
Requirements- trained sonographer, linear probes covering 9-15 MHz, standaridised color adjustment, consider wall swelling, stenosis, occlusion
Axillary artery can be included
Karassa et al Ann. Intern. Med. 2005; 142, 359–369

36. Superficial temporal artery

37. Temporal Artery
Ultrasound

38. TAUS – Settings summary
Vascular preset
Use colour not power Doppler
Colour frequency 8-12 MHz
Steer colour box
PRF 2-3 KHz
Adjust colour gain to be in vessel lumen
Test settings in 30 normals
Finalise settings with US equipment reps

39. Highest B mode frequency
Large image not too dark
Vascular preset
Steer color box
PRF 2-3 kHZ
Color freq ½ to 2/3 grey scale scale

40. Axillary scan in LVV

41. „Halo“ sign vs. clinical diagnosis
Results:
pSens 81%
pSpec 94%

42. „Halo“ sign vs. TAB
Results:
pSens 73%
pSpec 84%