Dr Steve Kara. Dr Margaret Macky

Transcription

1 Dr Margaret Macky Clinical Lead Proof of Concept Design Initiatives ACC Dr Steve Kara Sports Doctor Axis Sports Medicine Specialists 14:00-14:55 WS #32: Musculoskeletal MRI for GPs - What's the Catch? 15:05-16:00 WS #42:Musculoskeletal MRI for GPs - What's the Catch? (Repeated)

2 MRI ACCESS FOR GENERAL PRACTICE Dr Stephen Kara Dr Margaret Macky

3 TODAY Reasons for changing How a proof of concept can demonstrate an idea worth following After 18 months, what works best? critical success factors Rolling out what this means for you

4 THE PROBLEM WE WERE TRYING TO SOLVE Common MSK injuries presenting in primary care being referred to specialists when they could be managed within primary care environment Long delays inherent in pathway time cost to patients Lack of options for primary care ACC has a fragmented fee for service funding approach - [we] need to shift to a different model of funding based around the client ( patient) where we understand the outcomes we are seeking and enable those in the sector to work innovatively to deliver good healthcare. Overuse of highly skilled secondary care resource Not every referral actually needs specialist care Low conversion to surgery Potential for narrowing options for treatment

5 MRI ACCESS NOT ALWAYS SEEN AS COST EFFECTIVE Overseas experience demonstrates early access for MRI after injury is not contributing to better injury resolution Where guidelines and audit not in place, GP open access to MSK MRI has not led to better outcomes What s evident? MRI like all investigations have to be targeted at points in presentation where it will change management Guidelines and training do improve high yield investigations

6 PARTNERSHIP 2017 SECTOR PARTNERSHIP Shared decision making Shared responsibility Shared value Shared design & delivery Shared risk Shared outcomes Shared investment

7 CO-DESIGNED E referral Active patient centric engagement IT, call centre Clinical decision support Refined with GPs, radiologists, specialists, physios and clinical assurance 7 times Multi-disciplinary education delivery Physio, radiology, specialist, GPs GREAT OUTCOMES FOR PATIENTS

8 PATIENT JOURNEY FOCUSSED Patient centric Outcomes focused Measurable Equitable

9 PRINCIPLES

10 ACCREDITATION PROCESS

11 PRIMARY CARE CENTRED PATHWAYS Limited number of conditions: 1. Lumbar or Cervical Spine 2. Knee 3. Shoulder

12 MAKE A CLINICAL DIAGNOSIS Supported by: 1. Clinical hands-on teaching sessions that form part of your CME / CPD and therefore you need to attend 2. Clinical audits MOPS points attached 3. Quality assurance feedback 4. In-practice visits

13 History History - History GP EDUCATION & UPSKILLING Hands On practical sessions Time efficient clinical examinations Learnings fed back = common clinical pitfalls

14 Watch them walk into the room antalgic, alignment, walking aids, braces? Sit on edge of bed and straighten knee extensor mechanism intact Lie down straighten knee and bend knee fully Swipe test MOST IMPORTANT TEST YOU CAN DO Patella Palpation Test Ligaments in full extension and 30 degrees of flexion 2MIN KNEE EXAMINATION Bend knee to 90 degrees anterior drawer and posterior drawer Palpate joint lines and do a meniscal provocation tests

15 WHAT HAVE WE LEARNT FOR SHOULDERS? 1. MRI Utilization 6% 2. Clinical history and examination outweigh investigations in diagnosis and management CLINICAL HISTORY EXAMINATION IMAGING ACJ PATHOLOGY Zanca View ROTATOR CUFF FULL THICKNESS TEAR ADHESIVE CAPSULITIS GHJ INSTABILITY Westpoint View KINEMATIC SHOULDER PAIN RC partial thickness tear RC tendinopathy Bursitis Impingement

16 SHOULDER EXAM IN <5MINS? 1. Stand active ROM (painful arc flexion rotation) 2. Stand passive ROM (>active ROM esp. rotation?adhesive capsulitis) 3. Resisted movement abduction / ER / IR (pain or weakness) 4. Sub-acromial impingement testing (think biomechanical issues and need to correct these to best manage +/- pain management) 5. ACJ provocation test cross arm adduction + weakness with resistance 6. GHJ Instability anterior apprehension testing

17 API CONNECTED E-REFERRAL

18 RADIOLOGY COLLABORATION Radiology led patient appointment booking Primary Care Centric Reporting Comprehensive Standardised Contain radiology recommendation aligned to clinical pathways

19 543 (95%) Total MRIs reviewed for assurance JULY 2018 DASHBOARD Consistent with Guidelines Does not follow guidelines but still useful Does not follow guidelines & NOT useful 14% 5% 573 Total MRIs (to 31 st July 2018) 148 GP s from 65 practices now ordered MRI s 81%

20 1. MRI Reports 30 out of 573 not reviewed practices targeted for meetings due to compliance issues or high volume: 8 practices met with good feedback & appreciative of clinical updates 2 not being chased 1 GP leaving practice / 1 not ordered since April being monitored as ordered again after several months & again not an appropriate request (ordered total 6 with 66% not appropriate) 1 practice difficult to meet to date MONTHLY UPDATE Jul-18 May-18 Mar-18 Jan-18 Nov-17 Sep-17 Jul-17 May-17 Mar-17 Monthly Ordering of MRI s Series 1

21 MRI ORDERING BY BODY-SITE MRI BODY SITE (N=543 REVIEWED MRI S ONLY) Shoulder Knee Lumbar Spine Cervical Spine 6% 7% 31% 56%

22 JULY DASHBOARD 573 total MRI scans requested 543 (95%) Total MRIs reviewed for assurance 14% 5% 81% Consistent with Guidelines Does not follow guidelines but still useful Does not follow guidelines & NOT useful

23 QUALITY ASSURANCE &FEEDBACK Report to each GP Total no of MRIs Body-site breakdown of ordering Comparison of practice ordering with overall ordering Adherence to MRI Guidelines Individual ordering feedback re adherence to guidelines 1. Consistent with guidelines 2. Not consistent with guidelines but MRI still useful 3. Not consistent with guidelines & MRI not useful

24 BENEFITS TO PATIENTS, GP & ACC Yes we can! MSK skills gained and retained Time saving 16 working days in Auckland Good experience Responsible use of scanning Too early to know how cost effective it is but enough evidence to test out at larger scale

25 NEXT STEPS Extending to all radiology providers in Auckland region for MRI Plans underway to provide training and access for GPs in other regions Considering referral routes for GPs when surgery is not the preferred option : What about creating clearer pathways alongside physical therapy/physiotherapy?