Citation: British Journal of Haematology. 2019, 185, 181-82
Author: Shaw R.J.; Johnstone M.; Simon C.; Brearton G.
Abstract: Myeloma is a serious haematological cancer developing from the proliferation of clonal plasma cells. The presenting symptoms can be varied and include anaemia, bone pain or renal dysfunction; therefore patients may present to a number of different specialties. Delay in diagnosis and treatment can cause psychological distress, and may also mean the disease presents at a more advanced stage with increased end organ damage. In October 2014, the five year forward view was produced by NHS England to set out a direction for the NHS in a changing society. To improve outcomes specifically for cancer, targets were set with an aim to streamline cancer care by 2020. Local practice was compared against national standards as per the 5 year forward view: including time from referral to seeing a specialist being no more than 14 days and time from referral to diagnosis being confirmed / excluded being no more than 28 days. Local practice was also reviewed against local standards: time from internal referral of suspected malignancy to review by a specialist should be within 24 hours. Local outcomes were then compared pre and post introduction of the "one-stop" clinic model. A retrospective review was performed over a two year period from 01/07/2016 - 30/06/2018. A local database identified patients with a new diagnosis of multiple myeloma or plasmacytoma. The patient electronic medical record was used to identify patient characteristics including age, diagnosis and treatments. Unity was used to identify referral dates. Data was collected and analysed using Microsoft Excel 2013 and episodes were analysed pre and post introduction of a streamlined "one-stop" clinic model. 81 patient episodes were reviewed, 22 were excluded either due to incomplete data or due to patient decision to decline therapy. The mean age was 71 years (range 35-92 years). 54 had a new diagnosis of multiple myeloma, 19 with myeloma progressed from known MGUS and 8 with plasmacytoma. Referrals were received from GPs and various hospital specialties. Twenty-five patients were referred directly from their GP; frequently referring hospital specialties included Nephrology (N = 12), Orthopaedic/Spinal (N = 12), General Medicine (N = 13). The Trust is unique in providing care for patients from the Isle of Man, with 16 patients referred. The mean time from referral to seeing a specialist prior to the "one-stop" clinic model was 14 days vs. 7 days post implementation. Excluding those with plasmacytoma; the mean time from referral to diagnosis (on bone marrow biopsy) prior to the "one-stop" clinic model was 31 days vs. 22 days post implementation. The median time from date of clinically suspected diagnosis to commencement of treatment prior to the "one-stop" clinic model was 49 days vs. 36 days post implementation. This data demonstrates that the "one-stop" clinic model has improved time from suspected diagnosis to specialist review, diagnosis and commencement of treatment. The improvements implemented include: Identifying those with highly suspected diagnosis of myeloma at time of referral to facilitate bone marrow biopsy on the same day as 1st clinic review Telephoning patient ahead of 1st follow up appointment if further diagnostic testing required (eg PET-CT / MRI) The data highlighted the significant number of referrals from other specialties and therefore potential areas for ongoing improvement include education for trainees in frequently referring specialties.
