An evaluation of the Waitemata District Health Board Bowel Screening Pilot is being undertaken to help inform a decision on whether it is feasible to roll out a national bowel screening programme.
This report follows up issues identified in an immersion visit undertaken in 2012 to explore the early implementation of the pilot. It also explores the more recent impact of the pilot on the investigation, surveillance and treatment stages of the pathway.
The report includes excerpts from 30 phone and face-to-face interviews, and group discussions, with providers across the screening pathway.
Methodology
Evaluators from Litmus visited WDHB and undertook 30 face-to-face, phone interviews and group discussions with providers across the screening pathway (including representatives from the Ministry, WDHB, and LabPLUS). Fieldwork was undertaken in October 2013. All interviews followed an informed consent process.Key Results
By January 2014, the BSP will have completed screening round one as all those in the eligible population living in WDHB should have received a pre-invitation letter followed by the iFOBT kit. At the time of the 2013 immersion visit, the BSP had three core foci:- implementing business-as-usual screening processes across the BSP pathway
- monitoring quality standards and identifying, implementing and assessing quality improvements
- preparing for screening round two.
The following strengths were identified with the BSP:
- integrated with the Ministry’s Bowel Cancer Programme
- participants’ positive experience through the BSP screening pathway
- high functioning multi-disciplinary team working effectively across the screening pathway, linked together via a range of networked meetings and led by respected and motivated clinical leaders at national and regional levels
- quality improvement is embedded into the BSP through the monitoring and review of quality standards and auditing processes.
- Ensuring fair access for all New Zealanders. In 2013, work has been undertaken by WDHB to identify strategies to seek to increase the participation of Pacific people (in particular) and Māori, given their emergence as underscreened populations. Many of these strategies were implemented late 2013 or will be implemented in screening round two. Consequently, it is too early to assess their impact on participation.
- Having adequate colonoscopist capacity. As in 2012 having adequate colonoscopy capacity to meet quality standards continues to be identified as a key challenge for the BSP. While this challenge remains in 2013, the wait times for participants to have a colonoscopy have not exceeded the quality standard. To achieve this, the BSP Programme Manager, WDHB BSP Clinical Director and the Clinical Nurse Specialists (CNS) work continuously to encourage and support endoscopists from WDHB, other District Health Boards (DHBs) and private consultants to undertake the lists available.
- Ensuring the data quality and completeness of Register data. The following are key improvements needed to enhance the Register:
- develop a strategy to enhance accuracy of participant contact details and to identify eligible participants moving into WDHB
- ensure the knowledge management system on the Register is complete and clearly specifies variable definitions and assumptions underpinning data generated
- ensure the Register has all the data fields necessary to meet quality and other reporting requirements, particularly with regard to histopathology and treatment data
- agree the process and frequency to validate and audit data on the Register at WDHB and the Ministry
- ensure adequate IT support at the Ministry to undertake updates and refinements to the Register as needed.
- A number of issues reflecting the implementation stage of the BSP are now emerging:
- Management of completed samples using an expired iFOBT kit. By 10 December 2013, 72 completed iFOBT kits were received that had been completed after the printed expiry date (which is about 0.1% of completed kits). The Ministry, WDHB, LabPLUS and the supplier worked together to agree the appropriate response to this issue. Currently, expired kits are identified after they are tested. While this is not failsafe due to the potential for human error, there are fewer risks identifying at this stage than before testing.
- At present, participants with positive expired iFOBTs are referred for a colonoscopy, and those with a negative result using an expired iFOBTs are asked to repeat the test. Supply arrangements have been changed to ensure the maximum possible time before expiry, and participant brochures and pamphlets have been updated to encourage prompt completion.
- Management of incomplete colonoscopies. Endoscopists are aware that it is critical that BSP participants who have incomplete colonoscopies are rescheduled quickly. However, the process to transfer and the responsibility for ensuring these BSP participants are seen promptly via the symptomatic list is not clear to all and feedback indicates the process is not seamless. Action has been taken to address this issue through the establishment of a monthly general anaesthetic colonoscopy list at Waikatere Hospital.
- Impact on symptomatic services through increasing number of BSP surveillance colonoscopies. Stakeholders interviewed recognised that the high level of polyps detected via BSP colonoscopies will, over time, add significantly to the symptomatic colonoscopy lists. While the accumulative effect of the surveillance colonoscopies have not yet impacted on the symptomatic list, there is some evidence that BSP participants requiring surveillance colonoscopies at one year are not receiving timely appointments.
- Planning has been undertaken to quantify known issues with symptomatic colonoscopy lists and to assess the impact of BSP participants being referred for surveillance colonoscopies.
- A business case to the WDHB has resulted in additional resources to address the needs of symptomatic patients as well as to accommodate the flow on effect of BSP surveillance colonoscopies.
- The impact of the BSP on symptomatic services needs to be monitored.
- Impact of the BSP on treatment services both surgical and oncology. As at 30 June 2013, 98 people had been diagnosed with cancer through the BSP. Since the Pilot commenced there has been a decrease in the full time equivalent of surgeons available, as a result there are pressures on surgical resources. The availability of theatre space was also highlighted as creating a barrier to ensuring timely surgical intervention.
- Like surgical services, the increase in the number of cancer patients identified by the BSP is starting to put pressure on oncology services due to no additional resource being allocated to this service. As the BSP moves into screening round two, this pressure may dissipate as fewer BSP participants will be identified with late stage cancers.