New screening pathways could improve NHS England’s bowel cancer programme

NIHR | 13 September 2021 | New screening pathways could improve NHS England’s bowel cancer programme

 NHS England’s Bowel Cancer Screening Programme aims to find warning signs in people aged 60 to 74. This population are invited to take a faecal immunochemical test (FIT) every two years. FIT measures blood in faeces and people with levels above a certain threshold are invited to have their bowel tissue examined for signs of cancer. Growths which could become cancerous (polyps) are removed and cancers prevented.

The research team set out to:

1. Explore the relationship between FIT results and bowel pathology using truncated regression, in both a univariate and multiple regression model, with demographic factors including age, sex and area-based socioeconomic status; and
2. Use these results to estimate proportions of bowel abnormalities the screening programme would fail to diagnose at different FIT thresholds (false negative rates);
3. Generate hypotheses for fuller exploitation of quantitative FIT measures.

Researchers were surprised to find that the FIT threshold for further investigation is set at a point that may miss more than half of bowel cancer cases. This highlights a need to improve the NHS screening programme.

They suggest that the programme could make better use of FIT’s ability to provide the exact concentration of blood in faeces (rather than only whether it is above or below a cutoff level).

A new, multi-threshold strategy would mean referring people different follow-up according to their results. Screening intervals could be varied, and different ways of examining the bowel could be used (for example, sigmoidoscopy examines only the lower bowel). This could reduce the number of cancers missed while minimising the demand on services (Source: NIHR & Li et al, 2021).

Full details are available from NIHR

Primary paper Faecal immunochemical testing in bowel cancer screening: Estimating outcomes for different diagnostic policies

Li, S.J. et al | 2021| Faecal immunochemical testing in bowel cancer screening: Estimating outcomes for different diagnostic policies| Journal of Medical Screening | 28 | 3 P .277-285. doi:10.1177/0969141320980501

Abstract

Objectives

The National Health Service Bowel Cancer Screening Programme (NHS BCSP) in England has replaced guaiac faecal occult blood testing by faecal immunochemical testing (FIT). There is interest in fully exploiting FIT measures to improve bowel cancer (CRC) screening strategies. In this paper, we estimate the relationship of the quantitative haemoglobin concentration provided by FIT in faecal samples with underlying pathology. From this we estimate thresholds required for given levels of sensitivity to CRC and high-risk adenomas (HRA).

Methods

Data were collected from a pilot study of FIT in England in 2014, in which 27,238 participants completed a FIT. Those with a faecal haemoglobin concentration (f-Hb) of at least 20 µg/g were referred for further investigation, usually colonoscopy. Truncated regression models were used to explore the relationship between bowel pathology and FIT results. Regression results were applied to estimate sensitivity to different abnormalities for a number of thresholds.

Results

Participants with CRC and HRA had significantly higher f-Hb, and this remained unchanged after adjusting for age and sex. While a threshold of 20 μg/g was estimated to capture 82.2% of CRC and 64.0 per cent of HRA, this would refer 7.8% of participants for colonoscopy. The current programme threshold used in England of 120 μg/g was estimated to identify 47.8 per cent of CRC and 25.0 per cent of HRA.

Conclusions

Under the current diagnostic policy of dichotomising FIT results, a very low threshold would be required to achieve high sensitivity to CRC and HRA, which would place further strain on colonoscopy resources. The NHS BCSP in England might benefit from a diagnostic policy that makes greater use of the quantitative nature of FIT.

1. Exploring the relationship between FIT results and bowel pathology using truncated regression, in both a univariate and multiple regression model, with demographic factors including age, sex and area-based socioeconomic status; and
2. Using these results to estimate proportions of bowel abnormalities the screening programme would fail to diagnose at different FIT thresholds (false negative rates);
3. Generating hypotheses for fuller exploitation of quantitative FIT measures.

Outcomes for surgical procedures funded by the English health service but carried out in public versus independent hospitals: a database study

Crothers, H., et al| 2021| Outcomes for surgical procedures funded by the English health service but carried out in public versus independent hospitals: a database study|BMJ Quality & Safety| Published Online First: 07 September 2021. doi: 10.1136/bmjqs-2021-013522

This observational study uses patient data from a health database (Hospital Episodes Database) and statistics for mortality from the ONS. This piece of research covers a variety of operation types rather than being restricted to one or two classes of operations. It also covers an entire heath system (the whole of England). The authors also include operations over an extended period of nearly one and a half decades.

Their analysis suggests that, across the range of operation types studied, patients treated in ISHPs are more likely to be discharged from hospital sooner and are less likely to be readmitted. These findings are consistent across all 18 operation types, and the effect sizes in many instances are large (Source: Crothers et al, 2021).

Abstract

Background 

The outcomes of elective surgery in public versus Independent Sector Healthcare Providers (ISHPs) are a matter of policy relevance and theoretical interest.

Methods 

Retrospective study of all National Health Service (NHS) hospitals and ISHPs in England that provided NHS-funded elective surgery. We used data from the England-wide Hospital Episode Statistics to study 18 common surgical procedures performed between 2006 and 2019. In-hospital outcomes included length of stay, emergency transfers to another hospital or death. Posthospital outcomes included readmission or death within 28 days. Outcomes were compared for each operation type by propensity score matching and survival analysis.

Results 

The data set included 3 203 331 operations in 734 NHS hospitals and 468 259 operations in 274 ISHPs.

In-hospital outcomes: Across all 18 included operation types, length of stay was significantly longer for patients treated in NHS hospitals compared with ISHPs. Effect sizes ranged from a hazard ratio (HR) of 2.15 (95% CI 1.72 to 2.68) for total hip replacement to 1.07 (95% CI 1.05 to 1.09) for wisdom tooth removal; a mean difference of 2.49 and 0.02 days, respectively.

Postdischarge outcomes: Treatment at an ISHP was associated with a lower risk of emergency readmission compared with NHS treatment. HRs ranged from 0.36 (95% CI 0.28 to 0.46) for lumbar decompression to 0.75 (95% CI 0.67 to 0.85) for cholecystectomy; absolute risk differences of 1.5 and 1.3 percentage points. There was no difference in mortality.

Conclusion 

Elective surgery in an ISHP is associated with shorter lengths of stay and lower readmission rates than treatment in NHS hospitals across 18 operation types. The data were matched on observable covariates, but we cannot exclude selection bias due to unobserved confounders.

BMJ Outcomes for surgical procedures funded by the English health service but carried out in public versus independent hospitals: a database study

Harnessing technology for the long-term sustainability of the UK’s healthcare system: report

Council for Science & Technology, & Government Office for Science | 23 August 2021 | Harnessing technology for the long-term sustainability of the UK’s healthcare system: report

This recent report identifies priorities for change in the UK’s healthcare system. and opportunities to transform the UK healthcare system. Successful integration of existing healthcare technologies could enable health system leaders to radically reshape the model of health and care delivery. These innovations are also the key to rebalancing our healthcare system, to shift our focus from acute intervention to early-stage prevention and maintenance of good health

Harnessing technology for the long-term sustainability of the UK’s healthcare system: report

Mass production methods for mass vaccination: improving flow and operational performance in a COVID-19 mass vaccination centre using Lean

Smith, I.M. &  Smith, D.T.L. | 2021 | Mass production methods for mass vaccination: improving flow and operational performance in a COVID-19 mass vaccination centre using Lean |BMJ Open Quality | 10 | e001525|  doi: 10.1136/bmjoq-2021-001525

This case example describes how one site in Northern England used the Lean systematic improvement approach to make rapid operational improvements to reduce processing times and improve flow at a National Health Service (NHS) mass vaccination centre.

The rapid plan-do-study act (PDSA)  experiments that took place were predominantly low-tech interventions involving changes to layout and the distribution of work tasks between staff working as a multidisciplinary team. Therefore, both the changes made and the practices used may be readily transferable to other vaccination centres—both in the UK NHS and, potentially, other healthcare systems.

Abstract

The COVID-19 pandemic has infected tens of millions of people worldwide causing many deaths. Healthcare systems have been stretched caring for the most seriously ill and lockdown measures to interrupt COVID-19 transmission have had adverse economic and societal impacts. Large-scale population vaccination is seen as the solution.

In the UK, a network of sites to deploy vaccines comprised National Health Service hospitals, primary care and new mass vaccination centres. Due to the pace at which mass vaccination centres were established and the scale of vaccine deployment, some sites experienced problems with queues and waiting times. To address this, one site used the Lean systematic improvement approach to make rapid operational improvements to reduce process times and improve flow.

The case example identifies obstacles to flow experienced by a mass vaccination centre and how they were addressed using Lean concepts and techniques. Process cycle times were used as a proxy metric for efficiency and flow. Based on daily demand volume and open hours, takt time was calculated to give a process completion rate to achieve flow through the vaccination centre.

The mass vaccination centre achieved its aim of reducing process times and improving flow. Administrative and clinical cycle times were reduced sufficiently to increase throughput and the number of queues and queueing time were reduced improving client experience.

The design and operational management of vaccination centre processes contribute to client experience, efficiency and throughput. Lean provides a systematic approach that can improve operational processes and facilitate client flow through mass vaccination centres.

The findings have now been published in BMJ Open Quality

Mass production methods for mass vaccination: improving flow and operational performance in a COVID-19 mass vaccination centre using Lean [primary paper]