Rapid Access Lung Cancer Clinic Deferral Letter Audit

Title: Rapid Access Lung Cancer Clinic Deferral Letter Audit
Author(s): R. Tyrrell, O. Shinners, J. Lowry, A. Scott, S. Shahsavari, U. Khan, A. O’Brien
Institution: University Hospital Limerick
Poster: Click to view poster
Category: Lung Cancer/CF/ILD/Surgery
Abstract: The National Cancer Control Program (NCCP) provide guidance on optimum patient referral times within the Rapid Access Lung Cancer Clinic (RALC). NCCP recommends patients to be seen within two weeks of their referral window. University Hospital Limerick is the only centre that facilitates this within the Mid-Western Hospital Group which boasts a population of over 400,000 people. Furthermore, there is a large volume of referrals with a resultant strain to meet the optimal performance index. It was suspected that a number of referrals with abnormal chest x-rays may not need to be seen under the provision that the clinical picture was in keeping with acute infection. We devised a system to streamline the referral process and lessen the strain of increasing numbers. It involved triage of referral letters with careful selection of cases meeting the above criteria. A deferral letter would then be composed to the GP advising repeat imaging following a course of antibiotics with the caveat that if the abnormality persisted to to re-refer to the RALC. The aim of this audit was assess the efficacy of this deferral process and its impact on our our services continuity of care.

We performed a review of all deferral letters sent from July 2017 to March 2020. We carefully selected the letters which met the above inclusion criteria. Using the NIMIS radiology systems we separated the results into three categories: (1.) Those re-referred as repeat imaging showed persistent changes. (2.) Those who were not re-referred as repeat imaging showed total resolution of abnormality and (3.) Those not re-referred with no evidence of repeat imaging present on the NIMIS system. We subsequently contacted the referrers of the third category to investigate if the imaging had been requested.
Conclusion: A third can be safely triaged for primary care follow up.

Eighty five (n = 85) out of three hundred and twenty three letters (n=323) met the inclusion criteria. 38 patients (44%) were re-referred as repeat imaging showed persistent changes. 27 patients (32%) were not re-referred as repeat imaging demonstrated resolution of the abnormality. 20 patients (24%) were not re-referred and no repeat imaging was performed..
Of these 20 patients the initial referrers reported that 7 (34%) of patients did not attend their appointments, 6 (33%) patients had their follow up images performed either privately or in another hospital group and 6 (33%) patient’s referrers had not booked follow up imaging.

Not all RALC referrals require the same level of assessment. This is of particular importance in large centres where resources are being placed under increased strain. As a result of this audit, it can be shown that up to a third of patients can be safely triaged back to primary care for follow up. With further evaluation this is may be an important criterion for consideration when devising National Guideline. Further study is required to determine whether these improvements lead to improved efficiency and cost-effectiveness.