P008 Improving patient care cost-effectively through a virtual rheumatology biologic clinic

Background/Aims 

There are currently around 1,000 rheumatology patients on biologic therapy in the Southern Health and Social Care Trust (SHSCT) with annual growth of > 15%. Challenges facing the Rheumatology Biologics Service include: Continued increase in demand for biologics which makes timely review and management of patients difficult to maintain; Increased availability of approved treatments for inflammatory disease which makes drug choice difficult; Regional budget constraints and the need to comply with regional efficiency savings. Expenditure in SHSCT for rheumatology biologics in 2019 was over £5.5 million. A new service model, the multidisciplinary Virtual Rheumatology Biologics Clinic (VRBC) was established to address some of the challenges facing the Rheumatology Biologics Service.

Methods 

The VRBC was introduced in May 2019 after a successful ‘Invest to Save’ proposal to the Health and Social Care Board by the lead clinician (NM). Detailed biologic drug pathways reflective of drug cost, current guidelines and patient factors and a drug tapering protocol were agreed by the rheumatology team. Each week appropriate patients were identified who were either stable and 'in remission’, had grumbling disease and needed a treatment consideration or could be switched to a biosimilar drug. Treatment recommendations were made and communicated to the clinicians seeing these patients in clinic the following week. The aim of the VRBC was to: Improve the care provided to patients by facilitating multidisciplinary review of patients; Facilitate medicines optimisation enabling a minimum 5% reduction in 2019 expenditure on biologic drugs; Introduce tapering of the biologic doses of patients in stable remission for 10% of patients.

Results 

In the first 24 weeks of the VRBC, 928 patients attended biologic review clinics. Treatment recommendations were implemented in 283 (30%) patients. 172 patients were switched to biosimilar drug, 56 patients had their biologic drug changed to an alternative and 50 had their dose of biologic tapered. Going forward, switching of these 172 patients will lead to savings of £30,078 per month on biologic spend. Optimisation of biologic drugs will lead to savings of £4,592/month in 56 patients and tapering of drug dose will lead to savings of approximately £11,335/month in 50 patients going forward.

Conclusion 

Regular virtual clinics have facilitated multidisciplinary review of biologic patients and medicines optimisation within Rheumatology. Clinicians choose biologic drug based on safety, evidence-based guidelines, patient factors and cost. Drug dose tapering was achieved in 5.4% (n = 50) of patients seen at clinic. This number will increase as the clinic progresses because patients newly switched to biosimilar drugs were not considered for tapering. A 5% reduction in expenditure on biologic drugs last year is achievable through dose tapering and choice of cost-effective drugs.

Disclosure 

J. Whiteman: None. N. Maiden: None. E. Wylie: None. V. McGoldrick: None. S. Walker: None. N. Liggett: None. L. Neville: None. C. McAteer: None. T. Boyce: None. L. McWilliams: None.

Dorsalis pedis arterial pulse: palpation using a bony landmark

INTRODUCTION

The unreliability of the pulse examination of the foot has primarily been due to variability of technique between examiners. Whereas the groove between the medial malleolus and the Achilles tendon more readily defines the location of the posterior tibial pulse, the location of the dorsalis pedis pulse remains vague. In this paper a novel method of locating the dorsalis pedis pulse by physical examination is described.

METHODS

Forty one consecutive patients admitted to a general surgery service of a tertiary medical centre within a two month period were examined. Using the dorsal most prominence of the navicular bone as a landmark, the distance to the dorsalis pedis pulse in bilateral lower extremities was measured by palpation and compared to Doppler ultrasound. Measurements were confirmed by two separate examiners blinded to each others' results.

RESULTS

The dorsalis pedis artery was palpable in 78% of extremities and present by Doppler ultrasound in 95%. The location of the left dorsalis pedis artery was a mean (SD) 9.8 (1.4) mm by palpation and 11.1 (2.1) mm by Doppler ultrasound from the dorsal most prominence of the navicular bone. The right dorsalis pedis artery was 10.4 (3.4) mm by palpation and 11.5 (0.7) mm from the dorsal most prominence of the navicular bone. No significant differences in location of the dorsalis pedis artery were observed bilaterally between Doppler ultrasound and palpation; No significant differences were observed comparing contralateral dorsalis pedis arteries nor any differences between the examiners' results.

CONCLUSION

The dorsal most prominence of the navicular bone provides a bony landmark to readily locate the dorsalis pedis artery. Reliability of the examination may be increased as to the patency of the dorsalis pedis artery by using this dependable anatomic landmark.

Patient identifiers: stumbling blocks or cornerstones for CPRs (computer-based patient records)?

As the computer-based patient record, or CPR, moves closer to reality, patient identification issues remain unresolved. A mechanism already in place would be the Social Security number, or SSN. But legal questions surround its use for specific identification purposes. And not everyone has one. Healthcare Informatics asked several people closely involved with computerizing patient records about alternatives to social security numbers. Their responses may prove enlightening.

Electronic data interchange for pharmacy inventory control

The use of electronic data interchange (EDI) for controlling pharmacy inventory at a 303-bed hospital is described. The hospital, which belongs to a group purchasing consortium, uses EDI to exchange information with its primary drug wholesaler. The pharmacy's personal computer and software provided by the wholesaler are used. EDI enables the pharmacy to (1) select and order items by using hand-held bar-code scanning devices, (2) upload this information into the pharmacy's computer, (3) review the order before transmission, and (4) access the wholesaler's inventory. The pharmacy also uses EDI with its primary i.v. supplier. Using EDI for placing the daily pharmaceutical and i.v.-supply orders reduces by one half the daily time expenditure for purchasing. In addition, EDI provides various inventory-related reports. EDI provides an efficient and effective way to control pharmacy inventory.

Computer recognition of radiopaque myocardial markers

Radiopaque markers implanted in the heart have been used both clinically and experimentally to examine cardiac function. From the position of the markers, both regional and global function can be determined. A major problem with using radiopaque markers is the excessive time required for data analysis. Each marker in every cine frame must be identified and digitized by the investigator. To circumvent this problem, a computer system was developed to automatically identify the markers. The cine film is projected onto a TV camera from which the video signal is digitized and transferred into a computer. The investigator identifies the markers in the first cine frame and thereafter the computer advances the film and locates the markers. The markers are recognized based on positional information from the previous cine frame and on a video density profile. This system greatly reduced the investigators' time required for data analysis.

Semi-automated ECG processing: A simple method to improve efficiency in ECG laboratories

A method to expedite processing of electrocardiograms (ECGs) is described. The hardware configuration utilizes conventional equipment, and the ECG data is stored in magnetic data cards. The electrocardiographer's interpretation is made using a specially developed code of 253 diagnostic statements of 2 to 9 words each. A minicomputer converts the code into full alpha-numeric description and 2 characters into English statements. The diagnostic print-out appears in the same page as the reproduction of the original ECG data. This system has significantly reduced the ECG processing time, freed manpower to increase availability of technicians and decreased the size of permanent files.