Abstract
Introduction
It is increasingly recognised within oncogeriatrics that standard fast-track pathways for suspected malignancy can be inappropriate for frail and elderly patients (Thomas et. al.; Age and Ageing; 2021; 50; ii8-ii13). Specifically for colorectal referrals, following standard pathways can mean undergoing invasive and expensive endoscopic investigations which may be unwanted and not alter overall management. Streaming frail patients to elderly medicine may increase opportunities for comprehensive geriatric assessment whilst reducing unwanted invasive tests and time spent on fast-track pathways.
Methods
A 3-month retrospective audit of frail patients seen in colorectal fast-track clinic was conducted to evaluate existing practice at Bradford Teaching Hospitals. This informed the design of a new pathway streaming frail patients directly to elderly clinic within 2 weeks. This was implemented in a 3-month pilot with data prospectively collected to compare outcomes. Cohorts:
- 26 patients (median age 79, WHO performance status 3) seen by colorectal team March-June 2022.
- 20 patients (median age 85, WHO performance status 2) streamed to elderly medicine clinic October 2022- March 2023.
Results
- Median time to fast-track pathway removal was 62 days for patients managed via colorectal clinic compared to 31 days via elderly medicine.
- Invasive tests and imaging (CT/endoscopy) fell from 1.4 tests per patient in colorectal clinic to 0.4 patients in the pilot. - 2 diagnoses of cancer made via colorectal clinic, but no further treatment for either patient. 1 diagnosis of lung cancer in pilot group, patient undergoing radiotherapy.
- Patients seen in elderly clinic had greater rates of positive diagnosis for symptoms (eg: infective/iatrogenic).
Conclusions
Streaming frail elderly patients referred via colorectal fast-track to elderly medicine reduced the number of invasive investigations undertaken and time spent on fast-track pathways. Expanding this successful pilot could improve long-term clinical quality in the service and more widely if disseminated.
Comments
Use of Frailty Scores in triage process
Hi Aidan. A really great piece of work, and I'm looking forward to listening to your presentation this afternoon.
I'm interested to see your perspective on the use of the EFI in the triage process. We have found in Leeds that some patients that we end up reviewing in the Oncogeriatric GI clinic may not be deemed truly frail, but rather have "medical complexity". For example, they may have a complicated surgical history with lots of medical co-morbidities, but when we review them in clinic they're actually not frail when we work out their CFS after we've reviewed them. We use the Rockwood CFS in Leeds, so I wondered if you had come across any similar issues with the EFI during the triage process. We've found that sometimes information on referrals and GP records can be limited, so sometimes determining a patient's level of frailty can be challenging prior to a face to face review. This has been rare however, but I was interested to learn a bit more about your triage process.
Hi Emily,
Thanks for this! I hope you enjoyed the presentation. As we discussed in the session, EFI completion was limited and- as it sounds like is the case in Leeds- we were very reliant on the (fantastic) work of the surgical ACP team in triaging referrals. I think the scoping work we did before the pilot helped, as there were a few cases that the surgical team initially highlighted as potentially suitable for Elderly Medicine review who were similar to those you've described- 'medically complex' rather than frail. We excluded these patients from retrospective review on the understanding that we would not accept such patients in the pilot clinics.
We wanted to set quite a high bar in terms of frailty to come through to Elderly Medicine, so discussing these cases as a team was valuable and informed the triage process going forwards. In short- we adapted our streaming criteria to promote streaming of very frail patients rather than a 'catch all' approach. Rockwood might be more effective in streaming in fact, simply because primary care colleagues feel more comfortable using it and completion rate might be higher, but for us there seemed to be little replacement for clinical acumen and team discussion at the point of triage.