Outcomes and cost effectiveness analysis of fast track pathway in giant cell arteritis

Background: With an incidence of 2.2 per 10 000 patient years, it is estimated that 12 000 new cases of GCA are diagnosed every year in the UK of whom 20% lose sight permanently. This has significant implications on personal, social care and socioeconomic costs. A fast-track GCA pathway was introduced in 2012 aimed at reducing multiple referral routes, delayed review and treatment and improving outcomes. We report the outcomes and cost effectiveness of this pathway. Methods: A retrospective data analysis of 138 patients investigated for GCA (Jan 2009–Dec 2012), comparing costs of fast-track pathway (57 patients; Jan–Dec 2012) with the conventional referral route (81 patients; pre 2012) using the incremental cost effectiveness ratio (ICER). Data were collected from patient records, general practice and pathology databases along with telephone questionnaires. Direct costs included: GP appointments, investigations such as blood tests, scans and biopsies, outpatient appointments (Rheumatology, Eye Clinic and Neurology), A&E attendance, Inpatient stays, readmissions, drugs for treatment of GCA. Costing data for treatment and diagnosis costs was gathered from Reference Costs 2011/12, Prescription Cost Analysis 2012, and Unit Costs of Health and Social Care 2012. QOL was measured in 66 patients using the EQ5D. Health gains from diagnosis and treatment of GCA were quantified using Quality Adjusted Life Years (QALYs). Results: The fast track pathway resulted in significant reduction in irreversible sight loss from 22.0% (as seen in the historical cohort 2009–2011) to 9.1% (2012 onwards, OR 0.17, P = 0.009). Adjustment for clinical and demographic parameters including known risk factors for GCA associated blindness did not significantly change the primary result (OR 0.03, P = 0.007). We noted a reduction in symptom onset to diagnosis, particularly by reduction in time from GPs’ referral to the rheumatology review (59.1% of fast track pathway patients were seen within one working compared with 33.3% in the conventional pathway, P = 0.105). The fast-track pathway has seen a reduction in number of GP appointments and cost of diagnosis and treatment. The difference in QALYs between patients with and without sight loss due to GCA was 0.2. Each patient that did not lose vision gained on average 2.6 QALYs. The average cost of diagnosing and treating a patient with suspected GCA in the conventional pathway was £2600, whilst in the fast-track this was £2200, a difference of £400 per patient. The ICER of implementing the fast-track pathway is –£840 per QALY. Thus, there is an average cost saving to the NHS of £400 for each patient treated for suspected GCA (Table 1). Patients with sight loss and the costs of treatment/diagnosis in conventional and fast-track pathways Patients with sight loss and the costs of treatment/diagnosis in conventional and fast-track pathways Conclusion: Implementation of a GCA fast track pathway led to a reduction of permanent sight loss in newly referred GCA patients. The effect is attributable to reduction in delayed diagnosis and therapy; however, other difficult to measure factors including increased awareness of general practitioners, the public and direct referrals to the rheumatology clinic might have contributed to this result. Also, there is a significant reduction in diagnosis and treatment costs. It results in 2.6 QALYs gained for each patient that does not suffer sight loss, suggesting that the fast-track pathway is more cost effective than the conventional pathway for management of early GCA. The ICER of implementing the fast-track pathway is –£840 per QALY with an average cost saving to the NHS of £400 for each patient. Our results do not include the small educational/refresher costs and are preliminary but indicate that the Fast track GCA pathway should be rolled out globally. Disclosure: None