An integrated care pathway with direct access to a dietitian-led refractory IBS (RIBS) service was set up in Gloucestershire in 2016. GPs may refer patients<45 years with symptoms fulfilling ROME criteria for IBS which is refractory to first line management (as per NICE guidance) and with faecal calprotectin (FC) level less than 150 ug/g directly to a dietitian-led clinic. The pathway and service aim to provide effective and expert management for this patient group, whilst reducing invasive investigation and referrals into secondary care gastroenterology clinics.Methods
GP requests for faecal calprotectin testing and subsequent referral to the RIBS service were audited over a 2 year period. Outcomes from intermediate FC results and referrals for lower GI endoscopy were audited annually for 6 month and 1 month periods retrospectively.Results
GP’s requested on average 31 FC tests/month in 2016, rising to 54/month in 2017. 76% of these returned a negative (<50 ug/g) or intermediate (50–150 ug/g) result, with 60% of these patients being referred to the RIBS service. Proportion of patients with an intermediate FC referred directly to the RIBS service were similar in both audit periods (2016: 29%, 2017: 29.5%) Seven patients with an intermediate FC result had a high result at re-test three months later. These cases were discussed within MDT and referred for lower GI endoscopy as appropriate. Colonoscopy audit over a 1 month period prior to service set-up (May 2015) showed 100 patients<45 years had lower GI endoscopy, 35% of these met ROME criteria for IBS. One year later, 106 patients<45 years underwent lower GI endoscopy over one month with only 18% meeting ROME criteria for IBS. This figure fell again to 10% in May 2017. In all cases where symptoms met ROME criteria for IBS, lower GI endoscopy showed no major pathology. Over 300 direct access referrals have been managed through this pathway to date with 70% patients reporting satisfactory relief of IBS symptoms following dietary manipulation. Patients who do not respond are discussed in a consultant–led MDT with advice, review or investigation arranged as appropriate.Conclusions
The integrated care pathway and direct access RIBS service has led to a reduction in patients with ROME criteria IBS referred to GI consultants and for costly invasive lower GI investigation. GPs adhere to the care pathway and request FC tests appropriately as demonstrated by the 76% return of negative or intermediate results. Our data supports the validation of a higher negative FC cut off of 150 ug/g; no cases of IBD have been missed in this patient cohort to date. We continue to recommend ongoing education and audit prospectively to ensure optimisation of the service.