Evaluating a test-and-treat pathway

An evaluation is under way on a new pathway for patients with acute respiratory infections. Omobolanle Olagunju, who is working on the project for Health Innovation North West Coast, describes its aims.

This winter, Health Innovation North West Coast is working with PCNs in our region on the real-world evaluation of the new care pathway to test and treat acute respiratory infections (ARIs) in primary care settings. We are doing so to explore the clinical and economic impact of introducing on-demand, rapid point-of-care systems and tests in primary care and the resulting pathway changes.

Winter puts tremendous pressure on primary and secondary care because of the sudden increase in patients seeking medical attention and rises in acute respiratory infections (influenza A/B, SARS-CoV-2 and respiratory syncytial virus). Integrated Care Systems provide an opportunity to implement new ‘test and treat’ pathways which have the potential to significantly reduce pressures on hospitals, make the best use of resources across the healthcare system and improve outcomes for patients.

Traditional boundaries have often acted as barriers to implementation of new pathways. One of the beauties of the Integrated Care Systems is that they help us to dissolve these boundaries by the development of policies and governance frameworks, and many people agree that real-world evaluations are needed to inform recommendations and decision-making.

The existing care pathway for patients who have suspected ARIs in primary care settings is often based on the best judgement of the clinician. The GP will often advise patients to keep warm and stay hydrated; patients may be told to get over-the-counter treatments in community pharmacy; ‘rescue packs’ could be recommended for patients with comorbidities; the GP could direct patients to A&E and secondary care when they deteriorate quickly.

Patients with respiratory symptoms usually do not escalate to their GPs until 7-10 days after their first symptoms, by which time they would be acutely unwell, and it would be too late for the GP to prescribe antivirals under NICE guidelines. With authorisation from the Chief Medical Officer, at-risk cohorts can be treated with antivirals in primary care. However, without diagnostic certainty and the delays in presentation of the patient, many clinicians choose to err on the side of caution and administer antibiotics.

One of the challenges clinicians in primary care settings face is lack of diagnostic certainty. This project is very important in this respect: it will give GPs the all-important diagnostic certainty which will influence their decision as to what to prescribe to the patients, and thus improve antimicrobial stewardship. Also, it will improve the wellbeing and confidence of the patients as it means they are getting the right treatment for their illness. This would ultimately reduce the pressure on secondary care settings.

The project team will be using a theory-based real-world evaluation approach because the point-of-care tests will be deployed to a complex real-world setting – in a hub and/or GP practice – with multiple external influences.

We will be working with primary care to implement the tests and design the theory of change. The eligible patient cohort for this project will be those who meet the NHS England eligibility for flu vaccination.

We invited stakeholders from PCNs and pathology networks in the North West to co-design with us a robust theory of change which outlines the changes we expect to see in the new pathway, including the intended outcomes, activities, and inputs, and ultimately agree the aims of the evaluation. We also captured their insights into the barriers and unintended consequences of the pathway change as well as its advantages. The co-designed theory of change will be published shortly.

We will make use of mixed methods for the real-world evaluation: qualitative and quantitative. The qualitative method will involve a survey and semi-structured interviews with clinicians and primary care staff to understand acceptability, barriers to implementation and spread of the new pathway and any perceived benefits. The quantitative analysis will involve a cost benefit model to compare the costs of the new and old pathway and data from patients who present to the GP and are tested, to understand the impact of the new pathway.

Testimonials from the 2022-23 project

Last winter we carried out a similar pilot study to co-create the new pathway with primary care and complete a service evaluation on the influenza pathway. Here are testimonials from some of the patients who participated:

“I felt glad to have a confirmed diagnosis of why I felt the way I did – it was really helpful”

“The test was very quick and easy to do. I was informed that my test was clear promptly”

“Was good to know in 20 minutes that I had flu”

“The very thorough and quick response was excellent. I was asked to go in and see the GP at the surgery. I was thoroughly checked over and the test was done there and then. I returned home and was telephoned by the GP to confirm that I had flu. Medication was arranged. Although I got a secondary infection, I was relieved I had got the care from my GP's surgery at the outset. Extremely satisfied with the service”