P12 An audit on the use and monitoring of azathioprine (aza) in a paediatric gastroenterology centre. could nhs england via specialist commissioning rules (nhs-e-spr) be affecting quality of care?
Authors: Jones Emma , Cuevas Octavio Aragon 
Published: January 2018

Aim

To explore the centre’s adherence to the British Society of Gastroenterology Hepatology and Nutrition (BSPGHAN) guidelines1 regarding AZA use and monitoring and to suggest solutions in the event that substandard level of care is identified.

Methods

Data was collected on 110 gastroenterology patients (October 2014 to January 2016) on AZA from the dispensing and medicine management systems. They included patient demographics and the eleven basic AZA monitoring points recommended by the BSPGHAN guidelines: clinic attendance, height, weight, baseline Varicella Zoster status (VZS) and Thiopurine Methyltransferase (TPMT) and appropriate plasma monitoring (frequency and actual sample request) of FBC, U and Es, amylase, CRP and LFTs. The Mann Whitney Test was performed to determine if some of the demographic data had any correlation with suboptimal AZA monitoring. A ‘patient factor score’ was generated based on the centre’s compliance with these points, with a score of zero to eleven. A score of less than eleven was considered as substandard monitoring.

Results

Only 16 patients (19%) had a patient factor score of eleven. Regarding adherence to the recommended frequency of blood monitoring, only 27 (24.5%) patients were fully compliant. 3 patients (2.7%) did not have any of their blood components measured. Although TPMT was measured in 104 patients (97%), in 48 patients (46%) it was measured late. All the 7 patients (6.7%) whose TPMT was low had AZA prescribed at appropriate doses. Weight and height was not documented in 31 (28%) and 47 patients (43%) respectively. Baseline VZS was not checked in 23 (21%) of the patients. Clinic attendance was good, with only 6 (5%) patients missing their appointments. Patients who lived further away from the centre (P value=0.008), and who were taking AZA in tablet form (P value=0.000) showed a positive correlation with suboptimal monitoring. Gender, age and diagnosis showed no correlation.

Conclusion

The centre’s compliance with BSPGHAN guidelines is substandard. The positive correlation of patient distant postcodes and use of tablet formulation could be explained by poor communication between centres, the absence of a formal shared-care pathway and the fact that AZA liquid formulation is an unlicensed special. The introduction of shared-care guidelines whereby the monitoring of patients can take place at local level could improve the quality of care. However, due to the strict NHS-E-SPr2 this is not possible in paediatrics. We suggest these rules should be reviewed. Documentation and baseline checks could be improved by designing specific order sets containing all recommended parameters that could be performed at diagnosis and introducing a simple tick-based monitoring pro-forma that clinicians could use in clinic.

References

Sandhu BK, Fell JME, Beattie RM, et al. Guidelines for the management of inflammatory bowel disease in children in the United Kingdom. British Society of Paediatric Gastroenterology Hepatology and Nutrition2008:1–36.

Pan Mersey APC. Formulary: Chapter 1: Gastro-intestinal system. http://formulary.panmerseyapc.nhs.uk/chaptersSubDetails.asp?FormularySectionID=1&SubSectionRef=01.05.03&SubSectionID=A100#3555 [Accessed: 8 July 2016].