G361(P) Local vs. regional pathway and cost- implications in the renal monitoring and management of henoch-schönlein purpura

Abstract

AimsHenoch-Schönlein purpura (HSP) is an IgA mediated commonest systemic vasculitis with risk of long-term renal involvement. The regional pathway (Alder Hey) recommends a six- month nurse led follow-up with stratification of children into either Standard Pathway(SP) or Proteinuria Pathway(PP) at one week after presentation with PP cohort at increased risk of renal involvement. Our objectives were to compare our local practice management with regional pathway and study its cost implications.MethodsA retrospective audit involving 50 consecutive children (33 males;17 females) diagnosed with HSP from 2011–14 formed the study cohort. The mean age at presentation was four years and one child was followed-up at a different organisation. At presentation, blood pressure(BP) and urine analysis(UA) were undertaken in all 50 patients. 29 patients had normal UA and BP, 16 had abnormal UA and 4 had hypertension. All 49 patients were evaluated at one week and sub-classified into SP (47) and PP (2), but an additional 5 children in SP became proteinuric during the study course.ResultsSP cohort had far more than the recommended number of health professional(HP) reviews, UA and BP monitoring but at a random/variable frequency. PP cohort had more than the recommended number of HP reviews in the initial few weeks of presentation but the majority missed the later key intensive scheduled reviews. UA and BP was done at the majority of the reviews but none had the Primary investigations (Urea and electrolytes, Urine microscopy and Urine protein creatinine ratio), potentially missing out on early identification of renal involvement. None of the seven patients in the Proteinuriapathway developed any long-term renal sequelae. Altogether there were atleast 171 HP reviews and 15 inpatient admissions which were unwarranted and far more frequent UA monitoring. This created more anxiety/inconvenience among patient families and stretched HP resources.ConclusionWe introduced a modified local nurse-led community pathway(mLNCP) to standardise care, improve clinical care and cost-efficiency without compromising safety. Adherence to the new mLNCP would have resulted in an estimated cost-savings of £48,000. The second part of the audit evaluating the efficacy of mLNCP is on-going (2016 onwards) and closure of the audit loop is anticipated in near future.