London Memory Service Audit

Transcription

1 London Dementia Strategic Clinical Network Date London Memory Service Audit Dr Jeremy Isaacs Consultant Neurologist St George s University Hospitals NHS Foundation Trust Clinical Lead Effective diagnosis London Dementia SCN 04 November

2 Organisational data items: Memory service MSNAP accredited Integrated clinic (Geriatrician +/- neurologist) Home visit service Service 1 Yes No Yes Service 2 No No Yes Service 3 No No Yes Service 4 Null No Yes Service 5 No No Yes Service 6 No Yes with a geriatrician Yes Service 7 No Yes with a geriatrician Yes Service 8 Yes Yes with a geriatrician Yes

3 Referral breakdown: Memory service Number of patients Male Female Median age at referral % under 65 years Service % Service % Service % Service % Service % Service % Service % Service %

4 Patient demographics: Ethnicity 70% Ethnicity: % non-white british 60% 60% 50% 40% 36% 37% 36% 30% 24% 30% 24% 20% 10% 9% 0% Service 1 Service 2 Service 3 Service 4 Service 5 Service 6 Service 7 Service 8

5 Referral: Average wait to be seen in weeks Average wait to be seen % of patients seen within 6 weeks of referral date Service 8 Service 7 100% 100% 98% Service 6 80% 84% 86% Service 5 Service 4 60% 46% 54% Service 3 40% Service 2 20% 21% 23% Service Weeks 0% Service 1 Service 2 Service 3 Service 4 Service 5 Service 6 Service 7 Service 8

6 Referral: Reasons for delay Reason for > 6 weeks to be seen Service 8 Service 7 Service 6 Service 5 Service 4 Service 3 Service 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Patient choice or delay Service capacity constraint Poor quality referral Not specified

7 Referral: Place of assessment 100% 80% 60% 96% 40% 86% 73% 20% 22% 32% 28% 49% 0% Service 1 Service 2 Service 3 Service 4 Service 5 Service 6 Service 7 Home Memory service Not known/not recored

8 Diagnostics: scanning 80% % of patients who had a CT / MRI scan 70% 60% 50% 40% 30% 20% 10% 0% Service 1 Service 2 Service 3 Service 4 Service 5 Service 6 Service 7 Service 8 CT 14% 30% 56% 32% 67% 42% 3% 75% MRI 50% 15% 2% 55% 7% 26% 31% 4% No scan 36% 56% 42% 14% 27% 33% 29% 14% Unknown 0% 0% 0% 0% 0% 0% 37% 7%

9 Diagnostics: CT / MRI waiting time Memory service Service 1 Service 2 % of CT scans within 30 days of assessment date 71% (n= 5) 2 x unknown 25% (n=8) % of MRI scans within 30 days of assessment date 56% (n=14) 1 x unknown 0% (n= 2) 1 x unknown Service 3 28% (n= 25) 100% (n= 1) Service 4 Service 5 Service 6 86% (n= 7) 1 x unknown 23% (n= 30) 3 x unknown 50% (n= 18) 3 x unknown) 100% (n= 12) 100% (n= 3) 0% (n= 11) 3 x unknown Service 7 Not provided Not provided Service 8 95% (n= 21) 1 x unknown 100% (n= 1)

10 Assessment: Neuropsychology 100% % of patients referred to neuropsychology 90% 80% 70% 60% 50% 40% 30% 30% 20% 10% 0% 14% 4% 4% 4% 7% 4% 0% Service 1 Service 2 Service 3 Service 4 Service 5 Service 6 Service 7 Service 8 Yes Yes pt declined No Not required Unknown

11 Diagnosis: diagnosis of dementia 65+ years 100% 96% % of 65+ years diagnosed with dementia 100% 90% 82% 80% 70% 69% 68% 60% 50% 53% 55% 40% 37% 30% 20% 10% 0% Service 1 Service 2 Service 3 Service 4 Service 5 Service 6 Service 7 Service 8 Dementia diagnosis No dementia No diagnosis as yet NULL

12 Diagnosis: diagnosis breakdown 65+ years 100% Null 90% No diagnosis / No illness 80% No diagnosis as yet Subjective cognitive impairment 70% Primary psychiatric diagnosis MCI 60% Unspecified dementia 50% Creutzfeldt-Jakob disease Korsakoff Syndrome 40% 30% 20% 47% 52% 73% Parkinson's disease dementia Frontotemporal dementia Dementia with Lewy bodies Vascular dementia 10% 18% 29% 21% 13% 25% Mixed dementia Alzheimer's disease 0% Service 1 Service 2 Service 3 Service 4 Service 5 Service 6 Service 7 Service 8

13 Diagnosis: under 65 years Memory service Number of referrals under 65 years Total diagnosed with dementia Service 1 5 (n= 50) 1 Service Service 3 5 (n= 45) 1 Service Type of dementia Alzheimer's disease Vascular dementia Service 5 4 (n= 45) 1 Service 6 10 (n= 43) 0 Unspecified dementia (1 x no diagnosis as yet) Service 7 5 (n= 35) 1 Mixed dementia Service 8 0 0

14 Diagnosis: Stage of Alzheimer s disease Stage of Alzheimer's disease at diagnosis Service 8 43% Service 7 Service 6 11% Service 5 33% Service 4 31% Service 3 43% Service 2 21% Service 1 5% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Mild Moderate Moderate/Severe Servere Null

15 Diagnosis: Stage of mixed dementia Stage of mixed dementia at diagnosis Service 8 Service 7 Service 6 20% Service 5 Service 3 Service 2 13% Service 1 25% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Mild Moderate Moderate/Severe Servere Null

16 Diagnosis: Referral to diagnosis Date includes: dementia and non-dementia diagnosis (null return from service 7). 20 Average wait in weeks from date referral received to date of diagnosis Service 1 Service 2 Service 3 Service 4 Service 5 Service 6 Service 8

17 Number of patients Treatment: dementia drug - Alzheimer s disease Dementia drug: Alzheimer's disease Service 1 Service 2 Service 3 Service 4 Service 5 Service 6 Service 7 Service 8 Donepezil (Aricept) Galantamine (Reminyl) Memantine (Ebixa) Rivastigmine (oral) (Exelon) Rivastigmine (transdermal patch) Patient declined No drug Null Pt not seen

18 Treatment: Dementia drug - Dementia with Lewy Bodies 3 Dementia drug: Dementia with Lewy Bodies Service 1 Service 4 Service 5 Service 8 Donepezil (Aricept) Rivastigmine (transdermal patch) No drug

19 Number of patients Treatment: Dementia drug - Mixed dementia 8 Dementia drug: Mixed dementia Service 1 Service 2 Service 3 Service 4 Service 5 Service 6 Service 7 Service 8 Donepezil (Aricept) Memantine (Ebixa) Rivastigmine (transdermal patch) Patient declined No drug Null Pt not seen

20 Dementia diagnosis: Research Memory service No. dementia diagnosis % consented for research % patient declined research Service % 19% Service % 0% Service % 0% Service % 28% Service % 7% Service % (n= 15) 27% (n= 15) Service 7 12 Null Null Service % 0%

21 Diagnosis of MCI: Research Memory service No. MCI diagnosis % consented for research % patient declined research Service % 20% Service 2 1 0% 0% Service % 0% Service 4 1 0% 0% Service % 0% Service % 0% Service 7 10 Null Null Service 8 0 N/A N/A

22 Treatment: Cognitive stimulation therapy 100% % of diagnosed patients referred for CST 90% 80% 70% 60% 50% 40% 30% 20% 38% 50% 41% 46% 10% 16% 28% 0% Service 1 Service 2 Service 3 Service 4 Service 5 Service 6 Service 7 Service 8 Yes Patient declined No service not available Not clear from notes Not applicable

23 Follow-up: Continuation of dementia drug Alzheimer s disease, DLB and mixed dementia - Drug prescribed - % continuation of dementia drug. Service 8 50% Service 7 Service 6 17% Service 5 73% Service 4 88% Service 3 63% Service 2 67% Service 1 43% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Continued Switched Stopped Unknown (future OPA) NULL

24 Follow-up: Third sector involvement 100% % of diagnosed patients referred to third sector 90% 80% 70% 60% 50% 40% 30% 58% 53% 68% 64% 20% 41% 10% 0% 23% Service 1 Service 2 Service 3 Service 4 Service 5 Service 6 Service 7 Service 8 13% Yes No pt declined No not provided Null

25 Follow-up: Evidence of correspondence to the GP Data includes: - Dementia diagnosed patients who had a detailed follow-up appointment - % adherence to follow-up items: (1) pathway of follow-up care (2) what to do in a crisis (3) key contacts (4) social care support Service 8 n=21 Service 6 n=3 Service 5 n=13 Service 4 n=15 Service 3 n=8 Service 2 n=16 Service 1 n=18 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

26 Conclusions: The audit reveals substantial variation between services. Access to timely assessment, imaging, neuropsychology and post diagnosis interventions is very variable. - we can try to correlate this with resourcing Diagnoses vary widely from service to service. - we need a larger sample to understand if this is random or represents bias in some services. If confirmed, a drill down might be helpful into diagnostic practices in outlying services.

27 Next steps: Refine the audit parameters fewer data items without loosing impact. Encourage all services to take part. Share anonymised data with commissioners to cement buy in and resourcing. Take statistical advice on minimum number of patients.