Perspective 2019

6 PERSPECTIVE 2019  Calprotectin Self-Testing Four Years On The Benefits for Patients and Healthcare Staff of Routine IBDoc Use Kathleen Sugrue, Advanced Nurse Practitioner at Mercy University Hospital, Cork The Mercy University Hospital in Cork is a designated Gastroenterology Centre of Excellence and has one of the largest cohorts of IBD patients in Ireland. It was the first hospital to introduce the BÜHLMANN IBDoc® calprotectin patient self-testing into routine practice. This was back in the summer of 2015 and after 4 years the team there has gained a wealth of experience in the value of this test for monitoring their IBD patients. Kathleen Sugrue, the advanced nurse practitioner in IBD at the Mercy talks to us about how implementing IBDoc testing has positively impacted the patients and the clinic. Historically we used an external laboratory for calprotectin testing (Biomnis). However, this was extremely expensive and we were waiting 6-8 weeks for the results. This is too long to wait for clinical decision making. We first introduced use of the IBDoc test in the summer of 2015. After an initial trial period it was rolled out to all IBD patients that have compatible phones for reading the results. There are now over 50 devices that support the CalApp® and so we now have over 650 patients that are regularly using the system. All initial patient screening tests are now performed in our own laboratory, since calprotectin has been introduced in-house. This is using the BÜHLMANN fCAL turbo assay which has the advantage of being standardised with IBDoc. Once a patient has been diagnosed we would hope to get them onto the IBDoc system for monitoring. However, we don’t have funding for all patients and there are some that don’t have compatible phones, so we still use the lab as a fall back for these patients. Costs are similar for the two test formats but we do prefer to have patients on IBDoc, in terms of ease of testing and speed of the result. Thus we always try to use IBDoc as a priority wherever possible. Initially patients can be a little taken aback when they realise that they will do the test themselves but you explain that it isn’t much different from them taking their sample for the lab test. Most of them are familiar with having to provide the samples anyway so it is okay. The only extra bit they have to do is reading the result with the phone and actually they embrace it. For patients that are well, we use IBDoc to monitor their disease and we explain that without it they will require a colonoscopy; the vast majority are happy to do the test – the chance of avoiding a colonoscopy is a good motivator. Display of Results In the beginning we started with the traffic light system of results, but we found it somewhat restrictive. For example a patient could have a red result and a few weeks later test again and still get a red reading. What they didn’t see was that their actual calprotectin level had reduced from >3000µg/g down to 700µg/g, so it was in fact trending in the right direction. In the interests of transparency, selfmanagement and having a better understanding of their disease, patients are now able to see the numerical result which is very important for reassurance. Patients who are using IBDoc generally test a base line level on initiating their treatment with biologics and then re-test every four months. As a general rule we use four tests per patient, per year. The 4th test they keep at home to use if they having symptoms. Thus, if they aren’t sure if they are flaring or not they can use the test for reassurance. Funding The biggest issue we have at the moment is funding, despite the fact that IBDoc is cheaper than the previous method of testing and we are making significant savings on the use of biologics. We still don’t have a direct source of funding for the test (although we have had agreed an additional member of staff which will help significantly). Some of the pharma companies will fund patients on their drugs, and I am in discussion with some others so that all the biologics patients have access. However I would like the IBDoc for all IBD patients as it isn’t fair to have the test available for one cohort of patients and not another. I am hoping that it will become part of the care programme for all patients, but there is currently no funding for this. Patients love the IBDoc and have become reliant on it for selfmanaging their disease. Once they get started on it they don’t want to stop using it. I have even had patients enquiring about selffunding the tests because the cost isn’t huge for 3 – 4 tests a year. Unfortunately we currently don’t have the ability to bill patients for it so this isn’t happening here. The feedback from the Gastro team and other IBD nurses is also extremely positive: ■ Patients are more confident at self- managing ■ We aren’t having to chase results ■ Patients email if they get results they are concerned about, so it is a very safe system Sometimes you are investing a little bit more to make sure the longer term outcome is better. We do have a conversation with them about the testing and this takes a bit of time, but it is worth it in the long run as patients are with us for life. It saves us time going forward as we are not chasing results from the lab all the time. Patients love the IBDoc and have become reliant on it for self-managing their disease. Kathleen Sugrue (3rd from the left) and the IBD team at Mercy Hospital