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Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Elevated CA125: investigation & management, Gynaecology (1113)

Warning

Objectives

To provide guidance on how to investigate women where a raised CA125 is found

Audience

Healthcare providers in primary and secondary care in Great Glasgow and Clyde (GGC)

CA125 is considered to be the best available marker for epithelial ovarian cancer.  

The widely accepted normal range of CA125 in GGC is 0-35 IU/ml.

Clinical Specificity of CA125

CA125 may be elevated in many physiological and pathological conditions, with gynaecological and non-gynaecological causes.  These conditions are summarised in the table below.

Table: list of conditions causing a raised CA125

CA125 Testing Recommendations

Primary Care

NICE recommends CA125 testing in primary care in women presenting with  1 of these following symptoms on a persistent or frequent basis, particularly if ≥ 12 x per month.

  • Persistent abdominal distension (‘bloating’)
  • Early satiety +/- loss of appetite
  • Pelvic or abdominal pain
  • Increased urinary urgency +/- frequency
  • Unexplained weight loss
  • Unexplained fatigue
  • Unexplained change of bowel habit
  • New onset of symptoms suggestive of IBS if 50 years

If CA125 is elevated >35 IU/ml, arrange an Ultrasound of the Pelvis – ideally Transvaginal Scan within 2 weeks.

Additionally if physical examination in primary care suggests ascites and or a pelvic or abdominal mass (which is not obviously uterine fibroids) they should be referred urgently for review in gynaecology and referral should not be delayed whilst waiting for CA125 result. 

Secondary Care

Abnormal Ultrasound Scan or imaging findings – premenopausal women

The Royal College of Obstetricians and Gynaecologists (RCOG) advises that a CA125 level is not routinely needed for the diagnosis of a simple cysts in premenopausal women. 

If germ cell origin tumours are suspected following imaging (e.g. women < 40yrs), αFP, βHCG and LDH are recommended in addition to CA125.

Please see GGC guidelines for further details.

Abnormal Ultrasound Scan or imaging findings – postmenopausal women

A CA125 level should be measured in all postmenopausal women with a cystic lesion of 1cm or more.  This should be used in conjunction with the USS findings to calculate the Risk of Malignancy Index Score (RMI).  Please see GGC guidelines for further details.

Normal pelvic ultrasound scan or imaging & Raised CA125

If a CA125 has been measured prior to imaging, a normal ultrasound can exclude ovarian cancer with a high degree of confidence. 

Postmenopausal ovaries will appear smaller and more homogenous compared to those found in pre-menopausal women. It is therefore common not to visualize the ovaries on ultrasound in a postmenopausal woman.  For completeness an abdominal examination and bimanual examination may be undertaken to assess for potential non pelvic masses.

In the presence of a normal pelvic ultrasound scan or imaging, there is no clear evidence to repeat a CA125 measurement.  However, extrapolating from ovarian cyst data, a rapidly rising CA125 is more likely to be associated with malignancy, therefore consider a repeat CA125 after 8 weeks to assess trend.  If significantly rising, further imaging by urgent CT scan of abdomen and pelvis should be arranged. 

If no gynaecological cause identified, patient should be referred back to GP to assess for other clinical causes of symptoms and investigate or refer as appropriate.

CA125 Flowchart

Flowchart of the steps for elevated CA125 investigations

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Editorial Information

Last reviewed: 14/11/2023

Next review date: 31/10/2027

Author(s): Dr Jenifer Sassarini, Consultant O&G; Dr Claire Higgins Consultant O&G.

Approved By: Gynaecology Clinical Governance Group

Document Id: 1113

References

Ovarian cancer: recognition and initial management. NICE Guideline CG122 April 2011, Last review 2017.

Suspected cancer: recognition and referral, NICE guideline [NG12] Published: June 2015 Last updated: December 2021

Howe T, Sokolovsky N, Sayasneh A, Omar K, Tahmasebi F. Raised CA125–what we actually know... The Obstetrician & Gynaecologist2021;23:21–7.

RCOG Green-top Guideline No. 62. Management of suspected ovarian masses in premenopausal women. Dec 2011.

RCOG Green-top Guideline No. 34. Ovarian cysts in postmenopausal women. July 2016.

ACOG Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses, Obstetrics & Gynecology: November 2016 - Volume 128 - Issue 5 - p e210-e226

ACOG COMMITTEE OPINION Number 716 , September (Reaffirmed 2019) Committee on Gynecologic Practice Society of Gynecologic Oncology. The Role of the Obstetrician–Gynecologist in the Early Detection of Epithelial Ovarian Cancer in Women at Average Risk