E78. QUALITY IMPROVEMENT PROJECT ON MANAGEMENT OF ANTI-NEUTROPHIL CYTOPLASMIC ANTIBODY–ASSOCIATED VASCULITIS IN A UNIVERSITY TEACHING HOSPITAL

Abstract

Background: ANCA-associated vasculitis (AAV) is one of the most common type of primary systemic vasculitis. Validated clinical tools like Birmingham Vasculitis Activity Score (BVAS) and Vasculitis Damage Index (VDI) are widely used to assess disease severity, activity and damage. Cyclophosphamide remains the agent of choice for management of systemic disease and rituximab is an alternative in cases where cyclophosphamide use is contraindicated. We audited our hospital practice of management of AAV against BSR guidelines to identify any areas of practice and service improvement. Method(s): Patients with a diagnosis of AAV, who were assessed in Rheumatology clinics, other speciality clinics or as inpatients over a two year period between January 2014-January 2016 were included in the audit. Clinical notes were reviewed and data recorded in a structured proforma. Result(s): A total of 18 patients (13 male, 5 female), median age 53 years, were audited. All inpatients (n=5) were seen within 1 day of referral. Time to out patient review (n=13) ranged from 2 weeks to 10 months (median 2 months). 11/13 out-patient referrals were interspeciality referrals and 2/11 were referred from primary care. 2/13 patients were picked up to have additional renal involvement at the time of Rheumatology clinic appointment. One patient developed mono-neuritis multiplex while awaiting review. 9/18 patients received appropriate and timely treatment (5 seen an inpatients, 2 in Rheumatology clinics and 2 started on treatment by ENT). 7/18 patients did not receive any treatment while awaiting Rheumatology review and 2/18 received suboptimal treatment for the level of organ involvement. Cyclophosphamide was used as induction agents in 14/ 18 patients. 4/18 patients with Limited Wegener's received induction with Methotrexate. Azathioprine was used for maintenance in 11/18 and Methotrexate in 6/18 patients. 7/18 patients had relapses while on treatment and these were managed according to severity. Rituximab was used in 6/18 cases. 2/6 of these did not meet the NICE or NHS England guidelines for its use. BVAS and VDI score were recorded in only 3/18 patients. Conclusion(s): This audit highlighted that prioritising out patient referrals and arranging urgent review within a week of referral (as per BSR guidelines) was one of the main areas needing practice improvement. We propose mandatory training of staff to do BVAS and VDI scores, which are useful tools for clinical assessment and decision making for treatment change in vasculitis patients. The department is also looking at introducing service changes like starting multidisciplinary vasculitis clinics to optimize care pathways for patients with multi system disease. Collaboration with UK and Ireland vasculitis registry (UKIVAS) and maintaining database for existing and new patients are also being planned.