Introduction of an integrated care system (ics) dietitian-led pathway in irritable bowel syndrome (ibs): a service evaluation

Introduction

British Society of Gastroenterology guidelines recommend that irritable bowel syndrome (IBS) should be managed in primary care, however it is a leading cause of secondary care referrals to gastroenterology with huge cost implications. Dietary treatment is central to the IBS pathway and dietitian-led IBS pathways are associated with reduced gastroenterology referrals and provide healthcare cost savings. The aim of this project was to evaluate the introduction of a dietitian-led IBS service as part of an integrated-care system (ICS) in IBS.

Methods

Stakeholder engagement between dietitians, gastroenterologists and general practitioners enabled the development of a dietitian-led IBS triage service. Triage clinic inclusion criteria were based on NICE and BSG guidelines for suspected IBS to rule out organic disease and included: GP referrals for patients <40 years; negative coeliac screen; faecal calprotectin <50μg/g in patients with diarrhoea; CA125 <30 units/ml in female patients with pelvic pain and/or bloating. In addition, patients ≥ 40 years with suspected IBS referred to gastroenterology were accepted if deemed appropriate by the gastroenterology vetting process. After dietitian-led triage, patients would typically receive dietary intervention and would only be referred to gastroenterology for further investigations if any of the following were present: family history of bowel cancer; unresponsive to dietary and/or psychological interventions; unexplained weight loss; melena. Data was collected from electronic patient records and GP referral documents.

Results

Between June 2021 and December 2022, 166 patients, 113 female (68%), mean (SD) age 37 (13) years met the triage clinic inclusion criteria. of these, 31 (19%) were direct GP referrals and 135 (81%) were redirected from gastroenterology. Nine patients (5%) did not attend, all other patients received detailed information on their IBS diagnosis as well as dietary intervention. Thirty-two patients (19%) were referred for further gastroenterology investigations and 4 (2%) had pelvic floor assessment and 54 (33%) have been discharged from the service. Median (range) waiting time for the triage clinic was 52 (6–203) days. Six patients waited more than 18 weeks.

Conclusions

This service evaluation showed that the introduction of a dietitian-led IBS triage service reduced gastroenterology appointments, unnecessary investigations in secondary care, improved access to timely and appropriate dietary advice providing patients with a thorough assessment and explanation of their diagnosis.