Evaluating the impact of Advice and Guidance on diagnostic pathways and healthcare use in England: retrospective cohort study, 2015-2022

Objective

To determine outcomes by referral route (any Advice and Guidance [A&G] versus elective referrals only) for patients with inflammatory bowel disease (IBD), Parkinson’s disease, and systemic lupus erythematosus (SLE).

Design

Population-based retrospective cohort study.

Setting

Linked Clinical Practice Research Datalink (CPRD) Aurum primary care records, 2015-2022.

Participants

Patients with incident diagnosis of IBD, Parkinson’s disease, or SLE.

Main Outcome Measures

Time from the earliest recorded A&G or elective referral to diagnosis, first recorded definitive treatment and first attended outpatient appointment. Secondary outcomes included counts of primary care consultations, prescriptions, referrals, and outpatient appointments. Propensity score weighted flexible parametric survival analyses accounted for differences between exposure groups.

Results

Among 71,145 eligible patients, A&G was recorded for 1,137 (3.0%) with IBD, 971 (3.4%) with Parkinson’s, and 243 (4.9%) patients with SLE. Compared with elective referral only, A&G was associated with slower time to diagnosis for IBD (adjusted median difference 15.9 weeks; hazard ratio 0.58, 95% confidence interval 0.52 to 0.66), Parkinson’s disease (11.4 weeks; 0.57, 0.51 to 0.64), and SLE (6.3 weeks; 0.82, 0.73 to 0.91). However, A&G was not associated with a longer time to treatment or first attended outpatient appointment. An increase in primary care consultations following A&G was observed in patients later diagnosed with IBD and SLE.

Conclusion

A&G was associated with a longer diagnostic interval than elective referral only. These findings do not establish that A&G caused diagnostic delay. A&G might be used at an earlier stage of more complex diagnostic pathways.

What is already known on this topic

• Advice and Guidance (A&G) enables primary care clinicians to obtain specialist input before or instead of elective referral and is promoted to support patient management and reduce unnecessary outpatient activity.

• Evidence is limited on whether A&G shortens diagnostic and treatment pathways or instead adds an additional step for patients who ultimately require specialist care.

• The effects of A&G on subsequent primary care workload, secondary care use, and patient safety are uncertain, and implementation varies between local healthcare systems.

What this study adds

• Among patients subsequently diagnosed with inflammatory bowel disease (IBD), Parkison’s disease or systemic lupus erythematosus (SLE), the interval from the earliest recorded A&G or elective referral of any type to diagnosis was longer among those with any recorded A&G although we did not observe an increase time to treatment or first attended outpatient appointment.

• Patients with A&G had more all-cause subsequent referrals across all three conditions and more all-cause primary care consultations for IBD and SLE; no clear differences were found in attended outpatient appointments, unplanned hospital admission, or mortality.

• A&G may identify an earlier stage of the pathway; however, patients recorded with A&G tended to be more complex and findings should be interpreted as associations rather than evidence that A&G caused delay.