Revised 23/3/09

Doncaster Primary Care Trust

Local Enhanced Service for Deep Vein Thrombosis (DVT) D-dimer Test

Introduction

All practices are expected to provide essential and those additional services they are contracted to provide to all their patients. This enhanced service specification for Deep Vein Thrombosis (DVT) outlines more specialised services to be provided which are beyond the scope of essential services. No part of the specification by commission, omission or implication defines or redefines essential or additional services.

Background

This local enhanced service allows GPs to provide this screening service to their own patients as well as all patients registered with a Doncaster GP. The process will include assessment of the patient with a questionnaire (Wells Score) and a near patient D-dimer test. This proposal intends to ensure only patients with a possible risk of DVT are sent to Secondary Care. For the Patient Care Pathway (appendix 1)

Service Outline

The provider will assess any patient suspected of presenting with Deep Venous Thrombosis by means of the Wells Score using the attached proforma (appendix 2) and D-dimer test for those patients with a low risk Wells Score of zero or 1.

·  Any patient with a Wells Score of 2 or more is considered high risk and should be sent to Secondary Care immediately. DO NOT CARRY OUT A D-DIMER TEST

·  Any patient with a Wells Score of zero or 1 is considered low risk and will be assessed using the ‘Clearview’ D-dimer test (or other test that may from time to time be approved for use by the PCT).

·  Any patient with a positive D-dimer test result should be referred to Secondary Care immediately.

·  Any patient with a negative D-dimer test result should be managed in primary care for alternative conditions. See Care Pathway attached (appendix 1)

This locally enhanced service will fund:

All patients with a low risk Wells Score zero or 1 and subsequent D-dimer test ONLY.

The Wells score proforma will be stored in the patient record either electronically or physically.

Standards/Accreditation

Any GP or Nurse wishing to provide this service will have to demonstrate and evidence competency. Training may be provided as part of a TARGET session or carried out by the D-dimer supplier in the Practice.

The practice should submit a copy of the training certificate prior to the commencement of this LES.

Performance Management

The Practice will maintain a record of every patient who is assessed under this LES, including those referred and those managed in primary care. Practices are required to complete an annual audit by the PCT, which will review the following:

·  Low Risk Wells Score with Positive D-dimer test resulting in NO DVT

·  Low Risk Wells Score with Negative D-dimer test resulting in DVT

·  High Risk Wells Score resulting in NO DVT

·  The accuracy of the D-dimer test

Any concerns regarding the above throughout the year should be reported to the PCT using existing significant event reporting mechanisms as the practice becomes aware of them.

Quality Assurance

To quality assure the tests purchased, each practice must ensure that 1 sample test out of each purchased batch is completed. This quality assurance sample test should read positive.

If the sample test reads negative, the batch should be returned to the supplier.

Control test solution can be purchased from the supplier.

Control samples should be run on

·  receipt of each new consignment of Clearview Simplify D-dimer

·  at any time that the validity of results is questioned

·  when storage conditions have been compromised

When a test has not been made from a current batch in the previous six months.

D-dimer tests can be purchased in boxes of 10. As a minimum requirement the sample test should be carried out on each batch of tests purchased. If only 1 box of 10 is ordered a minimum of 1 sample test still applies.

Costing

There will be a fee of £60 per registered patient for a DVT Diagnostic Screening Service on Low Risk Wells Score patients zero or 1. This cost reflects GP and Nurse consultation time, questionnaire administration and D-dimer test.

There will also be a fee of £60 per non-registered patient for a DVT Diagnostic Screening Service on Low Risk Wells Score patients zero or 1. This cost reflects GP and Nurse consultation time, questionnaire administration and D-dimer test.

For non-registered patients in addition to the fee for the test GPs will be able to claim a fee of £23 for undertaking a consultation before the test

This fee is for undertaking the D-dimer test only. Undertaking a Wells Score would be part of normal GMS/PMS services.

The fee for this LES will be reviewed on annual basis inline with annual inflation and the increased cost of the D-dimer test.

Payment Mechanism

Practices will submit a claim monthly to their Primary Care Commissioning Manager. A claim form is attached (appendix 3). With affect from 1st April 2009 all claims for this service must be submitted within three months following the month in which the service has been provided.

The services delivered by the proposed LES will be subject to monitoring as part of the Annual Review.

This LES will be subject to annual review and can be cancelled with three months notice by the PCT or the contractor. The PCT will consider the results of the practice audit as part of the annual review.

Revised 23/3/09
Appendix 2

Doncaster PCT

Wells Score For assessment of Deep Venous Thrombosis

Patient Name

Date of Birth

Date of assessment

Wells score or criteria: (Possible score -2 to 9)

Active cancer (treatment within last 6 months or palliative)
Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity)
Paralysis, paresis or recent plaster, or immobilisation of lower limb
Recently bedridden for more than three days or major surgery in the past four weeks or more
Localised tenderness/pain along distribution of deep venous system
Entire leg swollen
Pitting oedema (confined to symptomatic leg)
Collateral superficial veins (non-varicose)
Prior History of DVT

Sub Total

Alternative diagnosis as likely or greater than deep vein thrombosis

Total Score

/ 1
1
1
1
1
1
1
1
1
………
-2
………

Interpretation:

Score of 2 or higher - deep vein thrombosis is likely.

REFER TO SECONDARY CARE

Score of less than 2 - deep vein thrombosis is unlikely.

Carry out D-dimer test to further rule out deep vein thrombosis.

D-Dimer positive – REFER TO SECONDARY CARE

D-Dimer Negative – consider alternative diagnosis

Appendix 3 Local Enhanced Service Claim Form

Deep Vein Thrombosis (DVT) D-dimer Test in Primary Care
Date of Assessment / Consultation non reg patients
£23 / Wells Score Questionnaire Result / D-dimer Test carried out
Y/N / D-dimer Test result Positive/Negative / Date of Birth / NHS Number / Notes
1
2
3
4
5
6
7
8
9
10
I declare to the best of my belief that this information is correct and I claim the appropriate payment as set out in Doncaster PCT's Local Enhanced Service. An audit trail is available at the practice for inspection by the PCT. / Authorised Signature
Name / Date / Practice stamp

PLEASE RETURN FORM TO: Primary Care Dept ,

Doncaster Primary Care Trust, Park Lodge, St. Catherine's, Tickhill Road, Balby, Doncaster, DN4 8QN