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BackgroundInflammatory bowel disease (IBD) is a chronic relapsing-remitting condition affecting 600 000 people in the UK. Traditionally, patients attend outpatient clinics for monitoring regardless of their symptoms or risk of developing complications. This can lead to a mismatch between need and access: patients in remission given elective appointments displace those in need of urgent specialist attention. Novel initiatives implemented in the UK to improve outpatient monitoring have often required a well-maintained patient registry, empowered patients and significant information technology support.Design and strategyIn this large-scale quality improvement project at St Mark’s Hospital, a tertiary centre for IBD, we stratified over 1000 patients attending three non-complex IBD clinics over 12 months according to disease activity and risk profile. The aim was to offer a choice and subsequently transfer 50% of eligible patients to specialist nurse-led telephone clinics and demonstrate non-inferior satisfaction levels to existing outpatient follow-up. We also sought to ensure there was timely access to a newly established rapid access clinic for patients requiring urgent specialist attention.A core project team consisting of healthcare professionals, patients and quality improvement scientists met regularly. The team tested and scaled up interventions using ‘Plan-Do-Study-Act’ cycles within the ‘Model for Improvement’ framework and analysed data continuously using statistical process charts.ResultsOver 12 months, the average number of eligible patients transferred to telephone clinics rose from 17.6% (42/239) using a questionnaire method to 59.3% (73/123) using active discussion in clinic. Patient satisfaction scores remained high and non-inferior to baseline scores in face-to-face clinics. The median waiting time to be seen in the rapid access clinic was 6.5 days.ConclusionThis is the first published study to report on the successful stratification of patients with IBD based on disease activity and risk of complications to create a more responsive, sustainable and patient-centred model for IBD monitoring.

Germ cell tumours (GCTs) have an excellent prognosis but rarely arise from the liver. Our case describes a young woman referred for urgent radiotherapy for a bone metastasis. There was also a large lesion in the liver and marked elevation of the serum α-fetoprotein (AFP) level. Liver biopsy indicated a germ cell tumour. Reduced intensity chemotherapy was commenced using the combination of etoposide, cisplatin and paclitaxel. After four cycles the AFP values had fallen, the liver function tests had normalised and the previous bone lesions had healed. The predominant lesion in the liver had also regressed. Hepatocellular carcinoma (HCC) is the main differential diagnosis. Hepatic germ cell tumours predominantly occur in young, healthy women whereas hepatocellular carcinoma occurs in cirrhotic male livers. These two malignancies are very different and accurate diagnosis is essential. Diagnosing this rare condition early allows the delivery of effective therapy and a better outcome.