Realistic Laboratory testing Reduce harm, waste & variation - - PowerPoint PPT Presentation

Realistic Laboratory testing

Reduce harm, waste & variation

With thanks to Dr Sara Jenks

The problem

• ˜5.5 million primary care haem/biochem tests

p.a.

• Many tests may be ‘inappropriate’ - ?? Up to

25%

• Why – defensive medicine, habit, ordersets,

repeat requests, patient demand, lack of consideration of cost, lack of experience, uncertainty, guidelines (or lack of)

Optimising benefit

Number of tests

Reference ranges

• Defined using a “healthy” population
• Impact of age, gender, medications, diet, exercise

Benefits of reducing inappropriate requests

• More appropriate use of doctor and

phlebotomist (less tests to do and less results to check)

• Reduced cost
• Improved lab efficiency
• Potentially better patient experience
• Avoidance of harm arising from over-

investigation

Rise in Requesting

200 400 600 800 1000 1200 1400 2013 2014 2015 2016 2017

Vitamin D requests

Impact on other associated tests

1000 2000 3000 4000 5000 6000 7000 8000 2013 2014 2015 2016 2017 25OH VitD imm'assay Calcium PTH Phosphate

Is this cost-effective, quality care?

Increase in testing from 2012 equates to approx:

– Vit D - £7.52 per test =£67,000 p.a. – Ca - £0.53 = £15,900 – P - £0.60 = £7,200 – PTH - £2.85 = £10,200

• Approx increase in lab spending p.a. = £100,000
• Also – GP appointments, prescription costs
• Balanced against costs associated with
• steomalacia/osteoporosis

B12 & Folate

500 1000 1500 2000 2500 3000 3500 4000 4500 5000 2013 2014 2015 2016 2017 Vitamin B12 Serum Folate

B12 = £1.35 Folate = £1.26 - increase approx £30,000 per annum

Coeliac testing

500 1000 1500 2000 2500 3000 2013 2014 2015 2016 2017

TTG IgA =£11.86 = increase equates to £149,000 p.a.

Reduction in testing

5000 10000 15000 20000 25000 30000 35000 40000 45000 2013 2014 2015 2016 2017

Urea requests

Reduction in urea saved £28,000 – has there been any harm?

Variation in requesting

Communicating variation

Lothian work

• Removed urea from C&Es
• Reducing frequency of interval testing in patients with

stable TFTs (non child bearing age only)

• Vitamin D guidance
• LFTs

– ALT only in statins – ?removal of GGT

• Urinalysis guidance
• PCR/ACR
• FSH
• Test prices displayed for secondary care

Ideas from other healthboards

• Fife – blocked repeat lipids within 8 weeks,

vitamin D blocked if Ca/P/ALP normal

• Glasgow – Duty biochemist reviews tests

within certain repeat intervals

• D&G – FSH blocked in women over 45 years
• GP variation data – used in Grampian, fife
• England – separation of Creatinine from Na/K

When is automatically cascading tests more appropriate?

• Intelligent LFTs – Tayside pilot successful
• GP selects iLFTs – question re:BMI, alcohol

intake answered and basic LFT panel checked

• Lab automatically cascades Hepatitis B, C

serology, autoantibodies, caeruloplasmin, ferritin, fibrosis scores, as appropriate

• Results returned to GP with probable

diagnosis, indication of presence of fibrosis and suggestion of whether to refer patient

Summary

• Over-requesting can both increase costs and may

impact negatively on quality of care

• Education and guidance may reduce requesting but

needs regular reinforcement

• The psychology of why tests are being over-requested

is important

• Balancing measures outside the laboratory need to be

considered

• Engagement with clinicians is vital
• Quality of care & patient safety are most important

considerations

• Realistic lab medicine isn’t just about reducing testing

but also about using tests more effectively

Ideas for discussion

• Where would updated testing guidelines be useful?
• Are there any tests in profiles which you feel could be

removed e.g. GGT from LFTs

• GPOC/ICE changes
• Visibility of test prices on ICE
• When is automatically cascading tests more efficient?
• Is showing data on the variation between practices

useful?

• Is blocking tests ever the solution?