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‘Getting the Service Right – creating an end-to-end service by adding value for the user’. Dr Danielle B Freedman Consultant Chemical Pathologist and Medical Director Luton and Dunstable Hospital NHS Foundation Trust. Autumn 2008. What do users really want?

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‘Getting the Service Right –

creating an end-to-end service by adding value for the user’

Dr Danielle B Freedman

Consultant Chemical Pathologist and Medical Director

Luton and Dunstable Hospital NHS Foundation Trust

Autumn 2008


What do users really want?

Role of Laboratory interface

  • Value of interpretative service

  • Demand management

  • Patient safety

    Pathways

    Effective use of POCT


New Directions in the NHS in UK

  • Our health, our care, our say (2006)

    - focus on prevention and health promotion

    - more care outside of hospital and in home

    - encouraging innovation and competition

    - joined up approach


New Directions in the NHS in UK

  • ‘Looking to the Future Out of Hospital Report’(2007)

    ‘Treatment of all patients in ‘out of the hospital’ as the ‘norm’, treatment by acute services as the exception

1 Co location of 1° care in A & E

1° care replacing many existing A & E functions – 50% A & E attendances in alternative setting

eg increased investment in community teams who can offer intensive support to patients with long term conditionsUrgent care centres:

1°care led

Minor injury/illness

Diagnostics

  • 2 Move 40% outpatient activity away from hospitals [Tariff 08 £189]

  • Non-complex surgery in 1° care

  • Poly Clinics


Darzi high quality for all
Darzi – High quality for all

  • Create an NHS that helps people stay healthy

    • Vascular risk assessment

    • Long term conditions

  • Quality at the heart of the NHS

    • Clinically and cost effective innovations in medicines and medical technologies is adopted

  • Working in partnership with staff


Quality in health care laboratory medicine and the darzi agenda
Quality in Health Care Laboratory Medicine and the Darzi agenda

  • Fair – equally available to all

  • Personalised – to individual needs

  • Effective – quality outcomes

  • Safe – confidence in the care received

Darzi 2007


What do users want from laboratory medicine
What do users want from Laboratory Medicine?

  • Information to allow clinicians to make better decisions about patients

  • Patient safety

  • Clinical governance, accountability, accreditation …

  • Investigations need to be cheap, quick and correct

  • Right investigation on the right patient at the right time

  • Report needs to get to the right clinician at the right time using the right medium


Role of laboratory interface
Role of Laboratory Interface

Clinical Vignette

48 year old male

GP routine bloods

Grossly lipaemic – triglyceride = 130 mmol/l

(<1.9)

DBF D/W GP – known alcoholic ? Risk of pancreatitis (from etoh and trigs) Commence ciprofibrate 100 mg od Cease etoh Suggest referral ASAP to hepatologist

Obviated need for acute admission


Clinical vignette
Clinical Vignette

56 year old Chinese male (poor historian)

Previous A&E attendance with 1/52 headache – given some medicine

Since then generally unwell – sweating, ? Weight loss

GP requested TFT – fT4 = 6 pmol/l, TSH = 1.23 mU/l

TSH inappropriate for fT4 – lab add other Ix

Sodium = 128 mmol/l Other U&E NAD

Cortisol (08:30am) = 108 nmol/l Prolactin 167 mU/l

Testosterone = 2.9 nmol/L LH = 1.9 U/l, FSH = 2.8U/l

Hydrocortisone cover advised, followed by replacement of other axes – Urgent Chemical Pathology OPD arranged with GP. Infarcted pituitary adenoma confirmed. Avoidance of acute admission


Clinical vignette1
Clinical Vignette

  • Patient presents to GP with bruising and nose bleeds

  • Platelet count <20

  • Consultant haematologist speaks to GP to start Prednisolone immediately at 7pm on Friday

  • - prevent inpatient admission

  • Microbiologist authorising reports 2 children with MRSA from swabs collected for ?otitis externa

  • Both patients from same surgery seen 2 hours apart

  • Discussion with GP revealed insufficient attention to cleaning ear pieces and issues around hand hygiene


Cost as pbr
Cost as PBR

Outpatients:

New : £194

F/U : £96

Admission Acute: £1500 + Market forces

16% S Beds

30%+ London

HDU : £800 / day + Market forces

ITU : £1900 / day + Market forces


Have you ever called clinical biochemistry for clinical or technical advice
Have you ever called Clinical Biochemistry for clinical or technical advice?

GP questionnaire (S Beds 2006)

No 14%

Yes 86%


Did the advice you received aid in patient management
Did the advice you received aid in patient management? technical advice?

Unsure 2%

No 2%

Yes 96%



“Before ordering a test, decide what you will do if it is either positive or negative, and if both answers are the same, then don’t do the test!”

Reference ranges

Factors influencing the result

Interpretation

Further investigations

‘Delivery’ of results


Reduction in unnecessary expenditure for commissioners
Reduction in unnecessary expenditure for commissioners either positive or negative, and if both answers are the same, then don’t do the test!”

Some examples

Demand Management

(costs based on Carter Baskets average)

Inappropriate or redundant investigations:

1 Variation across laboratories

Serum Angiotensin converting enzyme (ACE)

Hospital x :

L & D :

(not in house)

No evidence to support use of ACE in, other conditions, than monitoring Sarcoid

2006/7

= £4,800pa

1500/yr

50/yr

= £500pa


140 either positive or negative, and if both answers are the same, then don’t do the test!”

120

100

80

60

40

20

0

Variation in Practice

Number of tests per 1000 patients

PracticeNumber

Courtesy of Dr Stuart Smellie


Lipids – either positive or negative, and if both answers are the same, then don’t do the test!”requests by practice

Requests/

1000 pts/

Year

Practice

Courtesy of Mr MJ Hallworth


  • CRP requests either positive or negative, and if both answers are the same, then don’t do the test!” vetted

  • 2,000 per month  1,500 per month

  • Saving £1,770 per month = £21,000 pa

  • 3 All“send away” tests vetted

  • In 2006/7 >1000 not sent saving £25,000 pa

  • Redundant tests – based on new evidence or introduction of superior analyte eg LDH

  • Workload  1,000 per month

  •  £14,000 pa


  • 5 either positive or negative, and if both answers are the same, then don’t do the test!”Inappropriate

  • Gonadotrophin measurements in women >45 years

  • Repeat liver function tests in <48 hours

  • HbA1c requested too frequently

  • Oestradiols


It s the wrong question
It’s the wrong question! either positive or negative, and if both answers are the same, then don’t do the test!”

So how much does Laboratory Medicine cost?

  • ‘Ask not what the ‘Requestors’ can do for you, but what you can do for the ‘Requestors’ ’

  • Or to put it another way, ‘Get out more often and influence requestors’!

  • The question should not be ‘how much does Lab Medicine cost’ but ‘what value does it add for the patient?’

We as professionals:


“Prostitutes are the Pathologists of sex ….. they do their job detached from emotion and feeling …..”

Tom Clancy


45 year old female their job detached from emotion and feeling …..”

Cholesterol 11 mmol/L despite on Simvastatin 40mg

GP phoned Clinical Biochemistry

LFTs – ALP = 350 IU/L [25 – 120]

Prior to starting Statin ALP = 340 IU/L

Further investigations:

Antimitochondrial abs

U/S liver

Liver biopsy

Dx Primary biliary cirrhosis

Cost to Commissioners?

Cost to patient? Value to whole health economy?


Clinical vignette2
Clinical Vignette their job detached from emotion and feeling …..”

28 year old male

GPrequests routine investigations at 6pm Friday night, processed in lab at 7pm:

Sodium = 116 mmol/l (136 – 148) Potassium = 1.9 mmol/l (3.8 – 5.0)

Urea <0.3 mmol/l

Creatinine = 81 mol/l

Only clinical details available ‘alcoholic’

? Beer potomania

Emergency admission arranged by DBF via GP


Do you need clinical experience who can do what
Do you need ‘Clinical experience’? their job detached from emotion and feeling …..” - who can do what??


Bma news 2 june 2007 letter
BMA News, 2 June 2007 their job detached from emotion and feeling …..”(letter)

T-bone stake

“…It reminded me of the occasion when a FY2 rang while I was on call to inform me that he had seen a patient with a broken forearm – but did not know the anatomical name for the bone. At a guess it started with the letter “T”, he said.

I dashed to the patient’s side to clarify that the patient had actually injured what I was envisaging and was in no danger.

The FY2 had never sat a formal anatomy exam, nor had he undergone formal dissection/pro-section lessons at medical school…”


“Tomorrow’s Doctors” their job detached from emotion and feeling …..”

  • Smellie et al (J Clin Path) in 1995 25% of all emergencylaboratory requests were inappropriate

  • Kyle BMJ 10.2.07 “… NCEPOD includes several training recommendations for juniors doctors, … highlighted the need for increased recognition of acutely unwell patients and appropriate investigations …”

  • Khromova and Gray (accepted for publication Ann Clin Biochem) 2007 Questionnaire junior doctors at Sheffield Teaching hospitals (Future GPs)


How confident are you in requesting laboratory tests
“How confident are you in their job detached from emotion and feeling …..”requesting laboratory tests?”


How confident are you on interpreting laboratory tests
“How confident are you on their job detached from emotion and feeling …..”interpreting laboratory tests?”


Labs Are Vital™ Media Monitoring and Successful Results their job detached from emotion and feeling …..”


S ramsden hsj oct 2008
S Ramsden – HSJ Oct 2008 their job detached from emotion and feeling …..”

Junior Doctors

  • Front line of patient care

  • NHS’s clinical leaders of the future

    Consultant Safety Lead

    New intake of FY1 and FY2

    Competence of prescribing:

    17/22 failed

    - prescribed a penicillin-type antibiotic to patients with identified allergy to penicillin


“patients who are acutely ill are often cared for by most junior medical staff who have least knowledge and experience”


How can labs streamline pathways
How can labs streamline pathways? junior medical staff who have least knowledge and experience”

  • www.bettertesting.org

for GPs

What interests Practice Based Commissioners

  • Care Closer to Home eg Warfarin monitoring

  • Care pathways and pathology tests eg eGFR and Primary Care management of chronic kidney disease

  • Collection of specimens and electronic reporting of results

  • Need to establish clinical dialogue with laboratories

  • Development of Point of Care Testing

J Crockett CEO, Wolverhampton City PCT


Example junior medical staff who have least knowledge and experience”

How often should CK be measured in patients on Statins?

  • Baseline

>5 ULN

Normal

Noroutine monitoring if asymptomatic

Do not start statin


Welcome to BetterTesting.org.uk – home of the best practice in primary care pathology project

Latest news

Version 1.2

This website was launched in January 2008.

Feedback

Please contact us with your comments, so we can improve the website.

In print

These reviews were published in the Journal of Clinical Pathology and a supporting series of cases in the British Medical Journal. See Authors and acknowledgements.

The site provides information in question/answer style, to around 120 clinical scenarios which are frequently seen in general practice and reviews national and international best practice guidance for testing in these scenarios

This website in intended as an information source for healthcare professionals, particularly those working in primary care, and may also be of use to individual patients who wish to find out more about the tests they undergo, Patients can also obtain further information on Lab Tests Online (UK).

Browse the clinical topics


Effective use of point of care testing poct
Effective use of Point of Care Testing (POCT) practice in primary care pathology project

Hospital ‘Chemists’

Surgicentres Home

Polyclinics ‘other’ eg internet, van

GPs

Paramedical vehicle


World-wide POCT Market practice in primary care pathology project

1997

2001

USA $1.6 billion $2.8 billion

Outside USA $1.4 billion $2.6 billion

World-wide $3.0 billion $5.4 billion

2007 – 50% increase in sales


Applications of POCT practice in primary care pathology project

The Evidence – Clinical and/or cost effectiveness*

Some examples

Infection eg CRP*

Helicobacter Pylori?

Chlamydia?

Urine leukocyte*

Chronic Disease DM HbA1C*

Management Hyperlipidaemia Cholesterol*

Anticoagulation INR*

Hypertension Albumin:cr?

CHD BNP*

Acute U + E*

Gases*

Troponin*


Client satisfaction practice in primary care pathology project (patient, family, healthcare worker)

Reduced phlebotomy requirements

More rapid therapeutic TAT

Reduced waiting times

Studies using surveys demonstrate both patient and staff satisfaction

[Kilgore et al 1998, Cairns et al 1998, Grieve et al 1999, Galloway et al 1999]


Literature contradictory practice in primary care pathology project

Problems with data and methodology

  • advocates of POCT

  • against POCT

  • neutral POCT

Cost Benefit

Can find cost studies to support their case

Greendyke (1992) $11.50 vs $3.19

Lewandrowski (2001) $4.19 vs $3.84

Cost of blood glucose POCT varies from $4.2 - $13.19

(Lewandrowski 2001)

Kendall et al (1999), Collinson et al (1999) demonstrated significant savings

Need for more studies to compare cost for entire episode of care with POCT versus same care without POCT (Keffer 2004)


Cost benefits of poct anticoagulation management in primary care
Cost benefits of POCT anticoagulation management in Primary Care

P Johnson City + Hackney PCT (2008)

Net savings as result of transferring 460 patients from 2° to enhanced service in GP practices

> £150,000 pa

but

O’Connor, (J Clin Path Feb 2008)

In Shropshire error rate for 1 practice 164 times higher than hospital [INR>8]


Problems (RISK MANAGEMENT) when procedures for training and quality assurance are poor

  • Incorrect results can affect the well-being of a patient

  • Health hazards eg HIV and hepatitis viruses to both patient and operator

  • Implementation MUST follow National Guidance

Implementation of POCT

POCT is presented as

“Easy to use and capable of producing accurate results ....”

but


Case History quality assurance are poor

Miss DM, 28 year old

March ‘mild glycosuria’

GP performed GTT:

Time

0 mins

30 mins

60 mins

90 mins

120 mins

Glucose (mmol/l) - glucometer

8.4

18.6

22.0

15.2

12.3

Rx: Glibenclamide


Revisited GP - symptoms of hypoglycaemia quality assurance are poor

Glibebclamide stopped

September referred to Diabetic clinic

GTT (laboratory)

Time

0 mins

60 mins

120 mins

Glucose (mmol/l)

5.3

5.3

6.1

Glucometer - faulty

No QC


POCT Guidelines quality assurance are poor


In US quality assurance are poor

  • > 3200 incidents including 24 deaths and 986 injuries have been filed with FDA re blood glucose monitoring

Successful POCT

Joint endeavor

  • Manufacturers

  • Many different professional groups

  • Patients

… failure of professionals to indicate to top management the clinical risk involved (Burnett Ann Clin Biochem 2000)


Regulation of poct
Regulation of POCT quality assurance are poor

  • UK: no legal framework

  • Belgium, Finland: legal framework

  • Netherlands: mandatory guidelines that regulate laboratory testing, including POCT

  • Germany: legal framework for analytical quality control

  • Italy: regional but not national guidelines

  • France: legal regulation of public laboratories but not private labs (from report of Roundtable meeting, Abbott 2005)

  • USA: POCT is regulated by CLIA federal law

(Thanks to Dr J Pearson, Leeds)


View from Mr Gordon Cropper, Chair of Lay Advisory Committee RC Pathologists

(2006)

“…the members of lay committee would rather have the correct/right result and wait a couple of days, than have a ? wrong result immediately…”


And so
And so ….. ? RC Pathologists

  • Need existing POCT to be conducted within a QM framework [ISO 22870 – 2006]

  • Need convincing evidence from properly conducted trials to demonstrate:

    • Economic benefit

    • Improved Outcomes


October 2008
October 2008 RC Pathologists

ACB

RCPath (including lay representative)

IBMS

BSH

RCGP

MHRA

Acknowledgement the need for National Guidance for POCT for hospitals and community


What interests practice based commissioners
What interests practice based commissioners RC Pathologists

  • Care Closer to Home eg Warfarin monitoring

  • Care pathways and pathology tests eg eGFR and Primary Care management of chronic kidney disease

  • Collection of specimens and electronic reporting of results

  • Need to establish clinical dialogue with laboratories

  • Development of Point of Care Testing

J Crockett CEO, Wolverhampton City PCT 2008


Conclusion
Conclusion RC Pathologists

  • Pathology and laboratory services need to become more ‘dynamic’ and responsive to needs of patients, 1° care clinicians and commissions

  • Community pathology services should receive higher profile in commissioning and need dialogue PBC, PCTs and pathologists

  • Improve access to phlebotomy

  • NHS numbers and electronic requesting

  • Test ordering – education and training and feedback or behaviour, clinical guidelines

  • Accreditation – governance infrastructure

  • POCT


Thanks to: RC Pathologists

Dr David Housley

Luton and Dunstable Hospital NHS Foundation Trust

Mr Mike Hallworth

Royal Shrewsbury Hospital

Dr Stuart Smellie

Co Durham and Darlington Acute Trust


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