‘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 conditions
Urgent care centres:
1°care led
Minor injury/illness
Diagnostics
2 Move 40% outpatient activity away
from hospitals [Tariff 08 £189]
3 Non-complex surgery in 1° care
4 Poly Clinics
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
• 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?
•
•
•
•
•
•
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
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
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
Testosterone = 2.9 nmol/L
Prolactin 167 mU/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 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
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
:
GP questionnaire (S Beds 2006)
Have you ever called Clinical Biochemistry
for clinical or technical advice?
No
14%
Yes
86%
Did the advice you received
aid in patient management?
Unsure
2%
No
2%
Yes
96%
How important do you think the
availability of clinical and technical
advice is?
90
80
70
%
60
50
40
30
20
10
0
Very important
Quite important
Not at all important
No answer
“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
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
:
2006/7
1500/yr
L&D
(not in house)
:
50/yr
= £4,800pa
= £500pa
No evidence to support use of ACE in, other conditions,
than monitoring Sarcoid
Variation in Practice
Number of tests per 1000 patients
140
120
100
80
60
40
20
0
Practice Number
Courtesy of Dr Stuart Smellie
Lipids –
requests by practice
Requests/
1000 pts/
Year
Practice
Courtesy of Mr MJ Hallworth
2 CRP requests 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
4 Redundant tests – based on new evidence or
introduction of superior analyte eg LDH
Workload  1,000 per month
 £14,000 pa
5 Inappropriate
•
•
•
•
Gonadotrophin measurements in women
>45 years
Repeat liver function tests in <48 hours
HbA1c requested too frequently
Oestradiols
So how much does Laboratory
Medicine cost?
It’s the wrong question!
We as professionals:
•
•
•
‘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?’
“Prostitutes are the Pathologists
of sex ….. they do their job
detached from emotion and
feeling …..”
Tom Clancy
45 year old female
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 Vignette
28 year old male
GP requests 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??
BMA News, 2 June 2007
(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”
•
•
•
Smellie et al (J Clin Path) in 1995
25% of all emergency laboratory 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?”
LFT
U&E
Proteins
Mg, PO4
Confident
Usually Confident
Not Confident
Haematinics
PTH
Short Synacthen Test
Urine sodium and
osmolality
0%
20%
40%
60%
80%
100%
“How confident are you on
interpreting laboratory tests?”
LFT
U&E
Proteins
Mg, PO4
Confident
Usually Confident
Not Confident
Haematinics
PTH
Short Synacthen Test
Urine sodium and
osmolality
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Labs Are Vital™ Media Monitoring and Successful Results
S Ramsden – HSJ Oct 2008
Junior Doctors
1. Front line of patient care
2. 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?
• 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
How often should CK be measured in
patients on Statins?
•
Baseline
>5 ULN
Do not
start statin
Normal
No routine
monitoring if
asymptomatic
Welcome to
BetterTesting.org.uk –
home of the best practice
in primary care pathology
project
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
Browse the clinical topics
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.
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).
Effective use of Point of Care
Testing (POCT)
Hospital
‘Chemists’
Surgicentres
Home
Polyclinics
‘other’ eg internet, van
GPs
Paramedical vehicle
World-wide POCT Market
1997
USA
2001
$1.6 billion
$2.8 billion
Outside USA $1.4 billion
$2.6 billion
World-wide
$5.4 billion
$3.0 billion
2007 – 50% increase in sales
Applications of POCT
The Evidence – Clinical and/or cost effectiveness*
Some examples
Infection
eg CRP*
Helicobacter Pylori?
Chlamydia?
Urine leukocyte*
Chronic Disease
Management
DM
Hyperlipidaemia
Anticoagulation
Hypertension
CHD
Acute
U + E*
Gases*
Troponin*
HbA1C*
Cholesterol*
INR*
Albumin:cr?
BNP*
Client satisfaction
(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]
Cost Benefit
Literature contradictory
Problems with data and methodology
•
•
•
advocates of POCT
against POCT
neutral POCT
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
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]
Implementation of POCT
POCT is presented as
“Easy to use and capable of producing accurate results ....”
but
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
Case History
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
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
In US
•
> 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
•
•
•
•
•
•
•
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 ….. ?
• 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
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
•
•
•
•
•
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
•
•
•
•
•
•
•
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:
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