CONAN HASSIM
May 2012
AIMS
By the end of this session, I hope you are
 More confident about primary care investigations.
 Provide some knowledge helpful to the AKT.
 Provide some knowledge helpful to the CSA, in particular
balancing up possible patient demand to do tests against the
appropriate use of primary care resources.
 Consider more carefully the responsibility we all have when we
complete investigations and in particular the cost of your
investigations.
 Feel more able to be involved in the organisation of practice
systems.
 Develop skills of team working, chairing, summarising and
presenting.
 Provide you with a resource which may be helpful in your work
APPROPRIATE TESTING ?
What does appropriate testing mean:
 Evidence based as far as possible. ( why am I doing this test
?)
 Patient orientated.
 Leading to improved quality of medicine.
 Appropriate testing should lead to a lower cost to the NHS,
patients and individual doctors in the long run.
 It is an area for debate, and continually changes.
 Note that appropriate testing does not always mean doing
less tests, sometimes you will find yourself doing more
tests than you presently do.
EVIDENCE BASED
 What are the possible sources of information on
investigations ?
 National guidelines and summaries of evidence based
practice.
 Local guidelines
 Practice guidelines
 What are the problems with these different sources.
COST OF INVESTIGATIONS
 The UK national budget for pathology is
approximately 2 billion per annum.
 Individual cost of tests in private sector include Well
Woman and Well Man tests for £ 259 each.
 Cost is not just the cost of processing test but also cost
for patient attending for test (time and parking), cost
of phlebotomist time, cost for doctor reviewing tests
and following up within the practice.
 In the long run we are likely to take on pathology
budgets so the cost will be directly relevant to us.
1200
1000
800
mainly use Hillingdon
600
400
200
No. Requests per 000
Number of tests requested by
each practice.
Number of Bio-Heamatology No. of Requests Per Thousand Patients from GPs in BPCC
Q1-Q3 11/12 - BHT
1800
1600
1400
BPCC Average (excludes Practices mainly using Hillingdon)
0
Riverside Surgery
Hanover & Lynton…
Gladstone Road…
The Allan Practice
Lane End Surgery
Water Meadow…
Chiltern House Med…
The Hall Practice
Carrington House…
Kingswood Surgery
The John Hampden…
Prospect House
Amersham Health…
The Misbourne…
Hawthornden Surgery
Highfield Surgery
Pound House Surgery
Priory Surgery
Cherrymead Surgery
Stokenchurch…
The New Surgery
Millbarn Medical…
The Marlow Medical…
Wye Valley Surgery
Tower House Surgery
Desborough Surgery
Rectory Meadow…
Hughenden Valley…
The Simpson Centre
Little Chalfont Surgery
mainly use Hillingdon
2
BPCC Average (excludes Practices mainly using Hillingdon)
8
6
4
Cost per patient
Costs of tests for each practice
Cost of Bio-Heamatology Requests Per Patient from GPs in BPCC
Q1-Q3 11/12 - BHT
12
10
0
Gladstone Road…
The Allan Practice
Lane End Surgery
Prospect House
Riverside Surgery
The Hall Practice
Hanover & Lynton…
Highfield Surgery
The John Hampden…
Water Meadow…
Carrington House…
Chiltern House Med…
Hawthornden Surgery
Kingswood Surgery
Pound House Surgery
Amersham Health…
The Misbourne…
Millbarn Medical…
The Marlow Medical…
Stokenchurch…
Cherrymead Surgery
Tower House Surgery
Wye Valley Surgery
Priory Surgery
The New Surgery
Desborough Surgery
Rectory Meadow…
Hughenden Valley…
The Simpson Centre
Little Chalfont Surgery
EXAMPLES
 Best way of been involved in the learning and retaining



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information.
Imagine you are the new partner in the practice.
Consider also how one will discuss the tests with a patient,
particularly when patient has expectations that the doctor
will do some tests.
Consider how one would best present information back to
colleagues in your practice .
Consider practically how one would deal with the
organisation of regular routine blood tests in certain
conditions.
Allow some debate on various topics. Not always a right
answer. Note the focus of these examples is investigations.
TIREDNESS
 Patient JS, 39 year old male, working in the city and
living in Gerards Cross, presents for the first time with
a 4 week history of tiredness . What do you do in this
first consultation.
 You make a management plan, but when he sees you
in 3 months he feels there has been no improvement.
What if anything would you do now.
PRINCIPLES FOR TIREDNESS
 Illustrates the importance of considering if you have to
intervene immediately.
 Like the delayed prescription, you can give the patient
a “delayed” investigation.
 Can consider treating for the most common diagnosis
before embarking on tests.
CARDIOVASCULAR RISK
 A patient VL , 53 year old female , comes to see you
after seeing the practice nurse twice with raised blood
pressure of 170/ 100. When you see VL her blood
pressure is 149/93, how do you proceed.
 You subsequently find that VL has a qrisk of 30% and
so you decide to start her on blood pressure treatment
(lisinopril 10mg) and give her simvastatin 40mg
nocte. How would you follow her up in terms of any
further investigations.
PRINCIPLES CARDIOVASCULAR RISK
 Consider how you follow up patients.
 If one repeats an unnecessary test then this can be
repeated for a very long time unnecessarily.
 Equally if you do not review appropriately every so
often something will be missed.
DIARRHOEA
 IP, 26 year old man, presents to you with a 6 day
history of diarrhoea after returning from Spain. How
would you proceed?
 IP comes back to you 3 weeks later, there has been a
slight improvement but he still has regular diarrhoea.
What would you do if anything ?
PRINCIPLES FOR DIARRHOEA
 Consider what the most likely diagnoses is and what
you are looking for with your investigations.
 Consider what the treatment would be for the most
likely results from your investigations.
CONSULTATION 4 PROBLEMS
PATIENT RT, 49 YEAR OLD LADY, PRESENTS WITH A
NUMBER OF PROBLEMS INCLUDING :
 Symptoms of a UTI.
 Menopausal symptoms and wonders about doing a
blood test to confirm this.
 4th toe nail on her right foot is slightly thickened and
discoloured, she wonders about a fungal toe nail
infection.
 Discharging boil on her back.
Consider what investigations you might do in this case
PRINCIPLES 4 PROBLEM
CONSULTATION
 Though a test may be appropriate consider at what
point it is helpful.
 Always consider what you will learn from the test
result, and will it change your management.
 Always discuss with the patient what the treatment
might be . If they do not want the treatment then
question whether the test is necessary.
 Sometimes you will do tests to reassure patients.
BREATHLESSNESS
 DT, a 69 year old man , presents to you with a 1 week
history of breathlessness. He was discharged 2 weeks
ago following a total hip replacement during which
period he had an MI.
 After you initially find nothing wrong he returns 2
months later with breathlessness on exertion.
PRINCIPLES BREATHLESSNESS
 If doing a d-dimer consider carefully if needed. If
clinically unlikely to be DVT then consider if worth
doing at all.
 Consider heart failure in chronic SOB, clinically
difficult to be sure of diagnosis.
DMARD MONITORING
 AZ , a 50 year old lady, who is already been treated for
hypertension has been diagnosed with rheumatoid
arthritis by the local rheumatologist and started on
methotrexate. She asks you if you would continue the
prescribing of the methotrexate. What investigations
would you consider if any ( some baseline tests were
done by the hospital ).
 How would you arrange any further monitoring/
follow up of this patient within your practice. You have
a phlebotomist, one nurse and one receptionist
working with you. This question is not just about the
blood tests but also the organisation of your Practice.
PRINCIPLES OF DMARD
MONITORING
 Having a system of monitoring is as important as what
tests are been done.
DEMENTIA
RS, a 80 year old man, presents to you with symptoms of
dementia. Screening tests confirm the probability of
dementia. How do you proceed.
PRINCIPLE OF REFERRALS
 Consider relevant blood tests for any referral. If blood
tests need to be done at out patient appointment this
often results in an unnecessary repeat appointment.
Erectile dysfunction
 Rd, a 40 year old man, presents to you with a one week
history of sore throat. When you looking at his throat
you notices his breath smells heavily of alcohol. He
also tells you about his erectile dysfunction. What tests
might you do, if any ?
KIDNEY DISEASE
 CD, 80 year old with hypertension, returns to you after
completing some routine U&Es for her annual
hypertension review. The creatinine is 118, egfr 58 (
normal up to 102). How do you proceed in both the
short and long run.