Demand Management in Chemical Pathology a case study of five laboratories in the South West Peninsula of the UK Dr John O’Connor Biochemistry Department.

Demand Management in Chemical Pathology a case study of five laboratories in the South West

Peninsula of the UK

Dr John O’Connor

Biochemistry Department RD&E

ACB SW Meeting 30th June 2011

PeninsulaPathologyNetwork

5 Acute trustsPopulation 1.7 millionAround 4000 acute bedsApprox 400 GP surgeriesBiochemistrySamples received 2.5 million

Headlines: Profligate Abuse of Pathology Services

• Primary care produces a high and increasing volume of tests, constituting about 50% of laboratory activity in many DGH’s.

• Both Bandolier and Health Trends have acknowledged that some 30% of these tests are inappropriate, an unnecessary public expenditure of £540 million per annum

Headlines: Rising Demand

• Laboratory activity is rising at around 6-10% annually Number of Renal Function Tests performed at the

RDE by year

0

50000

100000

150000

200000

250000

300000

350000

400000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Year

No

Headlines: Rising Demand

• Increasingly elderly population will be reflected by ever increasing demand on pathology services AGEQUAKE

• Additional pressures of sophisticated new tests particularly in the field of molecular genetics being made increasingly available. Sophisticated = EXPENSIVE.

Headlines: QIPP

•QIPp (Quality improvement, prevention, productivity)

• Quality = right test, right TAT, right result, right response, patient centric to the care pathway

sacrificed for

• Productivity = Doing the wrong thing cheaper

“We did an audit in my accident and emergency department looking at therequests coming out from the junior doctors and, in a 24-hour period, 10 per cent of results – many of which were grossly abnormal – were not looked at.

So why were they requested in the first place?”

HeadlinesHeadlines: Danielle Friedman Nov 2010

Headlines: The prize

• Adopting some form of demand management predicts a saving of up to £180 million, against an annual NHS pathology spend of £1.8 billion (4% of total NHS annual expenditure), could be achieved.

• In the SW SHA we could expect to save £18 million

What is appropriateness in Pathology: The 3 R’s

Right Patient Right Test Right Time

Questions that should be asked when ordering a test

• Will it help me achieve the final diagnosis ?• Will it facilitate the referral from primary to secondary

care more efficiently?• Will it determine my immediate management of the

patient ?• Is the frequency of my requesting reflected by the

biological variation of what is being measured?• Do I know the sensitivity and specificity of what I am

requesting in the context of the clinical question being posed?

• Can I predict the result of what is being ordered to validate my hypothesis for this patient’s condition?

But in reality!!

• If I don’t order this ready for tomorrow’s ward round will my consultant kick my butt!!

• It would be quite interesting to know this result.

• This is a really difficult patient just order what they want and get them off our backs

• Groundhog day, I always order the same sets

And in actuality

• Defining what is Pathology Demand• Is a lot more complicated !!

•Balance of needs and demands•Consideration of the patient and wider healthcare objectives•Reduction in cost but better QOL•Agreeing targets•Auditing•Create as well as curtailing demand•Assess impact on lab•Consider service re-configuration

Defining Pathology Demand

Not re-inventing the wheel

• Australian Association of Pathology Practices (AAPP) published a series of recommendations based on analysis of the Australian Medicare database 2010

• Test cost feedback to requestors (Benchmarking)

• Minimum repeat intervals (MRI’s)• Requestor / Clinical restrictors• Pathology test guidelines and electronic

decision support for requestors• Education and communicationThese will form the framework of todays

presentation

Progress

• Toolkit developed based on the recommendations of the AAPP

• But are the 5 Penin trusts suitable candidates for review?

• C+G audit had established that the 5 Penin labs were in the top quartile of efficiency in the SW SHA (and if every other trust worked to that efficiency that would deliver Carter savings)

• Disseminated to the 5 laboratories in Oct 10• Completed March 11• Final report on website

www.pathologydemand.co.uk

National Benchmarking project

• Demand management for pathology services. • Increased focus of appropriate testing on

individual patients. • Reduction in redundant testing. • Improved cost effectiveness. • Equity of access to pathology services within

and across PCTs & GPs • Compliance with diagnostic and monitoring

aspects of NSFs, e.g. diabetes, CHD. • Monitoring testing practice in relation to new

commissioning arrangements.

But which tests

• Expensive, low volume? • High volume, cheap tests?• Winkelman JW. Clin Lab Med.

1985;5:635–651] “to get a 10 percent reduction in cost in the laboratory with automated testing, you need a 50 percent reduction in volume,”.

• Pulling tests off at the margins saves only incremental, variable costs; fixed costs

So why restrict routine tests?

• Normal range +/- 2 SD around the mean• 5% of normal patients will fall outside• Experienced docs will ignore these• Junior docs will further investigate• “Clinical Adventures”• Normal patients end up “Medicalised”• Cost and discomfort of unecessary

phlebotomy

Some benchmarking activity in SW labs has already been published for Cholesterol and CSU

• Useful information when linked with primary care QOF scores

• Valuable tool in practice based commissioning• Clinical governance issue could influence

change in practice• Information needs to be linked to education and

requesting guidelines• Information linked to cost of a test was useful

But granularity may be an issue: this works for Dr Richard Fink at the W Middlesex

• Year report• Clinical Speciality• Period (month)• Total number of attendances• Number of attendances involving pathology• Number of tests requested• Average pathology cost (all specialities)• Pathology cost for speciality• Then break this down into a monthly report by pathology discipline• Test• Monthly average year to date• No of tests requested• Pathology cost• Monthly average for current month • No of tests requested• Pathology cost• %+/- variation

But its about more than just activity and numbers!!

• Dr Stephen Pill “A pathology request should be treated as a clinical referral”

• Professor Batstone: “We need to move from being a results service to an interpretation service and then to a transactional service.”

• This would mean pathologists getting out of the labs and into the wider clinical setting. “unshackling pathology from the yoke of acute care”,

• Until labs become something other than trust-based cost centres, you stand no chance

• This is a wake up call for everyone in this audience “get out there and save this profession from being a results only service”

£££££££££££££££££££££

• AAPP recommendation• Provision of information on test cost to

requesting practitioners both at the time of requesting and as a regular individualized report

Frequency summary• National MRI project underway (Tim Laing / Stuart Smellie)• Appropriate frequency of testing in the context of

– EBM• Monitoring disease progression • Establishing the efficacy of an intervention • Where there is a plurality of therapeutic approaches available

• MRI applied 33 analytes across SW Labs• Biological half life, Critical Difference (account for analytical CV and intra-individual

variation, physiological change, all used for selection• Very good agreement on length of time between tests across analytes• Availability of past results through improved electronic communication and unique

patient identifiers;• IT (RDE) allowed re-reporting of previous results from LIS (overcomes primary care

not being copied in)• OCS systems generate warning at time of request to prevent samples being

needlessly taken• Simple and sensible measure to take

Expected reduction in workloadRDE over 3 month period

Test Total Not Done % Not done

FK 239 8 3.3

CEA 292 5 1.7

PSA 1454 1 0.1

CA199 32 2 6.3

CA125 276 9 3.3

K/L-Ratio 72 7 9.7

FER 3773 195 5.2

TSH 8230 150 1.8

VIT D 117 7 6.0

B12 2082 74 3.6

FOL 2082 74 3.6

PTHR 591 6 1.0

GHB 3916 69 1.8

IGA 487 13 2.7

Requestor Restrictions

AAPP:

Examination of tests and circumstances where requests may be restricted to certain requesting practitioners or specialities

Project RED in Australia

RED Consultant

AMBER Registrars

Green Junior docs and nurses

Authorisation An authorisation restriction which checks the user’s rights, roles or the subject of the order’s attributes, to test that the Service Item can be ordered.

Consultant only requestable

Precedent Check that one or all of the service items included in the repertoire have been previously performed. E.g. Require that a cross match has been performed before blood units can be ordered.

Contraindication These restrictions are useful where the ordering of an item could have a contradictory or negative effect on the subject of an order. E.g. Warn when ordering Digoxin for a patient who has a low potassium

Clinical Indication One or more items of Clinical Information must be available for an order to be processed. Whether it is the role of the lab to chase this information or if the notification of failure to progress the order is made by some other means

Quota Under consideration for Vit D (but on what basis)

New assays Clinical case, Business case and funding stream need to be identified for introduction of new assays

How do you deal with NICE recommendations e.g. Genetic tests for Familial Hypercholesterolaemia

Summary

• Speciality restrictions: Very different practices across SW labs (historical)

• Few restrictions from primary care requests (especially where there is PBR)

• Vetting sendaway tests for appropriate clinical indications £14,000 pa (RDE) denial of service report issued, samples stored for 2m, opportunity to challenge the lab

• Order sets available (where there is OCS)• Very different profile composition across 5

trusts ? Scope for harmonization

Education and Communication

1.AAPP: Development of education programs in the use of Pathology tests for requesting practitioners and consumers.

2.From the survey, plenty of scope for greater outreach into primary care

3.Greater involvement in undergrad training4.GP newsletter available across all 5 labs, but co-

ordinating content could be improved5.Greater involvement in GP commissioning to

improve demand management is currently a missed opportunity

“The doctor’s knowledge of laboratory investigation isinsecure. The reduction of basic science and pathology in medical education and training needs to be addressed and reversed..

REQUESTING

ANALYSISREPORTINGDecision support

REQUESTING

Decision support

Analytical Phase

Decision support

Analytical phase

• Strategies for reflex testing– Based on absolute concentrations– Based on Delta Checks– Based on Cascades– Based on Clinical Detail codes (RDE)

• Survey of the 5 laboratories showed vary practice

• “Dr Stephen Pill: treat a request like a clinical referral”

• Onus on the laboratory to do everything necessary to answer the clinical question being posed

Reporting

Decision support

Provocative Commenting

• Harmonize on “canned comments” to achieve the following:

• Promote best practice• Promote clinical action• Avoid misinterpretation• Justify request denial• Re-assure

Promote Best Practice

• Please note that IRON and TIBC analyses are not routinely available from the laboratory. The tests are reserved for cases where serum ferritin alone is not sufficiently informative in helping to reach a diagnosis. If this patient falls into such a category, please contact the Duty Biochemist for discussion [Tel. (01392) 402935].

Promote Clinical Action

• This man has now had two elevated results from his age- specific PSA tests. Provided MSU analysis has been done to exclude infection, a Urological referral should be considered. For a rapid appointment a fax-ed referral under the 2 week wait system is invited.

Request Denial

• Please note: The tests listed below are sent to another laboratory for analysis, and consequently require supportive clinical detail to justify the request. As none was given in this instance, please contact the Duty Biochemist (ext. 2935) to clarify your requirements. (The specimen will be kept for TWO MONTHS pending contact)....Requested Tests: Carotene

Reassure

• A 9am Cortisol > 550 nmol/L excludes Addisons Disease

• In Salisbury, when the reason for requestingthyroid function tests was introduced ratherthan simply requesting thyroid functiontests, the use of an algorithm enabled anappropriate response.

• One area that used this model saw a 25 percent reduction in the number of tests needed.It also led to the reports generated by the labbeing more relevant and comprehensible tothe clinician as they answered the questionposed.

‘problem-based’ requesting models encourage clinicians to state questions that they would like answered about the patient, and the pathologist then decides whattests this justifies.

On the face of it, difficult to work this way, sample types, conditions of collection etc. But not a bad idea in principleSo for example Hyponatraemia Hypovolaemic ? cause

HYPOVOLAEMIC LOW SODIUM ? CAUSE

Hyponatraemia ? cause

Action Plan

• Critically appraise what we currently do in DM as individual trusts

• Share our strategies

• Agree on best practice and harmonize

• Implement in our own institutions

• Treat this as an audit

Performance monitoring

• We must be in a position to demonstrate the effectiveness of change

• Use the initial analysis as a baseline• Need to identify the key indicators for

improving demand management and show which trusts achieve this

• Ultimately maintain a patient focus which may mean doing more testing in some areas