So this may be a good time to look at the frequency and nature of pathology testing by your practice team - or at just your own test ordering behaviour.
Matching your pathology test requests with best practice and clinical evidence should result in more effective clinical management of patients with long-term diseases and other benefits.
Around 70 to 80% of all decisions affecting diagnosis or treatment in general practice involve a pathology investigation, costing the NHS in England some £2.5 billion every year.
Monitoring and screening of patients accounts for a significant proportion of this workload. It has been suggested that 25 to 40% of all pathology requests in primary/acute care settings are unnecessary and many clinicians are unaware of the costs.
Before we started a local project in Stoke-on-Trent, Staffordshire, to minimise inappropriate pathology test requests, we calculated that a 10% reduction in thyroid function test (108,000 were undertaken in 2009/10) would result in a saving in pathology costs of £16,600 a year, while a similar reduction in HbA1c would generate £9,700 savings a year.
With national data suggesting that up to 40% of tests are unnecessary, savings could be considerable year on year.
The block contract with the trust would then need to be renegotiated.
Comparing different practices showed one particular area where efficiencies could be made: this is to move away from requesting a (fasting) lipids test to selecting total and HDL cholesterol only.
Practices in Stoke (275,000 population) requested just under 110,000 (fasting) lipids tests a year.
A 50% conversion to a random total cholesterol + HDL would achieve a pathology cost saving of £80,500 annually and reduce the need for patients to fast.
Local data showed that practices vary in their frequency of test ordering of FSH by 10 times, HbA1c and thyroid function by more than double. There was a 40-fold variation in ordering (fasting) lipid profiles compared with random cholesterol.
So what can you do? Check you are ordering the right tests at appropriate time periods. If there are cheaper tests substitute them (where appropriate) on the basis of 'just as good quality delivery' of care.
Review whether you are over or under ordering tests - focus on common tests - eGFR, urine albumin to creatinine ratio, lipids/cholesterol, FSH/LH, HbA1c and TFT. Then agree what you need to do to achieve best practice. Gauge what the results might be.
Ask your local pathology department for comparative data. Or compare a random selection of tests your practice team orders in one week against best practice guidelines.
In summary, deciding on the action that needs to be taken involves checking if tests are ordered more/less frequently than best practice, deciding who should do what and by when to match best practice and what the expected outcome will be. Record these details.
|Benefits of appropriate pathology testing|
Review your practice protocols for related long-term conditions. Look at the sections on pathology testing - do they match guidance on best practice? Are your various practice clinical protocols synchronous (for example, testing for patients with hypertension who also have CKD or diabetes)?
|Pathology Test Costs|
|Urine albumin to creatinine ratio (UACR)||£7|
|University Hospital of North Staffordshire,2011|
Promote effective pathology testing so that all clinicians ordering tests conform to best practice as far as possible.
- Professor Chambers is a GP in Stoke-on-Trent and honorary professor at Stafford University
- This article was in preparation for a Stoke project by Professor Tony Fryer, Dr Bhushan Rao, Professor Chambers, Dr Owen Driskell, of University Hospital of North Staffordshire and NHS Stoke-on-Trent. The project is part of the Health Foundation's Shine programme. The Health Foundation is an independent charity for improving healthcare quality
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