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How to... Cut the costs of pathology tests

Professor Ruth Chambers says reviewing your test requests could save funds and bring other benefits.

Saving funds on pathology tests: check you are ordering the right tests at the appropriate times (Photograph: Istock)
Saving funds on pathology tests: check you are ordering the right tests at the appropriate times (Photograph: Istock)

The focus on GP commissioning means that while preserving or enhancing the quality and safety of patient care, we also try to minimise unnecessary use of resources.

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.

Financial savings
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.

Step 1
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
  • Greater consistency and standardisation in requesting of specific tests.
  • Reduction in inappropriate testing and conversion to cheaper alternatives where equivalents exist.
  • Enhanced standards of clinical practice.
  • Improvements in patient experience and reduced inconvenience.
  • More effective and efficient use of resources within general practice and pathology laboratories (cost savings from phlebotomy, laboratory processing and subsequent GP consultation, and direct benefits at patient level through less travelling/time/absence from work).
  • Equity: reduction in variation of practice by primary care teams and adherence to guidelines to minimise inequalities for patients.

Step 2
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
Test Unit Cost
FSH £4
LH £4
TSH £2
FT4 £2
Hb1Ac £4
Urine albumin to creatinine ratio (UACR) £7
eGFR £1
(Fasting) Lipids £3
Cholesterol £1
University Hospital of North Staffordshire,2011

Step 3
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

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

As in steps 1 to 3 left:

  • Check you are ordering the right tests at appropriate time periods.
  • If cheaper tests will provide the details required within your 'just as good quality delivery of care' policy, substitute them.
  • Write/update protocols.

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