Chronic Disease Blood MonitoringDelivering Pathology Optimisation at pace and scale

Richard Croker

Chronic Disease Blood Monitoring

• Significant workload for primary care and labs

• Number of conditions (and drugs) that need monitoring in order to achieve QoF targets

• How do we ensure a “clean” approach to chronic disease monitoring?

QoF Blood Test requirements 2015-16

FBC Renal ALT HbA1CFasting LIPIDS

Non-HDL Cholester

ol TSH LFTS BoneB12 + Folate

ACR micro

albuminCardiovascular disease New X X X X XCardiovascular disease Annual X X XChronic Kidney Disease Annual X XDementia New X X X X X X XDiabetes New X X X X X XDiabetes Annual X X X X XDiabetes 6 Months XDowns Syndrome XHeart Failure New X X X X XHeart Failure Annual XHypertension New X X X XHypertension Annual XHypothyroid Annual XMental Health Annual X XObesity X

Liver function tests / ALT

• What percentage of citizens of North Devon had their ALT measured last year?

• What percentage of these have ‘abnormal’ ALT?

• What happens to these patients?

Patient StoryLiver Function Tests

76 year old man

History of leukaemia (8 years previously) and TIA (6 years previously)

On simvastatin 40mg for secondary prevention for 6 years

Had come in for “blood tests”, because Liver Function Tests (LFTs) had been raised at annual review

Patient StoryLiver Function Tests

Results:

GP undertook further blood tests, still abnormal results, simvastatin reduced (twice)

Patient has had 14 GP interactions in previous 12 months

GP assumed abnormal tests were due to statin usage, so statin reduced to much lower efficacy (if at all)

No referral for investigation, e.g. liver ultrasound

Patient StoryLiver Function Tests

Results:

Patient uncertainty and worry increased:

“I’m just coming in next week before I go on holiday to check with my doctor that the tests are all alright”

Also has false reassurance:When patient asked about his tests:

“the bloods should know most of the problems you have”

From an inside out lab perspective

• Each transaction was technically correct

• Assuming the result was accurate and timely, it therefore was “clean-through”

Is this clean in?

• Consideration of appropriate test• NICE Guidance on LFTs in patients on statin: “Measure

baseline liver transaminase enzymes (alanine aminotransferase or aspartate aminotransferase) before starting a statin. Measure liver transaminase within 3 months of starting treatment and at 12 months, but not again unless clinically indicated.

• Patient had been on statin for 6 years – so would not have been tested if per NICE guidance

• The patient is not consented. This leaves potential for misunderstanding about what has been done and why…

• ...we were not checking for relapse of leukaemia

Is this clean out?

• Difficult to say - as wasn’t clean in…

• But, assumption that statin was responsible and reduced to 10mg day (when this was clinically unlikely): more harm than good?

• Is patient lucky or unlucky he hasn’t received a referral for investigation?

• How do I know ‘what is normal for me’?

• Everything outside a reference range looks red.

• Results do not help anyone decide on the next step

How can we Improve?Actions:

• Consent for blood tests- pilot study

• Evidence based, rational testing for annual QOF monitoring- multidisciplinary team (secondary care specialists, pathologists and GP leads across NEW Devon)

• Results in meaningful format that patients can understand ‘what’s normal for me’, direct to patients- pilot

How do we get to an optimised service?

There is real similarities with pathology services and medicines optimisation:

• Both described as “golden thread” running through healthcare

• Drugs/tests usually delivered from separate clinical provider

• Optimal use of drugs/tests is complex

• Both under scrutiny to save money by reducing costs

Ensuring end-to-end effectiveness

“clean in” “clean through” “clean out”

Ensuring end-to-end effectiveness

“clean in”:Right drug

choice

“clean through”:Correctly dispensed

“clean out”:Correctly taken,

good patient outcome

Pre-analytical? Analytical Post-analytical?

Designing a pathology optimisation service

• Deliver through:– Clinical effectiveness– Identifying and understanding variation– Engagement

• Outside-in focused BMS• Clinical leads• Link clinicians in primary care• Half day peer to peer meetings• Practice visits

Designing a pathology optimisation service

Clinical Effectiveness

• Clinical and Cost Effectiveness assessment

• Clinical decision support

Understanding and reducing variation

• Information sources

• Benchmarking

Relationships and Engagement

• Clinical support and challenge

• Incentivisation

Designing a pathology optimisation service

All factors equally importantIn order to optimise care all three factors need to be successful

Medicines Optimisation started as a small team and grew – consider how to start this approach.

Implementation through engagement

Weekly ALTs from one practice

Practices that have fully implemented order comms have pushed requesting levels back to near 2002-4 levels.

Order sets for chronic diseases

2004 control limits

Some practices may need more support

Data provides assurance that clinically safe

Weekly number of ALTs above 120

2012 control limits

The future for pathology

• Effectiveness vs efficiency

• Needs increased focus for clean in and out

• Detail is important and requires expertise. Help interpret and implement complex guidance in a complex world

Our patient in an optimised world

Clinical Effectiveness

• Have a pathology group agreeing pathways of testing for chronic conditions

• Include in formulary and decision-support tool

Understanding Variation

• Benchmark GP practices to understand, following implementation, whether there has been change in LFT requests, and differences in requesting patterns

Engagement

• Discuss and challenge GPs on latest guidance on LFTs, and use this to deliver patient care. Be available for clinical guidance on interpretation of results.

Our patient in an optimised world

For our patient:

• Less inappropriate testing• More effective lipid modification• Less uncertainty and concern• less time• less change of harm through unwarranted testing

Care of the patient is more optimal

Our patient in an optimised world

For the system:

• 14 less GP appointments taken up in 12 months• Less chance of admission for further cardiovascular events• Reduced number and cost of unnecessary testing• Reduced cost of unwarranted further investigations

Improved patient care, reduced cost