Two other relevant issues are that :
A lot of results are never looked at - see Eric Kilpatrick in the Annals
and
if you benchmark GP usage there is up to a 6 fold variance in test usage per patient.
Assuming that disease is fairly randomly spread across the country and that care is about even then it follows that a lot of clinical decisions may be made with or without test results.
Hence as, is emerging from the discussion, we need a much more rigorous approach to understanding the types of decisions and the impact of different tests in each context. Then we might be able to work up strategies to ensure that where decisions are dependent on results we can provide them in an optimal way and where they make no difference we can stop wasting money.
Of course the outliers that over and undertest could be hiding some pretty poor outcomes - either by missing of mismanaging problems or by generating lots of false postives which can themselves be viewed as a poor outcome.
All fairly tough to do because there aren't many hard outcome endpoints.
Dr Rick Jones
Assoc Clin Director, Yorks and Humber Programme for IT
Sen Lect, Yorkshire Centre Health Informatics, Univ of Leeds
Consultant Chemical Pathologist, Leeds Teaching Hospitals NHS Trust
Current best book: Success through failure : the paradox of design. Henry Petroski.
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From: Clinical biochemistry discussion list [[log in to unmask]] On Behalf Of COLLINS MICHAEL (RM1) Norfolk and Norwich University Hospital [[log in to unmask]]
Sent: 11 July 2011 15:35
To: [log in to unmask]; Richard Jones [Pathology]
Subject: Re: THE 70% THING
Robert Michel of The dark Report recently wrote on MedLab-L:
Finally, another useful nugget. Around 2002, after Aurora Health Systems of
Milwaukee had implemented an electronic medical record system (EMR), the
Chair of Pathology, Jay Schamberg, M.D., spoke at the Executive War College
meeting that year. He stated during his presentation that, after converting
patient files to the EMR, his IT department had determined that the
average permanent patient electronic health record contained lab test
data/information that totaled about 82% of the total data bits used to story the
patient's full health record. This statistic maps to the oft-used statement that
about 70% of a patient's permanent health record consists of laboratory
test data
Mike Collins
BMS3
Biochemistry Automation
Norfolk & Norwich University Hospital
England
[log in to unmask]
http://www.nnuh.nhs.uk/
________________________________
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Dennis Huckerby
Sent: 11 July 2011 15:29
To: [log in to unmask]
Subject: Re: THE 70% THING
Hello to both of you Mike’s
Yes I do remember this paper and some of the discussions that evolved over the following two or so years all on a high for the benefits of UK Pathology but as far as I know it never went further than talk. Also the paper quotes “"We know that - - - “but where are all the stats for this “know” documented?? I certainly haven’t seen any and I was following this line of thought for boosting UK pathology at the time. I am not doubting that this figure is reasonably accurate as in the USA they would be carefully monitoring this financially to obtain vital figures. However from my observation (no - sorry no real stats apols) I believe it is nearer 80% (yes the good old 80:20 relationship again) in the major patient groups i.e those with serious diseases/disabilities/illnesses or how you want to describe them and it is these where we need the stats to ,prove the importance of pathology in the UK healthcare situation. I am not saying that those with minor diseases etc are not important but it is there that the GPs and their supporting colleagues are so vital in keeping under check the finances of the NHS
So what do I mean now and earlier when referring to specific patient groups?? Well here my thoughts (and this is not a complete listing ny any means) based on personal and professional experiences –
GP patients – in all my visits to my GP in recent years, only very rarely have he/them requested me to have a “path” test before diagnosing me and writing a prescription. However we have heard in these recent years that path test requests from GPs have increased by 40% and perhaps these were occasioned by the GP et al requiring tests to prove that the patient was suitable/fit enough for a particular pill/treatment and I have had my fair dose of these.
Patients through Out Patient appointments – again for myself I have only had one “path” test to rule out diabetes before a cataract op. No need for “path” tests to diagnose that I needed a new hip although I had a few before the op to make sure I was still alive and ready for the op
Patients thru A&E – not too many “path” tests” prior to diagnosing requested as far as I can see/judge from the patients they see – well you can easily tell a patient with a so-called sports injury or being drunk – by the words they use
Patients from Fracture clinics – again not too many “path” tests needed for diagnosis but plenty needed to make sure they are fit for the op.
Oncology and cardiac patients – now here is where the “path” tests escalate but mainly for monitoring their treatment once they have been diagnosed so does this group confuse the present stats of 70%???
Patients in care/retirement homes – not too many to assist with diagnosis as the local care assistant/nurse deals with all the minor diagnoses and treatments
School and young children referred to GP or hospital – probably best included under one of the above headings unless it is felt necessary to stat them separately. One interesting point here is that from a local stat some 25% of patients attending our A&E were under 16 – interesting??? Yes but probably of little relevance to this 70% stat.
Now don’t get me wrong. Even though I have been retired for many years I do still believe that pathology is a vital service to UK healthcare - and I have made this point (to many deaf ears and dead eyes it seems to me) in the many papers I have had published since retirement. BUT let’s make any stats totally UK and accurate and focused on the patient groups where pathology can be best used. THEN we - the pathology profession – may get some quality recognition at long last which won’t be the case if we keep relying on stats 25 years old and based on USA conditions.
OK that’s enough of my whingeing for now – I am sure that many of you will be annoyed at my interference from the depths of retirement in this discussion but that’s your privilege. However I still remain a pathology professional and want to see my colleagues best used for the benefit of UK healthcare……………………….Dennis
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Hallworth Mike (RLZ)
Sent: 11 July 2011 14:23
To: [log in to unmask]
Subject: Re: THE 70% THING
Thanks Mike - that is the 1996 paper I cited in my original post claiming
"We know that, although the laboratory represents a small percentage of medical center costs, it leverages 60-70% of all critical decisions, e.g. admission, discharge and therapy".
It does not support "70% of all NHS diagnoses depend on lab tests".
Mike
________________________________
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of COLLINS MICHAEL (RM1) Norfolk and Norwich University Hospital
Sent: 11 July 2011 14:10
To: [log in to unmask]
Subject: Re: THE 70% THING
This is the original paper
http://www.clinchem.org/cgi/reprint/42/5/813.pdf
Mike Collins
BMS3
Biochemistry Automation
Norfolk & Norwich University Hospital
England
[log in to unmask]<mailto:[log in to unmask]>
http://www.nnuh.nhs.uk/
________________________________
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Hallworth Mike (RLZ)
Sent: 11 July 2011 13:29
To: [log in to unmask]
Subject: Re: THE 70% THING
Not sure I agree - we're supposed to be scientists! I am fully convinced of the value of lab medicine but am not comfortable with the fact that the only statistic that seems to be widely used is based on very flimsy foundations. Cover-ups for political expediency have a way of getting out.... (Murdoch R, Brooks R - personal communication)
I will summarise the available evidence in a post in the next day or so.
Mike
________________________________
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of IAN WATSON
Sent: 11 July 2011 11:56
To: [log in to unmask]
Subject: Re: THE 70% THING
Quite so: no political benefit in potentially shooting ourselves in the foot……..!
Ian
________________________________
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Dennis Huckerby
Sent: 11 July 2011 09:51
To: [log in to unmask]
Subject: Re: THE 70% THING
Yes that wording has also intrigued me over the years and I guess it wouldn’t need much analytical expertise to come to that figure?? However it would be nice to find out where the original figure came from but would it be in the best interests of pathology to delve too deeply??...........................Dennis
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Colley, Michael
Sent: 11 July 2011 09:28
To: [log in to unmask]
Subject: Re: THE 70% THING
The telling point is that it actually says “Up to 70%” i.e. anything from zero to 70.
Michael
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Dennis Huckerby
Sent: 09 July 2011 22:19
To: [log in to unmask]
Subject: THE 70% THING
Hi Mike, Rick and all
My reason for entering this chat line was because I remembered writing a paper about this 70% and following an exchange of emails with you Mike over the weekend, I realised that the ref in my earlier email was not the answer. So digging around in my files I found my paper (MLW Sept 2002 Conspicuous by its absence P 6 et seq) and apart from identifying the first quote of the 70% figure in an HSC Report, I was annoyed/disturbed/disgusted at the time to find that neither the IBMS nor the ACB were represented as organisations in the list of witnesses interviewed even though they may well have been there as individual members.
However to cut a very long story short here is the ref for the HSC Report and I then copy the intro to the Pathology Section. You can read the rest for yourselves - -
http://www.parliament.the-stationery-office.co.uk/pa/cm200102/cmselect/cmhealth/308/30802.htm
[cid:image001.gif@01CC3FE0.27492130]
House of Commons
Session 2001-02
Publications on the internet<http://www.parliament.the-stationery-office.co.uk/pa/cm/cmpubns.htm>
Health Committee Publications<http://www.parliament.the-stationery-office.co.uk/pa/cm/cmhealth.htm>
Health - First Report
________________________________
Here you can browse the report together with the Proceedings of the Committee. The published report was ordered by the House of Commons to be printed 1 May 2002.
CONTENTS – You can read these for yourselves when you go to this site.
As promised/threatened above here is the intro to the Pathology section – please note #141 – but who/where was the analysis carried out??
VI PATHOLOGY AND PUBLIC PRIVATE PARTNERSHIPS
Pathology in the NHS
139. Our terms of reference extended to Public Private Partnerships. As we noted above, The NHS Plan outlined areas for further collaboration between the NHS and the independent sector. We chose to focus on pathology, one of the key areas where the Department anticipates growth.
140. The estimated total NHS expenditure on pathology services was £742 million in 2000-01, an increase of nearly £200 million on the figure for 1998-99.[231<http://www.parliament.the-stationery-office.co.uk/pa/cm200102/cmselect/cmhealth/308/30809.htm#note231>] The Royal College of Pathologists estimates that pathology consumes around 6% of the NHS acute services budget.[232<http://www.parliament.the-stationery-office.co.uk/pa/cm200102/cmselect/cmhealth/308/30809.htm#note232>] There are around 300 services in England, usually based in acute trusts, and about 1700 separate laboratories (principally haematology, microbiology, biochemistry, histopathology, immunology). Historically, pathology laboratories developed on-site in hospitals, serving local catchment populations. There are also approximately 250 private sector laboratories. There are a further 46 Public Health Laboratory services.[233<http://www.parliament.the-stationery-office.co.uk/pa/cm200102/cmselect/cmhealth/308/30809.htm#note233>]
141. Up to 70% of all diagnoses in NHS patients depend on laboratory tests, hence NHS pathology services are critical for the day to day evidence-based care of patients. Fewer than 5% of test requests ("hot tests") require a response within 24 hours. The NHS undertakes some pathology work for the independent sector, but very little NHS work is currently undertaken by the independent sector. In addition, the reprovision of laboratories has been included in a number of PFI projects. Only about 5% of pathology work undertaken in the UK is currently conducted by the private sector.[234<http://www.parliament.the-stationery-office.co.uk/pa/cm200102/cmselect/cmhealth/308/30809.htm#note234>]
I have to admit that I have not read thru the total report and it may well mention somewhere more about the work carried out to support the 70% figure. However if not then I am sure there are amongst you those who will know and be able to contact some of the more prominent Pathology personnel eg – Prof. Sir John Lilleyman and Karen Ward to mention just two
So hope this ramble helps you identify the source and accuracy of the 70% figure and then I hope you will publish your findings----------PLEASE
Happy reading everybody……………………Dennis
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