Thanks to those that contributed
This is the tidied version of comments and the ‘list’ thus far
Question
“in cash strapped times of austerity we are starting
of a discussion with our GPs on path / biochem / imaging / other tests that are
commonly ordered from General Practice that are poorly evidenced / rarely add
to clinical picture or change a clinicial decision
Just a discussion thus far, and obviously does need contextualising properly.
And obviously this is part of a much broader debate about areas on which we can
"spend less on health care whilst loosing little health outcomes"
Context and discussion
“This is a valuable project because commissioning groups appear (anecdotally) to concentrate on interventions. We need to put diagnosis under the spotlight too.”
“Don’t pursue this with only money in mind because some of the investigations you list have harm associated with them (particularly radiation).”
“a very neglected topic - the EBM tools are well developed for evaluation of interventions with drugs, but to my knowledge concepts on how to evaluate diagnostic interventions are not reasonably defined/disseminated. Since diagnosis selects to treatment, this methodological weakness of the diagnostic science seems like a huge paradox”
“There was an interesting article published in the early 90s in JAMA from the Mayo clinic showing that 99.98% of routine labs gave no added information.”
“GPs may have incentives to prioritise on the basis of
some criterion which could remotely have something to do with the scientific
evidence underlying the (for example) diagnostic performance of test X.”
”don’t forget the pressures to do "something, anything"
for the person or the family in front of me.”
“most of the evidence synthesis on offer may be insufficient or frankly too complicated to help GPs. There will also have to be wholesale butchery of sacred cows, both in primary and other forms of care. Are we ready for that given the current nature of healthcare (an industry both with small and capital Is)?”
“Don’t forget junior docs in hospital.”
“our increasing role as physicians was as patient
educators and not primarily providers of 'stuff'. I am inclined to agree with
him as this is a large part of shared decision making. Though it can be time
consuming and won't be make all pts 'happy', for the most it is a good.”
And the “list”
Some of the obvious ones that we have started with:
Other suggestions
1. any Xray for soft tissue injury
2. FSH in perimenopause
3. asking for PV/CRP and ESR at same time
4. MSU MC+S in uncomplicated lower UTI (in women ) (except if 3+/year- then MC+S)
5. haemoglobin without a blood picture
6. full Liver function tests instead of SGOT and SGPT which would suffice
7. A lot of tests for monitoring are probably done too frequently (eg cholesterol). These are also responsible for a large proportion of tests that are done (Paul Glasziou knows the situation for cholesterol testing in the UK)
8. wrist MRI/CT (let the hand specialist decide if one is necessary).
9. complete electrolyte or blood panel when only one part needed (eg, Hgb alone rather than full cbc/differential)
10. duplicates upon admission to the hospital. We have an electronic medical record, and things such as basic labs and cardiac enzymes may be ordered in the emergency dept. They may then also be ordered by the admitting hospitalist when the patient gets to the floor if they don't look under the lab section.
11. multiple CTs for patients with poorly defined abdominal/pelvic pain
12. labs in healthy preop pt.
13. EKGs start at age 50, I believe, with no other h/o cardiac dz.
14. Pelvic ultra-sound for young women with non-specific pain. Potential harm: anxiety on discovery of insignificant cysts.
15. CT scans for headache. GPs have been give direct access to reduce neurology referrals. Potential harm: radiation. Alternative less harmful procedure: a neurological examination, accompanied by commentary e.g. "Looking at the back of the eye tells us a lot about the brain", reassures 99% of patients.
16. Liver tests are irrelevant when prescribing stains. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2962142-3/fulltext?elsca1=TL-031210&elsca2=email&elsca3=segment
Greg Fell
Consultant in Public Health
NHS Bradford and Airedale
07957 144 899
01274 237361
-----Original Message-----
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On
Behalf Of Kalliainen, Loree K
Sent: 02 December 2010 11:45
To:
[log in to unmask]
Subject: Re: "needless"
path or biochem or imaging tests ordered from primary care
Greg
Though our trainees are 'guilty', so are staff.
Tom
In a chat with the CMO at my organization (Brian Rank, HealthPartners), he
proposed that our increasing role as physicians was as patient educators and
not primarily providers of 'stuff'. I am inclined to agree with him as this is
a large part of shared decision making. Though it can be time consuming and
won't be make all pts 'happy', for the most it is a good.
Loree
Sent from my HTC smartphone
From: Tom Jefferson
<[log in to unmask]>
Sent: Thursday,
December 02, 2010 3:28 AM
To: [log in to unmask]
<[log in to unmask]>
Subject: Re:
"needless" path or biochem or imaging tests ordered from primary care
Kev and all, in the last
line of your email are you suggesting that GPs will have incentives (I do not
like using the participle "forced") to prioritise on the basis of
some criterion which could remotely have something to do with the scientific
evidence underlying the (for example) diagnostic perfomance of test X.
I was a GP in the UK and remember the pressures to do "something,
anything" for the person or the family in front of me.
I fear however that most of the evidence synthesis on offer
will be insufficient or frankly too complicated to help GPs. There will also
have to be wholesale butchery of sacred cows, both in primary and other forms
of care. Are we ready for that given the current nature of healthcare (an
industry both with small and capital Is)?
Best wishes,
Tom.
On 2 December 2010 09:58, k.hopayian <[log in to unmask]> wrote:
Hello Greg,
This is a valuable project because commissioning groups appear (anecdotally) to concentrate on interventions. We need to put diagnosis under the spotlight too. I am certain that you will not pursue this with only money in mind because some of the investigations you list have harm associated with them (particularly radiation).
Here is my suggestion (purely anecdotal):
Pelvic ultra-sound for young women with non-specific pain. Potential harm: anxiety on discovery of insignificant cysts.
CT scans for headache. GPs have been give direct access to reduce neurology referrals. Potential harm: radiation. Alternative less harmful procedure: a neurological examination, accompanied by commentary e.g. "Looking at the back of the eye tells us a lot about the brain", reassures 99% of patients.
For those outside the UK, we should explain that over the next two years, general practitioners will be given the budgets to commission health care services with the hope that this will reduce spending. These new constraints were introduced in a government paper called "Equity and Excellence: Liberating the National Health Service".
Dr Kev (Kevork) Hopayian, MD FRCGP
General Practitioner, Leiston, Suffolk
Hon Sen Lecturer, School of Medicine, Health Policy and Practice, University of East Anglia
GP CPD Director, Suffolk
On 2 Dec 2010, at 08:14, Fell Greg wrote:
good point
and yes is the answer
but I, personally, am principally concerend with the primary care stuff. In the
English health care system tests ordered within hospital are covered within
tariffs - so therefore payers dont pay so directly as those in primary care
that said, needless tests to contribute to cost inflation more broadly.
I will circulate final list when trail goes cold.
g
________________________________
From: Evidence based health (EBH) on behalf of Anthony Cummins
Sent: Thu 02/12/2010 07:38
To: [log in to unmask]
Subject: Re: "needless" path or biochem or imaging tests ordered from
primary care
In the interests of fairness I assume that you are applying this to hospital
junior staff who would generally use much less discretion in ordering tests
than GPs?
Dr. Anthony Cummins MRCGP
Lecturer/ Academic Researcher
Dept of General Practice & HRB Primary Care Research Centre
RCSI Medical School
Beaux Lane House
Lower Mercer Street
Dublin 2
T +35314028604
E [log in to unmask]
W www.hrbcentreprimarycare.ie
Mon, Tues & Thur only. At other times please phone departmental secretaries
directly on 014022304 or 2306
On 1 Dec 2010, at 23:19, "Fell Greg" <[log in to unmask]>
wrote:
in cash strapped times of austerity we are starting of a discussion with our GPs on path / biochem / imaging / other tests that are commonly ordered from General Practice that are poorly evidenced / rarely add to clinical picture or change a clinicial decision
Just a disucssion thus far, and obviously does need contextualising properly. And obviously this is part of a much broader debate about areas on which we can "spend less on health care whilst loosing little health outcomes"
Some of the obvious ones that we have started with
Vit d deficiency test
Spinal xr- low back pain
Knee mr - many
Spinal mr - low back pain
pregnancy tests (£8 from lab rather than the £1 for doing them in house).
only doing creatinine instead or U and Es and creatinine
Apparently nail scrappings for fungus cost nearly £100 so I was told
any Xray for soft tissue injury
FSH in perimenopause
asking for PV/CRP and ESR at same time
MSU MC+S in uncomplicated lower UTI (in women ) (except if 3+/year- then MC+S)
what would you add to the list
Greg Fell
07957 144899
.
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