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I have been leading NICE's support for the NHS's 'Quality and Productivity' agenda. There is a main page of resources on the website here: http://www.nice.org.uk/aboutnice/whatwedo/niceandthenhs/CostSaving.jsp This includes a searchable database of 650 NICE's 'do not do' recommendations derived from guidance from 2007. This includes many diagnostics. There are additional resources on NHS Evidence here: http://www.library.nhs.uk/qipp/ Including potential disinvestment options derived from the Cochrane reviews and examples of actual NHS projects that have produced savings. Again there are examples of diagnostics. I have been working with other colleagues internationally in this area and will ask them to post or obtain a summary. Adam Elshaug from Australia has had a focus on diagnostics and there is a very active Spanish group. I am currently in the US looking at strategies for dealing with 'low-value' interventions which is proving an interesting experience! All Comments/queries/suggestions/insights welcome: [log in to unmask] Best wishes Sarah Garner Associate Director R&D NICE 2010 2011 Harkness Fellow Healthcare Policy and Practice From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Fell Greg Sent: 03 December 2010 11:59 To: [log in to unmask] Subject: Re: "needless" path or biochem or imaging tests ordered from primary care 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: 1. Vit d deficiency test 2. Spinal xr- low back pain 3. Knee mr - many 4. Spinal mr - low back pain 5. pregnancy tests (£8 from lab rather than the £1 for doing them in house). 6. only doing creatinine instead or U and Es and creatinine 7. nail scrapings for fungus (£100). The thing about treating fungal nail infections is that it is long term with drugs that can have significant adverse effects, so is not to be undertaken lightly. The CKS advice is only to send clippings/scrapings if considering treatment, but if considering treatment then the infection should be confirmed. http://www.cks.nhs.uk/fungal_nail_infection/management/scenario_diagnosis#-378744<https://webmail.bradford.nhs.uk/exchweb/bin/redir.asp?URL=http://www.cks.nhs.uk/fungal_nail_infection/management/scenario_diagnosis%23-378744> 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 [log in to unmask]<mailto:[log in to unmask]> -----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]<mailto:[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".<http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353> 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 [log in to unmask]<mailto:[log in to unmask]> www.angliangp.org<http://www.angliangp.org> Making your practice evidence-based <http://www.rcgp.org.uk/bookshop/info_1_9780850843316.html> 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]<mailto:[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]<mailto:[log in to unmask]> W www.hrbcentreprimarycare.ie<http://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]<mailto:[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 . __,_._,___ -------------------------------------------------------------------- This e-mail is intended for the use of the addressee only and may contain confidential information, copyright material or views/opinions that do not necessarily reflect those of Bradford and Airedale teaching Primary Care Trust. 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