Thanks to the 6 people who answered these questions. The questions were
obviously designed to record what we actually do so that we can uncover
the principles. IMHO these are pretty clear:
1 Many laboratories frequently add assays that were not explicitly
requested.
2 Laboratories differ in their practice.
3 The common principle is that we try to address the clinical question
that was being asked. We sometimes treat the assays that were
explicitly requested as a proxy for that. We add assays when we think
they will help answer the clinical question. We sometimes don't perform
assays that were were explicitly requested: I think this is common in
clinical biochemistry for thyroid-related assays, and very common in
immunology and microbiology. Identifying the clinical question is
helped by good clinical details.
What should we do in the future?
1 Develop a consent process that is based around the use of laboratory
investigations to answer the clinical question, not one that is based
on specific assays.
2 Develop requesting systems that are based around the use of
laboratory investigations to answer the clinical question, not ones
that are based on specific assays. This was raised in several of the
comments by other respondents. It's a crucial topic as we enter the era
of EPRs and protocol-based medicine. It would be desirable that the
same system and process was used to record consent.
3 Discuss whether it is desirable or undesirable that we differ in our
practice
Jonathan
On 20 Feb 2004, at 17:48, Jonathan Kay wrote:
> Perhaps seeing others' responses to a few examples might draw out the
> issues:
>
> How would you respond in each of the following situations:
> (Do the extra assays, talk to the clinician before doing them, do
> nothing, something else)
>
> 1 Adding other thyroid-related assays after seeing the result after
> receiving a request for TSH
A No problem adding tests.
B Add whatever is required to clarify thyroid function EXCEPT - no
clinical details - no further tests, in patients get comment that
results may be affected by acute illness and thyroid clinic consultants
get whatever they ask for.
C We always treat thyroid requests as a request for TFTs, whatever they
ask for, so see 2
D do the extra assays
E Yes
F ADD FT4 OR FT3 AS APPROPRIATE
> 2 Adding other thyroid-related assays after seeing the TSH result after
> receiving a request for "thyroid function tests"
A No problem adding tests.
B As above
C Yes - do this routinely
D do the extra assays
E Yes
F ADD FT4 OR FT3 AS APPROPRIATE
> 3 Adding hCG assay to a sample from a young woman with suppressed
> gonadotrophins
A No problem with adding tests
B Depends on clinical details but usually would add hCG if any
suggestive details.
C Almost certainly, provided clinical details appropriate
D only in clinical details suggested they were looking for the cause of
amenorrhoea
E Yes
F ADD 17BO FIRST. IF HIGH THEN ADD HCG. RING GP IF HCG RAISED.
> 4 Adding a tumour marker assay on a hypercalcaemic sample with
> suggestive clinical details.
A No wouldn't add anything
B No - which tumour marker would be appropriate ? - just draw attention
of clinician to hypercalcaemia
C No - as B says, it would be a fishing expedition
D no
E Would depend on clinical details - 'cos tumour markers aren't always
that good at diagnosis, are they?
F NO -JUST ADD COMMENT. REQUEST UNCUFFED SAMPLE & PTH SAMPLE FOR
ANALYSIS IF REPEAT CALCIUM REMAINS HIGH. WE DO NOT RECOMMEND TUMOUR
MARKERS FOR SCREENING -PSA AN EXCEPTION I GUESS.
> 5 Adding total protein assay to a request for "LFT" in order to detect
> asymptomatic paraproteinaemia
A No wouldn't do this
B Its in our profile as in my opinion it is an important additional
test in interpreting low albumin and raised level is significant in
many liver diseases. We have diagnosed many paraproteinaemias by
following up raised globulin which is flagged for our authorisation
list.
C Unlikely, unless there was a reason to think of paraproteinaemia
D TP part of our LFT anyway
E We (yes we do) still include TP in LFTs
F NO. COMMENT THAT SAMPLE BE SENT FOR
'IMMUNOLOGY' I.E ELECTROPHORESIS ETC
> 6 Adding GGT assay after seeing the results following a request for
> "LFT"
A GGT include in our LFTs but I guess no I would have a problem
B Yes and calcium if alk. phos is raised - again, depends on clinical
details.
C Would have done it in the first place, so not applicable!
D suggest when authorising that gamma GT might help when next tested
E Our LFT includes GGT
F GGT IS PART OF OUR ROUTINE LFT.
B If we don't do anything, then we are abrogating our duty to interpret
the results we are producing. The minimum is to suggest the further
tests to the requesting clinician, but the best results are obtained
when the sample is fresh and the original abnormalities are present in
the sample. Asking the patient to come back to outpatients or the
doctors surgery is probably more invasive than just doing the tests.
The College have always argued the view that a request for a test
includes a request for an opinion and most of us would want as much
information as possible to base this on. I take the rather nihilist
view that if there are no clinical details the requesting clinician is
not interested in my opinion so am usually much less likely to offer
it.
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