Evaluation is not necessarily the only part of the problem.
New tests are continually being invented and requested but the finance-led NHS blocks us from using them because tests must be chargeable for before they can be used. The rheumatologists at my hospital have been requesting anti-CCP as an early rheumatoid marker since it was available (about 10 years ago). It costs only £8/test and they want to do about 200 tests / year. They are not allowed to do them because there is no budget to cover new developments.
This is not an isolated occurrence: Tests such as BNP have been evaluated extremely well but we continue to be unable to get funding because our PCT does not want to pay for it (that is about £25/test). New genetic tests that are even more expensive are completely out of the question [so there is a severe post code lottery in test availability]
Some tests however have a completely opposite development, eGFR (using a formula that has only ever been published as a poster abstract and is theerfore not even peer-reviewed) was imposed via the GP contract [and expected of labs because as a calculated test its cost was 'nothing']. This requirement was without proper evaluation, and with no funding for the consequent increases in PTH and vitamin D analyses etc.
So, some tests are well-established but cannot be run because there is no money; some are imposed on labs with no funding which pushes other non-funded tests lower down the hierarchy; some tests are imposed by committees stuffed with people who have vested interests in imposing specific test combinations on labs because they have patent arrangements that make them personal fortunes, even when the development of the test was done at public expense; and there are probably some tests that are already accepted and widely used but have no good evidence for their use.
Perhaps, a good start for NICE might be to evaluate whether there is any benefit in measuring urea as part of a U&E, or the replacement of ESR with CRP, or even what referral criteria should be applied before a CRP is measured - that could save many laboratories a lot of money - which may then be available for redirection to introducing new tests. However, NICE only evaluates published literature which means that when it does review an area it can only pronoounce as far as evidence is available. Thus for example in the NICE guidelines on pre-op testing a strategy of Byzantine complexity was developed for who should be given which tests, but this was based on inconsequential foundations that did not stand up to analysis. For many tests only a fully developed HTA assessment approach will be necessary.
TIM
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Prof. Tim Reynolds,
Queen's Hospital,
Belvedere Rd,
Burton-on-Trent,
Staffordshire,
DE13 0RB
work tel: 01283 511511 ext. 4035
work fax: 01283 593064
work email: [log in to unmask]
home email: [log in to unmask]
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-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of IAN WATSON
Sent: 23 March 2007 15:57
To: [log in to unmask]
Subject: Evaluating New Tests: NICE etc
Dear Colleague,
Introducing new tests without validation is a pain. A new initiative [see attached] developed in conjunction with the Dept Health and RCPath aims to tackle this.
Please participate in contributing ideas to this initiative. We are assured good ideas will be appropriately considered; there is access to funding to progress good ideas!
Look forward to your contributions to: [log in to unmask]
Ian Watson
ACB Chair
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------ACB discussion List Information--------
This is an open discussion list for the academic and clinical
community working in clinical biochemistry.
Please note, archived messages are public and can be viewed
via the internet. Views expressed are those of the individual and
they are responsible for all message content.
ACB Web Site
http://www.acb.org.uk
List Archives
http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html
List Instructions (How to leave etc.)
http://www.jiscmail.ac.uk/
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