We do need to standardise on basic constituents of a profile. At least we should agree what has to be there, but leave allowance for the individual laboratory to give more. If a GP requests Liver or Lipid Profile from 5 hospital laboratories, there should at least be a common core, not 5 different combinations. Part of the need to have profiles has come from a need to reduce time in test ordering, and reduce time in test requesting inputting, for some it is all the one. It also helped to reduce "add on tests" which can be very demanding on resources, and it seems unethical to me to request further phlebotomy on a patient when there is an adequate sample in the laboratory. It seems we also need an Admission profile, which would be a broader sweep of tests, the ICU profile and the Oncology profile. i.e. tailor made for those specific sections. Maybe we need Initial Diagnostic liver profile, monitoring therapy liver profile etc
Helen
------------------------------------------------------------------------------------------
Dr Helen Grimes, Dept Clinical Biochemistry, University College Hospital, Galway, Ireland
-----Original Message-----
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]]On Behalf Of mike Toop
Sent: 11 May 2007 17:35
To: [log in to unmask]
Subject: Re: Standardised Test Profiles
Jeff
If we now in the realms of economics I would offer the following:
1) The use of costing of profiles or other collections of tests should not be allowed outside of a specific clinical context because it is a blunt tool for demand management and locks the profession (and the health economy) into an outmoded ways of thinking which once set up would be extraordinarily difficult to change
.
2) it would be better to give a tariff for each individual test as the first phase whilst looking at the results of an analysis of future patterns of use rather than past ways of thinking. If money had to be saved this should not be "hidden" in dubious test groupings but should be up front in the headline cost. Otherwise financial modelling for departments could be too complex.
3) Market management is much simpler on a test by test basis and tests thought to have limited use (e.g. chloride) or a low evidence base or low predictive value (e.g. homocysteine for heart disease could be banded lower than those with good evidence, high predictive value or many uses (e.g. troponin or alkaline phospatase).
(these are only examples and not an invitation to debate the values or not of those particular tests).
I am very concerned that the group designing this tariff is designing a market for the 20th century rather than 21st century and appears to be very narrow in its thinking. Even worse for the doH setting up a costing system that will be complex to administer and a poor tool for influencing change of practice
Mike
-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Jeff Seneviratne
Sent: 11 May 2007 17:10
To: [log in to unmask]
Subject: Re: Standardised Test Profiles
I agree that this is an important debate and feel we should be able to reach some agreement. We will be discussing this at the Greater Manchester Pathology Network Biochemistry group on Monday. Without preempting discussion there, Ian's suggestions below seem to form a basis for the likely outcome. While I have sympathy with the completely radical approach suggested by Mike Toop, this would take too long to agree and then even longer to implement, because of eg, the inflexibility of their LIS/HIS and the extra burden for those (most) still doing manual data entry.
With regard to thyroid, our practice has been to do TSH and free T4, but recently we have introduced a new box on our GP request form called " Monitoring T4 replacement". On these requests we only do TSH. This has been quite well received by our users. We have also put this option on our hospital order comms, although few requests of this type are received by this route.
Jeff
>>> IAN WATSON <[log in to unmask]> 11/05/2007 14:40 >>>
As has been pointed out by Martin Myers this is an important debate that
we need to have explored thoroughly so that when Commissioners are using
PbR we can give a coherent consensus rationale for what we are doing. I
would suggest that we should be looking to determine the minimum order
set compatible with meaningful interpretation in the majority (?>90%) of
patients and we should consider context i.e. hospital v GP.
it may be that we can save a lot of money by not doing GP ureas, but
that should be reinvested in adding T4 to TSH if not already done.
If we don't determine our own minimum quality standards, someone else
will.
So is it?:
renal: Na K creat urea [hospital] Na K creat (+ eGFR)[GP]
liver: Bili ALT or AST ALP ?+tot prot alb
bone Ca Alb PO4 ALP
Thyroid TSH (f)T4
The % of reflex tests added to each profile might become relevant if
high numbers, so some consideration of that too is needed.
Dr Ian D Watson
Consultant Biochemist & Toxicologist
Dept Clinical Biochemistry
University Hospital Aintree
Liverpool
L9 7AL
tel 01515293575
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