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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