So getting things straight in my mind here as I see them are the three major
points identified yesterday –
1 - 3 November 2005 - Lord Warner announced the setting up of the Pathology
Service Review Panel and its apparent main focus was on the fact that "Up to
70 per cent of all patient diagnoses depend on pathology but the importance
of pathology services to patient care are too often underestimated. - - - -
“
2 – This fact was originally announced in the UK as a major factor showing
the importance of Pathology to UK health in the Health Select Committee
Report published on 1 May 2002 (a gap of some 3+years)
3 – The fact announced seems to have been based on the paper in the
publication Clinical Chemistry –
http://www.clinchem.org/cgi/reprint/42/5/813.pdf - in 1996 (6 years before
the HSC Report and 9+ years before the PSR Panel was set up) claiming to
have derived this 70% figure without any supporting data from a single
source in the USA namely the Mayo Clinic which is of course absolutely
typical (NOT) of the UK Pathology Service.
An additional point of interest to you may be the fact while the Mayo survey
identified the pathology costs as 5% of the hospital’s budget, UK stats work
carried out around the same time by my very stats aware colleague Colin
Connolly, produced a figure of between 1 & 2%. Of course the budget profiles
may be different but it does show that in total cost terms pathology is not
a drain on the NHS or hospital budgets.
However whatever may be the case with the total cost stat, it seems to me
that the fact that the Modernisation of Pathology plan which the PSR Panel
was set up to monitor was apparently using an old, non-UK statistic obtained
from a single source not in any way typical of the pathology service in the
UK and thus makes the whole plan look as if it was based on the wrong basic
fact - to be polite about it. And as you say Rick – ”we need a much more
rigorous approach to understanding the types of decisions and the impact of
different tests in each context.”
So how does pathology progress from her if its eventual modernisation can be
adequately compared to pathology as it was when the whole idea of
modernisation was developed??
If I have drawn any incorrect conclusions from the facts revealed yesterday
then I would appreciate being so corrected so I can then withdraw my
non-too-polite comments about this plan
In the meantime keep progressing towards a more modernistic pathology
service to the UK population........................Dennis
-----Original Message-----
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of Richard Jones
[Pathology]
Sent: 11 July 2011 16:47
To: [log in to unmask]
Subject: Re: THE 70% THING
Two other relevant issues are that :
A lot of results are never looked at - see Eric Kilpatrick in the Annals
and
if you benchmark GP usage there is up to a 6 fold variance in test usage per
patient.
Assuming that disease is fairly randomly spread across the country and that
care is about even then it follows that a lot of clinical decisions may be
made with or without test results.
Hence as, is emerging from the discussion, we need a much more rigorous
approach to understanding the types of decisions and the impact of different
tests in each context. Then we might be able to work up strategies to ensure
that where decisions are dependent on results we can provide them in an
optimal way and where they make no difference we can stop wasting money.
Of course the outliers that over and undertest could be hiding some pretty
poor outcomes - either by missing of mismanaging problems or by generating
lots of false postives which can themselves be viewed as a poor outcome.
All fairly tough to do because there aren't many hard outcome endpoints.
Dr Rick Jones
Assoc Clin Director, Yorks and Humber Programme for IT Sen Lect, Yorkshire
Centre Health Informatics, Univ of Leeds Consultant Chemical Pathologist,
Leeds Teaching Hospitals NHS Trust
Current best book: Success through failure : the paradox of design. Henry
Petroski.
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From: Clinical biochemistry discussion list
[[log in to unmask]] On Behalf Of COLLINS MICHAEL (RM1)
Norfolk and Norwich University Hospital [[log in to unmask]]
Sent: 11 July 2011 15:35
To: [log in to unmask]; Richard Jones [Pathology]
Subject: Re: THE 70% THING
Robert Michel of The dark Report recently wrote on MedLab-L:
Finally, another useful nugget. Around 2002, after Aurora Health Systems of
Milwaukee had implemented an electronic medical record system (EMR), the
Chair of Pathology, Jay Schamberg, M.D., spoke at the Executive War College
meeting that year. He stated during his presentation that, after converting
patient files to the EMR, his IT department had determined that the average
permanent patient electronic health record contained lab test
data/information that totaled about 82% of the total data bits used to
story the patient's full health record. This statistic maps to the oft-used
statement that about 70% of a patient's permanent health record consists of
laboratory test data
Mike Collins
BMS3
Biochemistry Automation
Norfolk & Norwich University Hospital
England
[log in to unmask]
http://www.nnuh.nhs.uk/
________________________________
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of Dennis Huckerby
Sent: 11 July 2011 15:29
To: [log in to unmask]
Subject: Re: THE 70% THING
Hello to both of you Mike’s
Yes I do remember this paper and some of the discussions that evolved over
the following two or so years all on a high for the benefits of UK Pathology
but as far as I know it never went further than talk. Also the paper quotes
“"We know that - - - “but where are all the stats for this “know”
documented?? I certainly haven’t seen any and I was following this line of
thought for boosting UK pathology at the time. I am not doubting that this
figure is reasonably accurate as in the USA they would be carefully
monitoring this financially to obtain vital figures. However from my
observation (no - sorry no real stats apols) I believe it is nearer 80% (yes
the good old 80:20 relationship again) in the major patient groups i.e those
with serious diseases/disabilities/illnesses or how you want to describe
them and it is these where we need the stats to ,prove the importance of
pathology in the UK healthcare situation. I am not saying that those with
minor diseases etc are not important but it is there that the GPs and their
supporting colleagues are so vital in keeping under check the finances of
the NHS
So what do I mean now and earlier when referring to specific patient
groups?? Well here my thoughts (and this is not a complete listing ny any
means) based on personal and professional experiences –
GP patients – in all my visits to my GP in recent years, only very rarely
have he/them requested me to have a “path” test before diagnosing me and
writing a prescription. However we have heard in these recent years that
path test requests from GPs have increased by 40% and perhaps these were
occasioned by the GP et al requiring tests to prove that the patient was
suitable/fit enough for a particular pill/treatment and I have had my fair
dose of these.
Patients through Out Patient appointments – again for myself I have only had
one “path” test to rule out diabetes before a cataract op. No need for
“path” tests to diagnose that I needed a new hip although I had a few before
the op to make sure I was still alive and ready for the op Patients thru A&E
– not too many “path” tests” prior to diagnosing requested as far as I can
see/judge from the patients they see – well you can easily tell a patient
with a so-called sports injury or being drunk – by the words they use
Patients from Fracture clinics – again not too many “path” tests needed for
diagnosis but plenty needed to make sure they are fit for the op.
Oncology and cardiac patients – now here is where the “path” tests escalate
but mainly for monitoring their treatment once they have been diagnosed so
does this group confuse the present stats of 70%???
Patients in care/retirement homes – not too many to assist with diagnosis as
the local care assistant/nurse deals with all the minor diagnoses and
treatments School and young children referred to GP or hospital – probably
best included under one of the above headings unless it is felt necessary to
stat them separately. One interesting point here is that from a local stat
some 25% of patients attending our A&E were under 16 – interesting??? Yes
but probably of little relevance to this 70% stat.
Now don’t get me wrong. Even though I have been retired for many years I do
still believe that pathology is a vital service to UK healthcare - and I
have made this point (to many deaf ears and dead eyes it seems to me) in the
many papers I have had published since retirement. BUT let’s make any stats
totally UK and accurate and focused on the patient groups where pathology
can be best used. THEN we - the pathology profession – may get some quality
recognition at long last which won’t be the case if we keep relying on stats
25 years old and based on USA conditions.
OK that’s enough of my whingeing for now – I am sure that many of you will
be annoyed at my interference from the depths of retirement in this
discussion but that’s your privilege. However I still remain a pathology
professional and want to see my colleagues best used for the benefit of UK
healthcare……………………….Dennis
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of Hallworth Mike (RLZ)
Sent: 11 July 2011 14:23
To: [log in to unmask]
Subject: Re: THE 70% THING
Thanks Mike - that is the 1996 paper I cited in my original post claiming
"We know that, although the laboratory represents a small percentage of
medical center costs, it leverages 60-70% of all critical decisions, e.g.
admission, discharge and therapy".
It does not support "70% of all NHS diagnoses depend on lab tests".
Mike
________________________________
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of COLLINS MICHAEL (RM1)
Norfolk and Norwich University Hospital
Sent: 11 July 2011 14:10
To: [log in to unmask]
Subject: Re: THE 70% THING
This is the original paper
http://www.clinchem.org/cgi/reprint/42/5/813.pdf
Mike Collins
BMS3
Biochemistry Automation
Norfolk & Norwich University Hospital
England
[log in to unmask]<mailto:[log in to unmask]>
http://www.nnuh.nhs.uk/
________________________________
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of Hallworth Mike (RLZ)
Sent: 11 July 2011 13:29
To: [log in to unmask]
Subject: Re: THE 70% THING
Not sure I agree - we're supposed to be scientists! I am fully convinced of
the value of lab medicine but am not comfortable with the fact that the only
statistic that seems to be widely used is based on very flimsy foundations.
Cover-ups for political expediency have a way of getting out.... (Murdoch R,
Brooks R - personal communication)
I will summarise the available evidence in a post in the next day or so.
Mike
________________________________
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of IAN WATSON
Sent: 11 July 2011 11:56
To: [log in to unmask]
Subject: Re: THE 70% THING
Quite so: no political benefit in potentially shooting ourselves in the
foot……..!
Ian
________________________________
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of Dennis Huckerby
Sent: 11 July 2011 09:51
To: [log in to unmask]
Subject: Re: THE 70% THING
Yes that wording has also intrigued me over the years and I guess it
wouldn’t need much analytical expertise to come to that figure?? However it
would be nice to find out where the original figure came from but would it
be in the best interests of pathology to delve too
deeply??...........................Dennis
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of Colley, Michael
Sent: 11 July 2011 09:28
To: [log in to unmask]
Subject: Re: THE 70% THING
The telling point is that it actually says “Up to 70%” i.e. anything from
zero to 70.
Michael
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of Dennis Huckerby
Sent: 09 July 2011 22:19
To: [log in to unmask]
Subject: THE 70% THING
Hi Mike, Rick and all
My reason for entering this chat line was because I remembered writing a
paper about this 70% and following an exchange of emails with you Mike over
the weekend, I realised that the ref in my earlier email was not the answer.
So digging around in my files I found my paper (MLW Sept 2002 Conspicuous by
its absence P 6 et seq) and apart from identifying the first quote of the
70% figure in an HSC Report, I was annoyed/disturbed/disgusted at the time
to find that neither the IBMS nor the ACB were represented as organisations
in the list of witnesses interviewed even though they may well have been
there as individual members.
However to cut a very long story short here is the ref for the HSC Report
and I then copy the intro to the Pathology Section. You can read the rest
for yourselves - -
http://www.parliament.the-stationery-office.co.uk/pa/cm200102/cmselect/cmhea
lth/308/30802.htm
[cid:image001.gif@01CC3FE0.27492130]
House of Commons
Session 2001-02
Publications on the
internet<http://www.parliament.the-stationery-office.co.uk/pa/cm/cmpubns.htm
>
Health Committee
Publications<http://www.parliament.the-stationery-office.co.uk/pa/cm/cmhealt
h.htm>
Health - First Report
________________________________
Here you can browse the report together with the Proceedings of the
Committee. The published report was ordered by the House of Commons to be
printed 1 May 2002.
CONTENTS – You can read these for yourselves when you go to this site.
As promised/threatened above here is the intro to the Pathology section –
please note #141 – but who/where was the analysis carried out??
VI PATHOLOGY AND PUBLIC PRIVATE PARTNERSHIPS Pathology in the NHS 139. Our
terms of reference extended to Public Private Partnerships. As we noted
above, The NHS Plan outlined areas for further collaboration between the NHS
and the independent sector. We chose to focus on pathology, one of the key
areas where the Department anticipates growth.
140. The estimated total NHS expenditure on pathology services was £742
million in 2000-01, an increase of nearly £200 million on the figure for
1998-99.[231<http://www.parliament.the-stationery-office.co.uk/pa/cm200102/c
mselect/cmhealth/308/30809.htm#note231>] The Royal College of Pathologists
estimates that pathology consumes around 6% of the NHS acute services
budget.[232<http://www.parliament.the-stationery-office.co.uk/pa/cm200102/cm
select/cmhealth/308/30809.htm#note232>] There are around 300 services in
England, usually based in acute trusts, and about 1700 separate laboratories
(principally haematology, microbiology, biochemistry, histopathology,
immunology). Historically, pathology laboratories developed on-site in
hospitals, serving local catchment populations. There are also approximately
250 private sector laboratories. There are a further 46 Public Health
Laboratory
services.[233<http://www.parliament.the-stationery-office.co.uk/pa/cm200102/
cmselect/cmhealth/308/30809.htm#note233>]
141. Up to 70% of all diagnoses in NHS patients depend on laboratory tests,
hence NHS pathology services are critical for the day to day evidence-based
care of patients. Fewer than 5% of test requests ("hot tests") require a
response within 24 hours. The NHS undertakes some pathology work for the
independent sector, but very little NHS work is currently undertaken by the
independent sector. In addition, the reprovision of laboratories has been
included in a number of PFI projects. Only about 5% of pathology work
undertaken in the UK is currently conducted by the private
sector.[234<http://www.parliament.the-stationery-office.co.uk/pa/cm200102/cm
select/cmhealth/308/30809.htm#note234>]
I have to admit that I have not read thru the total report and it may well
mention somewhere more about the work carried out to support the 70% figure.
However if not then I am sure there are amongst you those who will know and
be able to contact some of the more prominent Pathology personnel eg – Prof.
Sir John Lilleyman and Karen Ward to mention just two
So hope this ramble helps you identify the source and accuracy of the 70%
figure and then I hope you will publish your findings----------PLEASE
Happy reading everybody……………………Dennis
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