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ACB-CLIN-CHEM-GEN  February 2012

ACB-CLIN-CHEM-GEN February 2012

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Subject:

Re: TFT panels

From:

"Richard Jones [Pathology]" <[log in to unmask]>

Reply-To:

Richard Jones [Pathology]

Date:

Mon, 13 Feb 2012 16:55:57 +0000

Content-Type:

multipart/mixed

Parts/Attachments:

Parts/Attachments

text/plain (143 lines) , ThyroidPolicies.JPG (143 lines)

Though you might like to see what the balance of policy is across the UK from the use of data mining techniques.

The attached jpeg shows displays of test rates per 1000 patients for data aggregated at PCT level. Each bar is a PCT. The data was extracted anonymously from PMIP as part of the safety audit (still ongoing - see www.ychi.leeds.ac.uk/pmipunits<http://www.ychi.leeds.ac.uk/pmipunits>) and is a short snapshop based on >1m test reports. We can assume PCTs are about equivalent coverage to labs though of course there will be overlap - one wonders how the poor clinicians and patients cope with the variance at the boundaries.

The upper panel shows TSH usage and the lower panel fT4 usage. The visualisation suggests about half the country is using parallel TSH/fT4 and half sequential protocols. By mapping these data to rates of 'missed' / 'late diagnosed' hypopits from HES we could probably answer the clinical effectiveness question once and for all. Hardly anyone is still sending TT4. The variance in terms of tests per patient gets worse as you drill down through PCTs to GP practices just as Stuart Smellie has shown. Whether the patient outcomes are affected is a moot point and cries out for some R&D.

Some of this data is now in the printed version of the Atlas of Variation - see http://www.sepho.org.uk/extras/maps/NHSatlas2011/atlas.html

The dataset includes thyroid ref ranges etc too - Julian Barth has been commissioned by Muir Gray to look into this in depth.

If anyone wants access to the data contact [log in to unmask]<mailto:[log in to unmask]> and they can provide all the IG forms you'll need to fill in.

Rick




________________________________
From: Clinical biochemistry discussion list [[log in to unmask]] On Behalf Of Jonathan Kay [[log in to unmask]]
Sent: 13 February 2012 14:08
To: [log in to unmask]; Richard Jones [Pathology]
Subject: Re: TFT panels

QIPP document on the Core Automated Laboratory in Oxford<http://wwwgoogle.co.uk/url?sa=t&rct=j&q=qipp%20oxford%20laboratory&source=web&cd=2&ved=0CCoQFjAB&url=http://arms.evidencenhs.uk/resources/qipp/29512/attachment&ei=rRc5T8i3KcKBhQf9o6iyCg&usg=AFQjCNEBO9hKwRUEZN2MJ7ss_t8Lqi6wYg&cad=rja>, including some data on TaTs and references.

Jonathan




On 13 Feb 2012, at 13:28, Jonathan Kay wrote:

I'd be interested in how others organise this, but I'm more concerned about staff cost than delay in reporting.

For us:

The cascade overwhelmingly schedules the next assay without human intervention while the specimen is still on the track so there is no staff cost. (Siemens analysers and track.)

We are analysing specimens from primary care 24 x 7 without cut-offs so the delay is typically "one more assay" and would very rarely be perceptible by the GP.

Jonathan


On 13 Feb 2012, at 13:21, Mainwaring-Burton Richard (SOUTH LONDON HEALTHCARE NHS TRUST) wrote:


Does anybody also have data regarding the processing delay introduced ?

This will depend on the number of samples needing reflex testing, with consequential doubled analysis time, as well as all reflexable samples having to be held in results pending space prior to first results availability.

with best wishes
Richard
Richard Mainwaring-Burton
Consultant Biochemist
South London Healthcare Trust
Queen Mary's Hospital, Sidcup
Queen Elizabeth Hospital, Woolwich
Princess Royal Hospital, Farnborough
020-8836-5724
020-8308-3084
mob: 07831-739876

________________________________
From: Clinical biochemistry discussion list [[log in to unmask]] On Behalf Of Jonathan Kay [[log in to unmask]]
Sent: 13 February 2012 11:57
To: [log in to unmask]<mailto:[log in to unmask]>
Subject: Re: TFT panels

PS: There's no theoretical reason why population reference intervals should be the best decision limits for cascading further assays.

Jonathan

On 13 Feb 2012, at 11:56, Jonathan Kay wrote:

Good morning.

There's lots on this in the literature. I suggest you start with Barth's surveys published in Annals. There may also be something on current diversity of practice in recent Keele benchmarking reports.

In Oxford we start with TSH only (except in certain defined groups) and use on-analyser cascade rules from there.

Do you have computerised requesting by clinicians in either or both of primary care and secondary care that you can use as a platform for the rules?

Does anyone have experience of using this platform to implement different pathways for diagnosis and monitoring?

For primary care I am unconvinced by the argument about picking up hypopituitarism making it necessary to start with two assays in all patients. Does anyone have relevant figures on incidence of disease detected in this way or cost-effectiveness?

Jonathan


On 13 Feb 2012, at 11:43, Wainwright Laura - Clinical Scientist wrote:

Morning all,

I would be grateful for a bit of advice from the collective.  Like everywhere, we are under increasing budget pressures and one idea that has come up is to offer only TSH as our first line thyroid panel.  I find this a bit concerning as, even if you reflex FT4 when TSH is outside the reference range, we will no longer pick up hypopit patients.  I would be interested to hear your thoughts on this, particularly from anyone who already has this or a similar strategy in operation
Happy to summarise responses and feed back.
Many thanks,
Laura



Dr Laura Wainwright
Clinical Scientist
Queen Alexandra Hospital
Portsmouth
023 9228 6345
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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<http://www.acb.org.uk/> Green Laboratories Workhttp://www.laboratorymedicine.nhs.uk<http://www.laboratorymedicine.nhs.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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------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<http://www.acb.org.uk/> Green Laboratories Work http://www.laboratorymedicine.nhs.uk<http://www.laboratorymedicine.nhs.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/


------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 Green Laboratories Work http://www.laboratorymedicine.nhs.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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