Overtesting is not without a risk of harm, either through incorrect further investigations, action, or patient worry. It has delivered using the model of existing medicines optimisation teams in CCGs, working on: 1) clinical effectiveness, 2) understanding variation, 3) engagement. A pathology optimisation team who can engage with GPs and practices is vital.
The production and sharing of data is also extremely important. This allows the pathology optimisation team to identify variation between practices and therefore to provide a level of GP discussion and engagement.
A pathology optimisation team, combined with benchmarking data and a good clinical evidence base can support and challenge GPs to change their requesting behaviour in line with what is best for the patient. We have learned that, although many of our interventions have been conceptually simple, there have been blocks to implementation at a practice or individual level that have required targeted support, and sometimes review of our guidance. It has also allowed different models of contracting to be used with pathology providers, focussing on pathology effectiveness, rather than volume and efficiency.
We undertook an in-depth multidisciplinary clinical interview with 14 patients, the outcome of which was that harm may have been caused in a number of these patients. Inappropriate uses of full blood count (FBC) in chronic disease care are an example. A FBC does not answer the clinical question of ‘’how is my disease going’’ at annual review, but can add anxiety if reported as ‘abnormal’, although it may be normal for the patient.
The project also identified where this had happened in practice. We made an information video, including interviews with the patient and the GP, available at
https://youtu.be/rPU0o6YfEiQ
The patient interviews also showed that possible harm from false reassurance may occur. Patients were not being routinely consented for blood tests. This led to the false reassurance that ‘everything wrong in the body’ would be picked up.
Devon has shown to be a high user of alanine aminotransferase (ALT) testing. The introduction of order sets and pathology optimisation has shown a marked decrease in the number of tests requested in the Northern Locality. One concern of our approach is that we may be reducing diagnosis of significant liver disease, Generally, it is agreed that an ALT above 120 iU/ml is of potential pathological significance, and requires further investigation (note this level is 3 times above the upper limit of ‘normal’). However, the number of tests above this ‘pathological threshold’ has not reduced. This suggests our actions have not led to reduced testing when it is clinically justified. This also implies that the predictive value of abnormal tests will have increased, as we are now tending to test a population with a higher prior probability of disease. There are also wider system benefits.
In one case, there were 14 further contacts with primary care after the initial test. As there was little apparent need for the GP to undertake the test in the first place, these appointments would have avoided. By providing GPs with better clinical rationale and guidance for the use of testing in chronic diseases, agreed by both primary and secondary care, rather than by solely populating order sets within clinical systems, GPs have reported increased confidence in using the recommended tests.