Richard Croker shows how an innovative approach to service redesign can improve patient outcomes at pace and scale through the safe and effective use of testing at NHS Northern, Eastern and Western Devon CCG.

1. Chronic Disease Blood
Monitoring
Delivering Pathology Optimisation at pace and scale
Richard Croker

2. Chronic Disease Blood Monitoring
• Significant workload for primary care and labs
• Number of conditions (and drugs) that need monitoring in order
to achieve QoF targets
• How do we ensure a “clean” approach to chronic disease
monitoring?

3. QoF Blood Test requirements 2015-16
FBC Renal ALT HbA1C
Fasting
LIPIDS
Non-HDL
Cholesterol TSH LFTS Bone
B12 +
Folate
ACR micro
albumin
Cardiovascular
disease New X X X X X
Cardiovascular
disease Annual X X X
Chronic Kidney
Disease Annual X X
Dementia New X X X X X X X
Diabetes New X X X X X X
Diabetes Annual X X X X X
Diabetes 6 Months X
Downs Syndrome X
Heart Failure New X X X X X
Heart Failure Annual X
Hypertension New X X X X
Hypertension
Annual X
Hypothyroid Annual X
Mental Health
Annual X X
Obesity X

4. Liver function tests / ALT
• What percentage of citizens of North Devon had their ALT
measured last year?
• What percentage of these have ‘abnormal’ ALT?
• What happens to these patients?

5. Patient Story
Liver Function Tests
76 year old man
History of leukaemia (8 years
previously) and TIA (6 years
previously)
On simvastatin 40mg for secondary
prevention for 6 years
Had come in for “blood tests”,
because Liver Function Tests
(LFTs) had been raised at annual
review

6. Patient Story
Liver Function Tests
Results:
GP undertook further blood tests,
still abnormal results,
simvastatin reduced (twice)
Patient has had 14 GP interactions
in previous 12 months
GP assumed abnormal tests were
due to statin usage, so statin
reduced to much lower efficacy
(if at all)
No referral for investigation, e.g.
liver ultrasound

7. Patient Story
Liver Function Tests
Results:
Patient uncertainty and worry
increased:
“I’m just coming in next week
before I go on holiday to check
with my doctor that the tests are
all alright”
Also has false reassurance:
When patient asked about his
tests:
“the bloods should know most of
the problems you have”

8. From an inside out lab perspective
• Each transaction was technically correct
• Assuming the result was accurate and timely, it therefore was
“clean-through”

9. Is this clean in?
• Consideration of appropriate test
• NICE Guidance on LFTs in patients on statin: “Measure baseline liver
transaminase enzymes (alanine aminotransferase or aspartate
aminotransferase) before starting a statin. Measure liver transaminase
within 3 months of starting treatment and at 12 months, but not again
unless clinically indicated.
• Patient had been on statin for 6 years – so would not have been
tested if per NICE guidance
• The patient is not consented. This leaves potential for
misunderstanding about what has been done and why…
• ...we were not checking for relapse of leukaemia

10. Is this clean out?
• Difficult to say - as wasn’t clean in…
• But, assumption that statin was responsible and reduced to 10mg
day (when this was clinically unlikely): more harm than good?
• Is patient lucky or unlucky he hasn’t received a referral for
investigation?
• How do I know ‘what is normal for me’?
• Everything outside a reference range looks red.
• Results do not help anyone decide on the next step

11. How can we Improve?
Actions:
• Consent for blood tests- pilot study
• Evidence based, rational testing for annual QOF monitoring-
multidisciplinary team (secondary care specialists, pathologists
and GP leads across NEW Devon)
• Results in meaningful format that patients can understand ‘what’s
normal for me’, direct to patients- pilot

12. How do we get to an optimised service?
There is real similarities with pathology services and medicines
optimisation:
• Both described as “golden thread” running through healthcare
• Drugs/tests usually delivered from separate clinical provider
• Optimal use of drugs/tests is complex
• Both under scrutiny to save money by reducing costs

13. Ensuring end-to-end effectiveness
“clean in” “clean through” “clean out”

14. Ensuring end-to-end effectiveness
“clean in”:
Right drug choice
“clean through”:
Correctly
dispensed
“clean out”:
Correctly taken,
good patient
outcome
Pre-analytical? Analytical Post-analytical?

15. Designing a pathology optimisation service
• Deliver through:
– Clinical effectiveness
– Identifying and understanding variation
– Engagement
• Outside-in focused BMS
• Clinical leads
• Link clinicians in primary care
• Half day peer to peer meetings
• Practice visits

16. Designing a pathology optimisation service
Clinical Effectiveness
• Clinical and Cost Effectiveness assessment
• Clinical decision support
Understanding and reducing variation
• Information sources
• Benchmarking
Relationships and Engagement
• Clinical support and challenge
• Incentivisation

17. Designing a pathology optimisation service
All factors equally important
In order to optimise care all
three factors need to be
successful
Medicines Optimisation started
as a small team and grew –
consider how to start this
approach.

18. Implementation through engagement

19. Weekly ALTs from one practice
Practices that have fully implemented order comms have pushed
requesting levels back to near 2002-4 levels.
Order sets for
chronic diseases
2004 control limits

20. Some practices may need more support

21. Data provides assurance that clinically safe
Weekly number of ALTs above 120
2012
control
limits

22. The future for pathology
• Effectiveness vs efficiency
• Needs increased focus for clean in and out
• Detail is important and requires expertise. Help interpret and
implement complex guidance in a complex world

23. Our patient in an optimised world
Clinical Effectiveness
• Have a pathology group agreeing pathways of testing for chronic conditions
• Include in formulary and decision-support tool
Understanding Variation
• Benchmark GP practices to understand, following implementation, whether there
has been change in LFT requests, and differences in requesting patterns
Engagement
• Discuss and challenge GPs on latest guidance on LFTs, and use this to deliver
patient care. Be available for clinical guidance on interpretation of results.

24. Our patient in an optimised world
For our patient:
• Less inappropriate testing
• More effective lipid modification
• Less uncertainty and concern
• less time
• less change of harm through unwarranted testing
Care of the patient is more optimal

25. Our patient in an optimised world
For the system:
• 14 less GP appointments taken up in 12 months
• Less chance of admission for further cardiovascular events
• Reduced number and cost of unnecessary testing
• Reduced cost of unwarranted further investigations
Improved patient care, reduced cost