Preclinic Investigation Is Popular With Endocrinology Staff
Preclinic Investigation Is Popular With Endocrinology Staff
Performing tests prior to completing a clinical assessment of a patient is controversial. Some clinicians might argue that this could lead to inadequate clinical assessments, with too much reliance on test results. In turn, this might lead to clinicians 'treating' test results rather than patients.
However, we felt strongly that care could be improved in this way. Patients referred to an endocrinology clinic have already been assessed by general practitioners or other physicians, and on the basis of a high-quality referral, endocrinologists can confidently form a differential diagnosis in most patients. We propose that performing the appropriate tests to confirm or refute this diagnosis before the patient comes to clinic, allows clinicians time to concentrate on a thorough clinical assessment of the patient. If the diagnosis has already been confirmed, a management plan can be formed with the patient and treatment started immediately. Conversely, if the most obvious differential diagnoses have already been ruled out by preclinic blood tests, then more time can be spent exploring other possibilities. In other health care systems, such as dedicated office-based practices, results may be available rapidly and communication with patients significantly quicker and easier to achieve. This system is therefore not necessary or applicable to all, but has led to a streamlining of care in this NHS unit.
Anecdotally, we have also received reports of inexperienced doctors temporizing in clinics: requesting ever more tests rather than taking a decision or making a firm diagnosis. This system could be said to force this issue. Some clinicians might also resist such a change as potentially challenging their clinical autonomy. However, the survey confirmed 100% of hospital clinical staff wanted the system to continue which perhaps reflects the high level of involvement of local clinicians in the development of the system. Finally, the web-based guide aims to improve and unify the clinical assessment of new patients, and taken with a complete set of results, it is hoped that an appropriate plan can be made on day one in most cases.
Performing tests prior to clinical assessment might also lead to unnecessary and perhaps expensive tests being performed without due diligence as to whether each is indicated in an individual case, with a subsequent increase in cost. All test sets were discussed extensively with chemical pathology as well as the clinical teams prior to introduction, minimizing the use of expensive tests from the outset. Local laboratory practices, for example, the availability of in-house assays and the economy of scale afforded by a large laboratory should also be taken into account in test selection. Exactly which tests to perform 'up-front' will depend on local populations and laboratory pressures and should be reviewed regularly. For example, 17-hydroxyprogesterone was initially tested in all patients referred with possible PCOS and vitamin D in all patients presenting with hypercalcaemia. After 3 months, a significant increase in requesting of these expensive tests was noted by chemical pathology. 17-hydroxyprogesterone was felt to contribute little to the majority of cases and so was removed, while vitamin D had proved highly useful and so an in-house assay was deemed worthwhile to mitigate this cost pressure.
Furthermore, the involvement of senior clinicians in the selection of initial tests for each patient category is hoped to ensure that the right tests are performed at the start of the patient's pathway, potentially reducing subsequent unnecessary or repeated tests. Unfortunately, we are unable to isolate the costs specific to new patients for the endocrine clinics to perform a cost analysis of this project. Thus, we cannot confirm whether the presumed increase in up-front testing costs actually occurred, or whether this was mitigated by reduced subsequent tests. We perceive that the overall cost to the health economy and to the patient will have been reduced due to the reduced number of appointments and follow-up letters required as well as the acceleration of the treatment pathway. However, this is impossible to confirm. A minimal increase in directorate external laboratory expenditure was seen over this time period, though as the vast majority of preclinic tests were analysed in-house, and as chemical pathology continuously evolves, this may not be directly relevant. For example, since 2007 urinary catecholamines have been superseded, and other tests are now offered in-house. We are therefore unable to confirm whether this system is cost saving though we can confirm that it is time saving, accelerates treatment and is highly acceptable to patients and staff.
The reduction in time to start treatment and to discharge from clinic was gratifying. The NHS constitution in England includes a target that patients referred to hospitals should start consultant led treatment within 18 weeks of referral by their general practitioner. Achieving this RTT target is straight forward in many cases: for example, antithyroid drugs are generally started immediately on receipt of referral depending on local arrangements. However, this absolute maximum time limit applies across all diagnoses and specialties. Hyperparathyroid patients typically require endocrinology assessment followed by investigation for end organ damage, localizing studies and a surgical assessment before the actual surgery goes ahead. Definitive treatment is only said to have occurred at the point of surgery. Minimizing the delay at the start of such pathways is therefore vital to ensure surgery occurs within 18 weeks of initial referral. From 2013–2014, the NHS Commissioning Board established zero tolerance for protracted waits, with contractual fines for long delays. All hospitals are therefore obliged to collect national RTT codes continuously to indicate the stage of every patient's referral to confirm compliance with national standards. This system led to a marked improvement in our RTT compliance, more rapid diagnosis and treatment and earlier discharge from clinics.
Education of referring physicians is also key to this system. Without a quality referral letter, a differential diagnosis cannot be formed and so preclinic tests cannot be identified. We regularly meet with colleagues in primary care, have agreed local diagnosis and management guidelines available via our hospital and local healthcare website (www.knowledgeanglia.nhs.uk) and have also made the educational resource freely available. We have also agreed suggested investigations to be performed in primary care with our local clinical commissioning groups of primary care physicians. If these have been performed, preclinic tests are unnecessary. However, the current restructuring of the NHS has led to reluctance on the part of some primary care physicians to request such tests in the community if the patient will require a hospital assessment anyway. When tests are requested by the hospital team, they are paid for by the hospital wherever the test is actually performed minimizing the costs to primary care.
Minimizing trips to the hospital and reducing the need for hospital-based follow-up attendances is generally popular with patients. One-stop clinics are associated with reduced anxiety, thought to be due to reduced delays in patients receiving diagnostic test results. Attempts to implement preclinic test protocols in other specialties have been driven by Royal College or National Institute for Health and Care excellence (NICE) recommendations. However, there is little evidence behind these recommendations, and these efforts have not been universally successful. In this institution, 100% patients and 93% referring clinicians wished the system to continue.
About 92·4% of Norfolk patients describe themselves as White British compared with 79·8% of the total England population. This very low level of non-English-speaking patients might explain why we have encountered very few cases of patients unable to read or understand their letters, with 94% patients able to arrange the tests easily. Furthermore, this hospital serves a geographically large and rural area, including the clinical commissioning group with the highest median age in the United Kingdom (North Norfolk). This leads to particular transport issues for many of our patients, which may have contributed to the high patient satisfaction we have encountered with this and previous measures to reduce hospital visits, for example a one-stop thyroid assessment clinic.
Our survey also suggests that there has been a reduction in queries to general practitioners, hospital nursing and administrative staff, with comments indicating less chasing up of results on patients for whom the 'RTT clock' was still ticking. Hundred percent hospital staff wanted the system to continue. The system has also reduced the number of follow-up letters and appointments many patients require, with a consequent improvement in the directorate financial position, and an unusually high new/follow-up ratio of 1:2·5.
It is difficult to convincingly show that this system has improved the quality of care for endocrine patients referred to our clinic. However, the surrogate markers of exceptional patient and referring clinician satisfaction and improved hospital RTT targets are highly suggestive that it has. We therefore propose that appropriate focussed investigations prior to first appointment improve patient care and free clinicians to perform a more thorough clinical assessment. This in turn accelerates the decision-making process, reducing delays to diagnosis and treatment. We feel that this system could easily be adapted for use in other specialties and regions, though local clinician and chemical pathology engagement in the process has been crucial to its success in this department.
Discussion
Performing tests prior to completing a clinical assessment of a patient is controversial. Some clinicians might argue that this could lead to inadequate clinical assessments, with too much reliance on test results. In turn, this might lead to clinicians 'treating' test results rather than patients.
However, we felt strongly that care could be improved in this way. Patients referred to an endocrinology clinic have already been assessed by general practitioners or other physicians, and on the basis of a high-quality referral, endocrinologists can confidently form a differential diagnosis in most patients. We propose that performing the appropriate tests to confirm or refute this diagnosis before the patient comes to clinic, allows clinicians time to concentrate on a thorough clinical assessment of the patient. If the diagnosis has already been confirmed, a management plan can be formed with the patient and treatment started immediately. Conversely, if the most obvious differential diagnoses have already been ruled out by preclinic blood tests, then more time can be spent exploring other possibilities. In other health care systems, such as dedicated office-based practices, results may be available rapidly and communication with patients significantly quicker and easier to achieve. This system is therefore not necessary or applicable to all, but has led to a streamlining of care in this NHS unit.
Anecdotally, we have also received reports of inexperienced doctors temporizing in clinics: requesting ever more tests rather than taking a decision or making a firm diagnosis. This system could be said to force this issue. Some clinicians might also resist such a change as potentially challenging their clinical autonomy. However, the survey confirmed 100% of hospital clinical staff wanted the system to continue which perhaps reflects the high level of involvement of local clinicians in the development of the system. Finally, the web-based guide aims to improve and unify the clinical assessment of new patients, and taken with a complete set of results, it is hoped that an appropriate plan can be made on day one in most cases.
Performing tests prior to clinical assessment might also lead to unnecessary and perhaps expensive tests being performed without due diligence as to whether each is indicated in an individual case, with a subsequent increase in cost. All test sets were discussed extensively with chemical pathology as well as the clinical teams prior to introduction, minimizing the use of expensive tests from the outset. Local laboratory practices, for example, the availability of in-house assays and the economy of scale afforded by a large laboratory should also be taken into account in test selection. Exactly which tests to perform 'up-front' will depend on local populations and laboratory pressures and should be reviewed regularly. For example, 17-hydroxyprogesterone was initially tested in all patients referred with possible PCOS and vitamin D in all patients presenting with hypercalcaemia. After 3 months, a significant increase in requesting of these expensive tests was noted by chemical pathology. 17-hydroxyprogesterone was felt to contribute little to the majority of cases and so was removed, while vitamin D had proved highly useful and so an in-house assay was deemed worthwhile to mitigate this cost pressure.
Furthermore, the involvement of senior clinicians in the selection of initial tests for each patient category is hoped to ensure that the right tests are performed at the start of the patient's pathway, potentially reducing subsequent unnecessary or repeated tests. Unfortunately, we are unable to isolate the costs specific to new patients for the endocrine clinics to perform a cost analysis of this project. Thus, we cannot confirm whether the presumed increase in up-front testing costs actually occurred, or whether this was mitigated by reduced subsequent tests. We perceive that the overall cost to the health economy and to the patient will have been reduced due to the reduced number of appointments and follow-up letters required as well as the acceleration of the treatment pathway. However, this is impossible to confirm. A minimal increase in directorate external laboratory expenditure was seen over this time period, though as the vast majority of preclinic tests were analysed in-house, and as chemical pathology continuously evolves, this may not be directly relevant. For example, since 2007 urinary catecholamines have been superseded, and other tests are now offered in-house. We are therefore unable to confirm whether this system is cost saving though we can confirm that it is time saving, accelerates treatment and is highly acceptable to patients and staff.
The reduction in time to start treatment and to discharge from clinic was gratifying. The NHS constitution in England includes a target that patients referred to hospitals should start consultant led treatment within 18 weeks of referral by their general practitioner. Achieving this RTT target is straight forward in many cases: for example, antithyroid drugs are generally started immediately on receipt of referral depending on local arrangements. However, this absolute maximum time limit applies across all diagnoses and specialties. Hyperparathyroid patients typically require endocrinology assessment followed by investigation for end organ damage, localizing studies and a surgical assessment before the actual surgery goes ahead. Definitive treatment is only said to have occurred at the point of surgery. Minimizing the delay at the start of such pathways is therefore vital to ensure surgery occurs within 18 weeks of initial referral. From 2013–2014, the NHS Commissioning Board established zero tolerance for protracted waits, with contractual fines for long delays. All hospitals are therefore obliged to collect national RTT codes continuously to indicate the stage of every patient's referral to confirm compliance with national standards. This system led to a marked improvement in our RTT compliance, more rapid diagnosis and treatment and earlier discharge from clinics.
Education of referring physicians is also key to this system. Without a quality referral letter, a differential diagnosis cannot be formed and so preclinic tests cannot be identified. We regularly meet with colleagues in primary care, have agreed local diagnosis and management guidelines available via our hospital and local healthcare website (www.knowledgeanglia.nhs.uk) and have also made the educational resource freely available. We have also agreed suggested investigations to be performed in primary care with our local clinical commissioning groups of primary care physicians. If these have been performed, preclinic tests are unnecessary. However, the current restructuring of the NHS has led to reluctance on the part of some primary care physicians to request such tests in the community if the patient will require a hospital assessment anyway. When tests are requested by the hospital team, they are paid for by the hospital wherever the test is actually performed minimizing the costs to primary care.
Minimizing trips to the hospital and reducing the need for hospital-based follow-up attendances is generally popular with patients. One-stop clinics are associated with reduced anxiety, thought to be due to reduced delays in patients receiving diagnostic test results. Attempts to implement preclinic test protocols in other specialties have been driven by Royal College or National Institute for Health and Care excellence (NICE) recommendations. However, there is little evidence behind these recommendations, and these efforts have not been universally successful. In this institution, 100% patients and 93% referring clinicians wished the system to continue.
About 92·4% of Norfolk patients describe themselves as White British compared with 79·8% of the total England population. This very low level of non-English-speaking patients might explain why we have encountered very few cases of patients unable to read or understand their letters, with 94% patients able to arrange the tests easily. Furthermore, this hospital serves a geographically large and rural area, including the clinical commissioning group with the highest median age in the United Kingdom (North Norfolk). This leads to particular transport issues for many of our patients, which may have contributed to the high patient satisfaction we have encountered with this and previous measures to reduce hospital visits, for example a one-stop thyroid assessment clinic.
Our survey also suggests that there has been a reduction in queries to general practitioners, hospital nursing and administrative staff, with comments indicating less chasing up of results on patients for whom the 'RTT clock' was still ticking. Hundred percent hospital staff wanted the system to continue. The system has also reduced the number of follow-up letters and appointments many patients require, with a consequent improvement in the directorate financial position, and an unusually high new/follow-up ratio of 1:2·5.
It is difficult to convincingly show that this system has improved the quality of care for endocrine patients referred to our clinic. However, the surrogate markers of exceptional patient and referring clinician satisfaction and improved hospital RTT targets are highly suggestive that it has. We therefore propose that appropriate focussed investigations prior to first appointment improve patient care and free clinicians to perform a more thorough clinical assessment. This in turn accelerates the decision-making process, reducing delays to diagnosis and treatment. We feel that this system could easily be adapted for use in other specialties and regions, though local clinician and chemical pathology engagement in the process has been crucial to its success in this department.
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