1. Demand management – Vetting survey Julie Stinson, CWPS

2. Survey of Vetting Participants asked to fill in table to details tests for Participants asked to fill in table to details tests for automated interventions automated interventions manual vetting of in-house tests manual vetting of in-house tests manual vetting of send-away tests manual vetting of send-away tests Details included Details included Criteria for vetting eg MRI, clinical details, exceptions Criteria for vetting eg MRI, clinical details, exceptions Reason/evidence Reason/evidence Agreement with clinicians Agreement with clinicians For manual vetting - how often vetted, and by whom For manual vetting - how often vetted, and by whom

3. Responses Responses from 10 labs/groups, in addition to ACB MRI group preliminary data: Responses from 10 labs/groups, in addition to ACB MRI group preliminary data: Wolverhampton, UHB, City, Walsall, BWH, BCH, UHNS, CWPS, Cheshire, Burton, ACB MRI Wolverhampton, UHB, City, Walsall, BWH, BCH, UHNS, CWPS, Cheshire, Burton, ACB MRI

4. Automated intervention Specific tests automatically blocked based on time rule - MRI set into IT system. Specific tests automatically blocked based on time rule - MRI set into IT system. This ranged from 0 for BWH, to all tests by Burton (1h to 999h = 42d) This ranged from 0 for BWH, to all tests by Burton (1h to 999h = 42d) 37 different analytes mentioned by labs other than Burton 37 different analytes mentioned by labs other than Burton some of these may come under disciplines other than Biochem in some places (eg ANA - immunology, B12F - haematology) some of these may come under disciplines other than Biochem in some places (eg ANA - immunology, B12F - haematology) some may not be tests still offered in some places eg FOB some may not be tests still offered in some places eg FOB

5. Automated intervention No of labs with responses for particular analyte: No of labs with responses for particular analyte: 6 – TSH 6 – TSH 5 – HbA1c 5 – HbA1c 4 – A1AT, B12F, CRP, Ferritin, Immunoglobulins, SPE, TTG, Vit D 4 – A1AT, B12F, CRP, Ferritin, Immunoglobulins, SPE, TTG, Vit D 3 - ACE, FEL, Prolactin, PTH, Testo, Trace elements, TPMT 3 - ACE, FEL, Prolactin, PTH, Testo, Trace elements, TPMT 2 - AFP, ANA, BJP, 19-9, DHEAS, FOB, fT4, fT3, IgE, Insulin, LFT, lipids, TPO, valproate, Vitamin A/E 2 - AFP, ANA, BJP, 19-9, DHEAS, FOB, fT4, fT3, IgE, Insulin, LFT, lipids, TPO, valproate, Vitamin A/E 1 – Cryoglobulins, IGFBP-3, sex hormones, 6-TGN, tumour markers 1 – Cryoglobulins, IGFBP-3, sex hormones, 6-TGN, tumour markers

6. Automated intervention No consistent agreement on MRI No consistent agreement on MRI What done not necessarily best practice/evidence based What done not necessarily best practice/evidence based Tests not on this list, which should perhaps be included ?lipids, LFTs Tests not on this list, which should perhaps be included ?lipids, LFTs Simple MRI rule - ? systems not intelligent enough to gather together many different pieces of data. MRI set for condition requiring most frequent measuring Simple MRI rule - ? systems not intelligent enough to gather together many different pieces of data. MRI set for condition requiring most frequent measuring [ Some systems clever enough to pick up on combinations of tests requested eg all tumour markers, or sex and analyte eg female with PSA, but none reported in survey. ] [ Some systems clever enough to pick up on combinations of tests requested eg all tumour markers, or sex and analyte eg female with PSA, but none reported in survey. ]

7. Manual vetting Manual vetting of specific tests/groups of tests/clinical details Manual vetting of specific tests/groups of tests/clinical details ? systems not intelligent enough to gather together many different pieces of data, so done manually instead ? systems not intelligent enough to gather together many different pieces of data, so done manually instead Requires staff time of appropriate level to be able to make decisions, at the appropriate time Requires staff time of appropriate level to be able to make decisions, at the appropriate time

8. Manual vetting Mostly done for sendaways Mostly done for sendaways Fewer numbers – not looking at 1000 UE per day Fewer numbers – not looking at 1000 UE per day Higher cost tests Higher cost tests More specialist tests, therefore indication for measurement may not be as well known amongst clinicians More specialist tests, therefore indication for measurement may not be as well known amongst clinicians If don’t have IT holding list, easier to put in place for batched tests – few in-house tests are batched If don’t have IT holding list, easier to put in place for batched tests – few in-house tests are batched identifying samples for decisions - outstanding list reviewed, or specimen reception post can bring to DB before sending identifying samples for decisions - outstanding list reviewed, or specimen reception post can bring to DB before sending not delaying any other analytes while making decision - these tend to have tap-off not delaying any other analytes while making decision - these tend to have tap-off

9. Manual vetting Mostly done post booking in Mostly done post booking in Difficult to put in place rules for specimen reception – too complex, ?inappropriate responsibility, risk of errors. Difficult to put in place rules for specimen reception – too complex, ?inappropriate responsibility, risk of errors. Few rules at stage of booking in: Few rules at stage of booking in: Thyroid function. TSH front line, except endo, (paed auto fT4) – goes to validation Thyroid function. TSH front line, except endo, (paed auto fT4) – goes to validation Iron studies – ferritin front line – goes to validation Iron studies – ferritin front line – goes to validation

10. Manual vetting No of labs with responses for particular analyte: No of labs with responses for particular analyte: 6 – Insulin, c-peptide 6 – Insulin, c-peptide 5 – ACTH, thyroglobulin, TPMT, trace elements 5 – ACTH, thyroglobulin, TPMT, trace elements 4 – FOB, fT3, Vitamin D 4 – FOB, fT3, Vitamin D 3 - 17OHP, ACE, ALP isoenz, calcitonin, Faecal elastase, fT4, genetic tests, GH, GTT, gut hormones, IgE, porphyria screen, TPO, TSH Receptor Ab, Tumour markers, Valproate 3 - 17OHP, ACE, ALP isoenz, calcitonin, Faecal elastase, fT4, genetic tests, GH, GTT, gut hormones, IgE, porphyria screen, TPO, TSH Receptor Ab, Tumour markers, Valproate 2 – aa, acylcarnitines, BNP, C1E, CCP, CgA, androstenedione, DHEAS, fructosamine, Gal1Put, GGT, IFA, IGF1, P3NP, SFLC, urine free cortisol etc 2 – aa, acylcarnitines, BNP, C1E, CCP, CgA, androstenedione, DHEAS, fructosamine, Gal1Put, GGT, IFA, IGF1, P3NP, SFLC, urine free cortisol etc 1 – ADH, EPO, FFA, homocysteine, metabolic screen, methotrexate etc 1 – ADH, EPO, FFA, homocysteine, metabolic screen, methotrexate etc

11. Manual vetting Samples stored Samples stored 1w, 1m, 12m, discretion of vettor 1w, 1m, 12m, discretion of vettor Length of vetting process Length of vetting process depends on clinical details provided, ability to contact clinician depends on clinical details provided, ability to contact clinician UHB 15-30’/d UHB 15-30’/d UHNS 60-90’/w UHNS 60-90’/w Wolverhampton 1h/m Wolverhampton 1h/m UHCW 60-90’.d UHCW 60-90’.d How often vetted How often vetted Daily Mon-Fri Daily Mon-Fri Who vets Who vets Mostly Clinical Scientist/DB. Some by BMS – esp if batched in-house eg SPE; cnst Mostly Clinical Scientist/DB. Some by BMS – esp if batched in-house eg SPE; cnst

12. Manual vetting Agreement with clinicians Agreement with clinicians Burton – yes (what mechanism?) Burton – yes (what mechanism?) Evidence – Burton refered to some guidelines Evidence – Burton refered to some guidelines Vetting criteria – no SOPs supplied – Vetting criteria – no SOPs supplied – Cheshire – test specific criteria (not given) Cheshire – test specific criteria (not given) City - clinical indication (not given) City - clinical indication (not given) Wolverhampton – clinical appropriateness (not given) Wolverhampton – clinical appropriateness (not given) UHB – insulin, c-peptide hypo; if appropriate UHB – insulin, c-peptide hypo; if appropriate UHNS – EPO, IgD/E - haematology const request UHNS – EPO, IgD/E - haematology const request UHCW – SOP containing test specific criteria UHCW – SOP containing test specific criteria

13. Manual vetting UHCW UHCW Pilot ’10. 60-90’ vetting/d by clinical scientist of send-aways using SOP Pilot ’10. 60-90’ vetting/d by clinical scientist of send-aways using SOP Cost of analysis saved £23,097/y Cost of analysis saved £23,097/y Staff cost £8,361/y Staff cost £8,361/y Net Cost £14,736 Net Cost £14,736 Tests vetted which have given biggest cost saving Tests vetted which have given biggest cost saving INF INF Trace elements Trace elements Insulin, C-peptide Insulin, C-peptide 17OHP 17OHP ACTH ACTH

14. Manual vetting Areas for concentrating effort to get agreement, may depend to some extent on: Areas for concentrating effort to get agreement, may depend to some extent on: education/knowledge of requestors – how frequent/crazy are “inappropriate” requests education/knowledge of requestors – how frequent/crazy are “inappropriate” requests organisation of how requests made eg GTT organisation of how requests made eg GTT Ability to tailor IT system eg put onto holding list, make vetting automatic Ability to tailor IT system eg put onto holding list, make vetting automatic Cost/benefit ratio Cost/benefit ratio Manual interventions require staff time to be protected for this purpose – more difficult in smaller labs with fewer staff Manual interventions require staff time to be protected for this purpose – more difficult in smaller labs with fewer staff

15. Suggestions for areas to get agreement Suggestions for areas to get agreement Hypoglycaemia screen (? other indications for tests within this eg acylcarnitines) Hypoglycaemia screen (? other indications for tests within this eg acylcarnitines) Prolonged jaundice screen Prolonged jaundice screen TDM monitoring TDM monitoring Tumour markers Tumour markers Insulin, c-peptide; Insulin Ab Insulin, c-peptide; Insulin Ab Nutrition - Trace elements, Vit A, E Nutrition - Trace elements, Vit A, E Vitamin D Vitamin D Ab: Ab: thyroid (TPO, TSH Receptor Ab); thyroid (TPO, TSH Receptor Ab); IFA, GPA; IFA, GPA; C1E; C1E; CCP CCP GH, IGF1 GH, IGF1 Androstenedione, DHEAS Androstenedione, DHEAS

16. Alternative - education Effect on requesting patterns - Effect on requesting patterns - Reduction in FOBs – from 150/m to 0/m in 7 months Reduction in FOBs – from 150/m to 0/m in 7 months GP newsletter GP newsletter Comments on reports Comments on reports Letters to practice managers to discuss with GPs Letters to practice managers to discuss with GPs Visits to GP practices Visits to GP practices

17. Alternative - education Education – audit of current practice Education – audit of current practice Presentations - Location - GP practice visits, talks at GP education days, hospital grand rounds, ward round Presentations - Location - GP practice visits, talks at GP education days, hospital grand rounds, ward round Other Formats - Leaflets, emails, posters, newsletters, websites, screen savers, Comments put on results – manual or automated, IT – e-requesting./e-learning Other Formats - Leaflets, emails, posters, newsletters, websites, screen savers, Comments put on results – manual or automated, IT – e-requesting./e-learning Frequency Frequency Duration Duration Audience Audience

18. Alternative - education Audit - Feedback to commissioners and requestors Audit - Feedback to commissioners and requestors tests (numbers, range of tests, interval) – cost of tests saved/extra, change with time tests (numbers, range of tests, interval) – cost of tests saved/extra, change with time Time spent on intervention – cost of time spent on this, change with time Time spent on intervention – cost of time spent on this, change with time Audit of Patient outcome Audit of Patient outcome