Making a difference to Staying Healthy Jeff Seneviratne Joint Clinical Lead Chair, Biochemistry NAG GM Pathology Network

What is health?  Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (WHO 1948)  Health is a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. (WHO 1986)

Pathology makes a difference  Risk assessment  Diagnosis  Long term conditions  Monitoring treatment  Appropriate investigation

Risk Assessment Cardiovascular disease

Serum lipid analysis  Guidelines for lipid concentrations Cholesterol < 5.0 mmol/L (4.0) Cholesterol < 5.0 mmol/L (4.0) HDL-C > 1.0 mmol/L GOOD HDL-C > 1.0 mmol/L GOOD LDL-C < 3.0 mmol/L (2.0) BAD LDL-C < 3.0 mmol/L (2.0) BAD Triglycerides < 2.3 mmol/L Triglycerides < 2.3 mmol/L

Diagnosis  Investigating symptoms  Screening

Heart Failure  BNP or NTproBNP should be checked prior to commencing therapy for suspected heart failure Grade B recommendation  Echocardiography: Not feasible or cost effective to refer all patients Not feasible or cost effective to refer all patients Screen by any combination CxR, ECG and/or BNP Screen by any combination CxR, ECG and/or BNP BNP has highest sensitivity BNP has highest sensitivity ? Central role as initial screening test ? Central role as initial screening test  Note BNP falls after commencing therapy for HF, such as diuretics Scottish Intercollegiate Guidelines Network (August 2005) Scottish Intercollegiate Guidelines Network (August 2005)

Integrated service  Uses a Special request form which is a referral for echocardiography (no form, no test!)  Send a blood sample for NTproBNP  Report to: GP – with relevant interpretative comment GP – with relevant interpretative comment Likelihood of left ventricular systolic dysfunction <5%. Suggest investigate for other causes of breathlessnessLikelihood of left ventricular systolic dysfunction <5%. Suggest investigate for other causes of breathlessnessor NTpBNP is elevated, which may indicate LV dysfunction. Appointment for echocardiogram will be arrangedNTpBNP is elevated, which may indicate LV dysfunction. Appointment for echocardiogram will be arranged Cardiology Cardiology Appointment booking Appointment booking

Audit of Outcomes  A negative NTproBNP result is both safe and effective for ruling out heart failure. The negative predictive value of NTproBNP is 97.5%.  Certain treatments (e.g. loop diuretics, ACE inhibitors) can potentially interfere with NTproBNP levels, but a negative NTproBNP result is still effective in excluding heart failure  NTproBNP is useful for excluding left ventricular failure.  It is not useful for assessing murmurs or arrhythmias  In first year.( ) 287 requests from 36 practices. 287 requests from 36 practices. 162 “negative”, potential saved echo. 162 “negative”, potential saved echo. Potential net saving > £4000 Potential net saving > £4000

Screening Criteria 1. The condition should be an important health problem. 2. There should be a treatment for the condition. 3. Facilities for diagnosis and treatment should be available. 4. There should be a latent stage of the disease. 5. There should be a test or examination for the condition. 6. The test should be acceptable to the population. 7. The natural history of the disease should be adequately understood. 8. There should be an agreed policy on who to treat. 9. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole. 10. Case-finding should be a continuous process, not just a "once and for all" project.

Screening programmes  Cervical Screening Smear – detect about 90% Smear – detect about 90% HPV testing HPV testing Vaccination Vaccination  Neonatal Screening (blood spot 5-8 days) Phenylketonuria (1in 10,000 births) Phenylketonuria (1in 10,000 births) Chromosone 12Chromosone 12 Treat in 1 st month, normal intellectual developmentTreat in 1 st month, normal intellectual development Congenital Hypothyroidism (1 in 4000 births) Congenital Hypothyroidism (1 in 4000 births) Treat in 2 weeks, usually normal intellectual developmentTreat in 2 weeks, usually normal intellectual development

What about Prostate Cancer Screening?  All screening programmes cause some harm. This could include false alarms, inducing anxiety, and the treatment of early disease which would not otherwise have become a problem.  The PSA test is not a test for prostate cancer. It is a test for abnormalities of the prostate, one of which may be cancer.  2 out of 3 men with a raised PSA will not have any cancer cells in their prostate biopsy.  Up to 1 in 5 men with prostate cancer will have a normal PSA result.

Long Term Conditions  Diabetes  Chronic Kidney disease  Hypertension  Heart disease  Care Pathways for investigation and treatment

Pathology and QOF (Quality & Outcomes Framework)  Dependent of Pathology Results CHD7 & 8 CHD7 & 8 CholesterolCholesterol Stroke 7 Stroke 7 CholesterolCholesterol Diabetes 5, 6, 7, 13, 14, 16, Diabetes 5, 6, 7, 13, 14, 16, HbA1c, MicroalbuminHbA1c, Microalbumin Thyroid 2 Thyroid 2 Thyroid function testsThyroid function tests Mental Health 3, 4, 5 Mental Health 3, 4, 5 Lithium, Creatinine, TSHLithium, Creatinine, TSH From 2006 – Chronic Kidney Disease From 2006 – Chronic Kidney Disease Creatinine (eGFR), Urine Protein, HaemoglobinCreatinine (eGFR), Urine Protein, Haemoglobin

Monitoring  Anticoagulant therapy  Diabetes  Epilepsy  Transplant  Thyroid  Anaemia  Diuretics  Cancer

Appropriateness of investigations QuestionTestDecisionAction Is the test effective? If ineffective, is it harmful?

Misuse of tumour markers  83 y female  Ca 3.09 mmol/L (high) ****  PTH 8.3 ng/L  Urea 23.1 mmol/L (high)  Creatinine 242 umol/L (high)  CRP 227 g/L (high)  Ultrasound abdomen consistent with chronic urinary retention

CA125 – associated with ovarian malignancy  CA u/L (<35)  CT pelvis - no evidence of gynae malignancy, marked soft tissue thickening at ano-rectal junction, “highly suggestive of local malignancy”  Flexible sigmoidoscopy - unsuccessful, repeat awaited

CA125  February 8017  14th March1281  21st April 56  CA125 also increased, non-specifically, in other inflammatory conditions of abdomen

Pathology Network – improving services  Care Pathways and outcomes  Point of Care Testing providing results immediately when this will improve care, eg, HBA1c providing results immediately when this will improve care, eg, HBA1c  Electronic ordering by GPs Guidance on testing Guidance on testing  Standardising results between labs eGFR, drug units, reference ranges eGFR, drug units, reference ranges  Electronic transfer between labs improved time to report results improved time to report results