Transcript Making a difference to Staying Healthy

Making a difference to
Staying Healthy
Jeff Seneviratne
Joint Clinical Lead
Chair, Biochemistry NAG
GM Pathology Network
What is health?
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Health is a state of complete physical, mental and social
well-being and not merely the absence of disease or
infirmity. (WHO 1948)
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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
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for lipid concentrations
Cholesterol
HDL-C
LDL-C
Triglycerides
< 5.0 mmol/L (4.0)
> 1.0 mmol/L
GOOD
< 3.0 mmol/L (2.0) BAD
< 2.3 mmol/L
Diagnosis
 Investigating
 Screening
symptoms
Heart Failure
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BNP or NTproBNP should be checked prior to
commencing therapy for suspected heart failure
Grade B recommendation
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Echocardiography:
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Not feasible or cost effective to refer all patients
Screen by any combination CxR, ECG and/or BNP
BNP has highest sensitivity
? Central role as initial screening test
Note BNP falls after commencing therapy for HF, such as
diuretics
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Scottish Intercollegiate Guidelines Network (August 2005)
Integrated service
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Uses a Special request form which is a referral
for echocardiography (no form, no test!)
 Send a blood sample for NTproBNP
 Report to:
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GP – with relevant interpretative comment
• Likelihood of left ventricular systolic dysfunction <5%.
Suggest investigate for other causes of breathlessness
or
• NTpBNP is elevated, which may indicate LV dysfunction.
Appointment for echocardiogram will be arranged
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Cardiology
Appointment booking
Audit of Outcomes
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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.(2005-06)
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287 requests from 36 practices.
162 “negative”, potential saved echo.
Potential net saving > £4000
Screening
Criteria
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The condition should be an important health problem.
There should be a treatment for the condition.
Facilities for diagnosis and treatment should be available.
There should be a latent stage of the disease.
There should be a test or examination for the condition.
The test should be acceptable to the population.
The natural history of the disease should be adequately
understood.
There should be an agreed policy on who to treat.
The total cost of finding a case should be economically balanced in
relation to medical expenditure as a whole.
Case-finding should be a continuous process, not just a "once and
for all" project.
Screening programmes
 Cervical
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Screening
Smear – detect about 90%
HPV testing
Vaccination
 Neonatal
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Screening (blood spot 5-8 days)
Phenylketonuria (1in 10,000 births)
• Chromosone 12
• Treat in 1st month, normal intellectual development
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Congenital Hypothyroidism (1 in 4000 births)
• Treat in 2 weeks, usually normal intellectual
development
What about Prostate Cancer Screening?
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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
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CHD7 & 8
• Cholesterol
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Stroke 7
• Cholesterol
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Diabetes 5, 6, 7, 13, 14, 16,
• HbA1c, Microalbumin
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Thyroid 2
• Thyroid function tests
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Mental Health 3, 4, 5
• Lithium, Creatinine, TSH
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From 2006 – Chronic Kidney Disease
• Creatinine (eGFR), Urine Protein, Haemoglobin
Monitoring
 Anticoagulant
 Diabetes
 Epilepsy
 Transplant
 Thyroid
 Anaemia
 Diuretics
 Cancer
therapy
Appropriateness of investigations
Question
Test
Decision
• Is the test effective?
• If ineffective, is it harmful?
Action
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
 CA125
8017 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 March 1281
 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
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providing results immediately when this will
improve care, eg, HBA1c
 Electronic
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ordering by GPs
Guidance on testing
 Standardising
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eGFR, drug units, reference ranges
 Electronic
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results between labs
transfer between labs
improved time to report results