Making a difference to Making a difference to Staying HealthyStaying Healthy

Jeff SeneviratneJeff SeneviratneJoint Clinical LeadJoint Clinical Lead

Chair, Biochemistry NAGChair, Biochemistry NAG

GM Pathology NetworkGM Pathology Network

What is health?What is health? Health is a state of complete physical, mental and social Health is a state of complete physical, mental and social

well-being and not merely the absence of disease or well-being and not merely the absence of disease or

infirmityinfirmity. . (WHO 1948)(WHO 1948) Health is a resource for everyday life, not the objective of Health is a resource for everyday life, not the objective of

living. Health is a positive concept emphasizing social living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. and personal resources, as well as physical capacities. (WHO 1986)(WHO 1986)

Pathology makes a difference Pathology makes a difference

Risk assessmentRisk assessment DiagnosisDiagnosis Long term conditionsLong term conditions Monitoring treatmentMonitoring treatment Appropriate investigationAppropriate investigation

Risk Assessment Risk Assessment Cardiovascular diseaseCardiovascular disease

Serum lipid analysisSerum lipid analysis

Guidelines for lipid concentrationsGuidelines for lipid concentrations Cholesterol < 5.0 mmol/L (4.0)Cholesterol < 5.0 mmol/L (4.0) HDL-C > 1.0 mmol/L HDL-C > 1.0 mmol/L GOODGOOD LDL-C < 3.0 mmol/L (2.0) LDL-C < 3.0 mmol/L (2.0) BADBAD Triglycerides < 2.3 mmol/LTriglycerides < 2.3 mmol/L

DiagnosisDiagnosis

Investigating symptomsInvestigating symptoms

ScreeningScreening

Heart FailureHeart Failure BNP or NTproBNP should be checked prior to BNP or NTproBNP should be checked prior to

commencing therapy for suspected heart failure commencing therapy for suspected heart failure Grade B recommendationGrade B recommendation

Echocardiography: Echocardiography: Not feasible or cost effective to refer all patientsNot feasible or cost effective to refer all patients Screen by any combination CxR, ECG and/or BNPScreen by any combination CxR, ECG and/or BNP BNP has highest sensitivityBNP 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 Note BNP falls after commencing therapy for HF, such as diureticsdiuretics

Scottish Intercollegiate Guidelines Network (August 2005)Scottish Intercollegiate Guidelines Network (August 2005)

Integrated serviceIntegrated service Uses a Special request form which is a referral Uses a Special request form which is a referral

for echocardiography (no form, no test!)for echocardiography (no form, no test!) Send a blood sample for NTproBNPSend a blood sample for NTproBNP Report to:Report to:

GP – with relevant interpretative commentGP – with relevant interpretative comment• Likelihood of left ventricular systolic dysfunction <5%. Likelihood of left ventricular systolic dysfunction <5%.

Suggest investigate for other causes of breathlessnessSuggest investigate for other causes of breathlessnessoror• NTpBNP is elevated, which may indicate LV dysfunction. NTpBNP is elevated, which may indicate LV dysfunction.

Appointment for echocardiogram will be arrangedAppointment for echocardiogram will be arranged CardiologyCardiology Appointment bookingAppointment booking

Audit of OutcomesAudit of Outcomes A negative NTproBNP result is both safe and effective A negative NTproBNP result is both safe and effective

for ruling out heart failure. The negative predictive value for ruling out heart failure. The negative predictive value of NTproBNP is 97.5%.of NTproBNP is 97.5%.

Certain treatments (e.g. loop diuretics, ACE inhibitors) Certain treatments (e.g. loop diuretics, ACE inhibitors) can potentially interfere with NTproBNP levels, but a can potentially interfere with NTproBNP levels, but a negative NTproBNP result is still effective in excluding negative NTproBNP result is still effective in excluding heart failureheart failure

NTproBNP is useful for excluding left ventricular failure.NTproBNP is useful for excluding left ventricular failure. It is It is notnot useful for assessing murmurs or arrhythmias useful for assessing murmurs or arrhythmias In first year.(2005-06)In first year.(2005-06)

287 requests from 36 practices.287 requests from 36 practices. 162 “negative”, potential saved echo.162 “negative”, potential saved echo. Potential net saving > £4000Potential net saving > £4000

ScreeningScreeningCriteriaCriteria1.1. The condition should be an important health problem.The condition should be an important health problem.

2.2. There should be a treatment for the condition.There should be a treatment for the condition.

3.3. Facilities for diagnosis and treatment should be available.Facilities for diagnosis and treatment should be available.

4.4. There should be a latent stage of the disease.There should be a latent stage of the disease.

5.5. There should be a test or examination for the condition.There should be a test or examination for the condition.

6.6. The test should be acceptable to the population.The test should be acceptable to the population.

7.7. The natural history of the disease should be adequately The natural history of the disease should be adequately understood.understood.

8.8. There should be an agreed policy on who to treat.There should be an agreed policy on who to treat.

9.9. The total cost of finding a case should be economically balanced in The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.relation to medical expenditure as a whole.

10.10. Case-finding should be a continuous process, not just a "once and Case-finding should be a continuous process, not just a "once and for all" project.for all" project.

Screening programmesScreening programmes Cervical ScreeningCervical Screening

Smear – detect about 90% Smear – detect about 90% HPV testing HPV testing VaccinationVaccination

Neonatal Screening (blood spot 5-8 days)Neonatal Screening (blood spot 5-8 days) Phenylketonuria (1in 10,000 births)Phenylketonuria (1in 10,000 births)

• Chromosone 12Chromosone 12

• Treat in 1Treat in 1stst month, normal intellectual development 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?What about Prostate Cancer Screening?

All screening programmes cause some harm. This could All screening programmes cause some harm. This could include false alarms, inducing anxiety, and the treatment include false alarms, inducing anxiety, and the treatment of early disease which would not otherwise have become of early disease which would not otherwise have become a problem.a problem.

The PSA test is not a test for prostate cancer. It is a test The PSA test is not a test for prostate cancer. It is a test for abnormalities of the prostate, one of which may be for abnormalities of the prostate, one of which may be cancer. cancer.

2 out of 3 men with a raised PSA will not have any 2 out of 3 men with a raised PSA will not have any cancer cells in their prostate biopsy. cancer cells in their prostate biopsy.

Up to 1 in 5 men with prostate cancer will have a normal Up to 1 in 5 men with prostate cancer will have a normal PSA result.PSA result.

Long Term ConditionsLong Term Conditions

DiabetesDiabetes Chronic Kidney diseaseChronic Kidney disease HypertensionHypertension Heart diseaseHeart disease

Care Pathways for investigation and Care Pathways for investigation and treatmenttreatment

Pathology and QOF Pathology and QOF (Quality & Outcomes Framework)(Quality & Outcomes Framework)

Dependent of Pathology ResultsDependent of Pathology Results CHD7 & 8 CHD7 & 8

• CholesterolCholesterol Stroke 7Stroke 7

• CholesterolCholesterol Diabetes 5, 6, 7, 13, 14, 16, Diabetes 5, 6, 7, 13, 14, 16,

• HbA1c, MicroalbuminHbA1c, Microalbumin Thyroid 2Thyroid 2

• Thyroid function testsThyroid function tests Mental Health 3, 4, 5Mental Health 3, 4, 5

• Lithium, Creatinine, TSH Lithium, Creatinine, TSH From 2006 – Chronic Kidney DiseaseFrom 2006 – Chronic Kidney Disease

• Creatinine (eGFR), Urine Protein, HaemoglobinCreatinine (eGFR), Urine Protein, Haemoglobin

MonitoringMonitoring

Anticoagulant therapyAnticoagulant therapy DiabetesDiabetes EpilepsyEpilepsy Transplant Transplant ThyroidThyroid AnaemiaAnaemia DiureticsDiuretics CancerCancer

Appropriateness of investigationsAppropriateness of investigations

Question Test Decision Action

• Is the test effective?

• If ineffective, is it harmful?

Misuse of tumour markersMisuse of tumour markers

83 y female83 y female Ca 3.09 mmol/L (high) ****Ca 3.09 mmol/L (high) **** PTH 8.3 ng/L PTH 8.3 ng/L Urea 23.1 mmol/L (high)Urea 23.1 mmol/L (high) Creatinine 242 umol/L (high)Creatinine 242 umol/L (high) CRP 227 g/L (high)CRP 227 g/L (high) Ultrasound abdomen consistent with Ultrasound abdomen consistent with

chronic urinary retention chronic urinary retention

CA125 – associated with ovarian CA125 – associated with ovarian malignancymalignancy

CA125 CA125 8017 u/L (<35)8017 u/L (<35) CT pelvis - no evidence of gynae CT pelvis - no evidence of gynae

malignancy, marked soft tissue thickening malignancy, marked soft tissue thickening at ano-rectal junction, “highly suggestive of at ano-rectal junction, “highly suggestive of local malignancy”local malignancy”

Flexible sigmoidoscopy - unsuccessful, Flexible sigmoidoscopy - unsuccessful, repeat awaitedrepeat awaited

CA125CA125

February February 8017 8017 14th March14th March 12811281 21st April21st April 56 56

CA125 also increased, non-specifically, in CA125 also increased, non-specifically, in other inflammatory conditions of abdomenother inflammatory conditions of abdomen

Pathology Network – improving servicesPathology Network – improving services

Care Pathways and outcomesCare Pathways and outcomes Point of Care Testing Point of Care Testing

providing results immediately when this will providing results immediately when this will improve care, eg, HBA1cimprove care, eg, HBA1c

Electronic ordering by GPsElectronic ordering by GPs Guidance on testingGuidance on testing

Standardising results between labsStandardising results between labs eGFR, drug units, reference rangeseGFR, drug units, reference ranges

Electronic transfer between labs Electronic transfer between labs improved time to report resultsimproved time to report results