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The Product Concept

So, pathology tests are not optimally used in the NHS. The outgoing President of the Royal College of Pathologists recently highlighted the potential impact of Pathology services struggling under current workload on delivery of clinical services and waiting lists.

Testing rates of 2 to almost 150 per 1000 patients, per year, can be found between different general practices for the same test (Figure 1). Whilst some random differences of testing are to be expected, the magnitude of these differences is striking. They do not reflect differences in patient demographics or practice type.

Figure 1
Figure 1 (click to enlarge)

Referring to an editorial he had written in JAMA in1984, George Lundberg then President of the American Medical Association asked the question in a further 1998 JAMA editorial:

. . . .have we had advances in the field of best practice (in Pathology)?

“Sadly, the answer in 1998 is that we still don’t know, not even in a research mode. We not only haven’t gotten to first base, we haven’t even picked up our bat.”

  • Laboratory medicine testing is increasing at around 6-10% annually 5,6. Changes in NHS contracting will mean that increased pathology expenditure must ultimately be paid for by reducing clinical activity even though this is not fully reflected at present because of block service contracting.
  • Around 30% of all laboratory tests are estimated to be inappropriate 1,2,3,4.
  • There are several recent publications on the subject of the differences in laboratory testing and the need for a demand control agenda in primary care requesting of laboratory tests and methods of improving practice 5,6,7,8,9,10,11.

Large inequalities exist in testing activity between different general practices and between hospital laboratories. These are not explained by patient or practice factors (number of practitioners, age, sex distribution of patient list, deprivation index, etc.) 7,8,9. Inequalities in matching health care use to population needs are recognised by the Department of Health 12.

Inappropriate use of tests leads to unnecessary expenditure, avoidable further investigation and referrals and, conversely, under-use of certain tests leaves patients with sub-optimal management and potentially missed diagnoses 5,6,9,13,14,15.

The need for a better evidence base and for improvement in use of pathology tests has been recognised for 20 years 16 although little progress has been made. This has been the subject of several recent reviews 5,6,17-21.

There is good evidence that practice behaviour can be changed by a combination of educational and facilitating mechanisms 22,23,24, although these must begin with knowledge of what is best practice.

Although falling reagent costs have limited the rise in laboratory costs in recent years, this fall appears to be flattening out and future rises in laboratory costs may be considerably greater 5 (Figure 2).

Test 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
Numbers 450000 500000 600000 650000 700000 720000 780000 850000 900000 940000 1040000
Test Cost       1.22 0.99 0.82 0.7 0.62 0.55 0.5 0.48

Figure 2
Figure 2 (click to enlarge)

Changes in unit test reagent cost for TSH (thyroid stimulating hormone: benchmark high volume endocrine test) versus total laboratory activity at Bishop Auckland General hospital 1991-2002. Increases in activity for this test have mirrored overall laboratory test activity. The change in test cost between 2000 and 2001 includes the effects of a six-fold increase in contract activity through a multi-site procurement and the rise in test activity includes an initiative in 1996 which produced a 10% fall in activity, cancelling out the annual rise. From 5.