Making a difference to Staying Healthy

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

2. 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)

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

4. Risk Assessment Cardiovascular disease

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

7. Diagnosis • Investigating symptoms • Screening

8. 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 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 Scottish Intercollegiate Guidelines Network (August 2005)

10. 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 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 Cardiology Appointment booking

11. 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.(2005-06) 287 requests from 36 practices. 162 “negative”, potential saved echo. Potential net saving > £4000

12. Screening Criteria • 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.

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

14. 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.

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

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

17. Monitoring Anticoagulant therapy Diabetes Epilepsy Transplant Thyroid Anaemia Diuretics Cancer

18. Appropriateness of investigations Question Test Decision Action • Is the test effective? • If ineffective, is it harmful?

19. 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

20. 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

21. CA125 February 8017 14th March 1281 21st April 56 CA125 also increased, non-specifically, in other inflammatory conditions of abdomen

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