Putting pathology at key clinical decision points – the importance of clinical value and developing strong user-laboratory relationships.

By Tom Lewis (Lead Clinician for Pathology, North Devon) and Darunee Whiting (GP and Lead Commissioner for Diagnostics, NEW Devon CCG)

The concept of ‘value’ is increasingly being used in healthcare. Essentially, ‘value’ describes a willingness to pay for a service. In pathology, one can consider value to reflect the utility of a test (ie. its ability to inform patient management), offset against costs of the test (both financial, but also in terms of patient and user acceptability).

While diagnostic tests can enhance patient management, it is clear that diagnostic tests are often used in a way that fails to deliver value to the patient (ie. inform good, timely management). There are a number of ways in which diagnostics may fail, despite high quality internal laboratory performance, for example:

Pre-analytical

• Test that could inform management not used at correct time
• Inappropriate test for condition, leading to wrong management choice
• Test not carried out appropriately, leading to erroneous result
• ‘Shifting the burden’. Performing a simple, but inappropriate action as a way of delaying a harder, more appropriate action. This is seen in pathology as :
  • Inappropriate action in place of testing (eg: prescription/ referral/ admission). Maybe due, for example, to difficulty in accessing test, or time delay from test to result.
  • Inappropriate testing due to difficulty accessing other more appropriate action (eg. other test/ prescription/ referral/ specialist review/ intervention).

Analytical

• Time frame of testing does not match time frame of clinical decision

Post-analytical

• Test not acted upon appropriately

For a pathology service to deliver true value, it is important to recognise that tests cannot exist outside of the system in which they are performed. Thus, an accurate test that is either inappropriately requested, or inappropriately acted upon, has little or no value, and may indeed result in harm (negative value). A high value test is affordable, acceptable, and supports key clinical decisions.
The logical conclusion of these issues is that pathology tests cannot sit outside a diagnostic framework that places the test firmly within its clinical context.  To determine this context, pathologists must work closely with all users who have an interest in the area under discussion, to understand how pathology services can best support key decision steps (deliver value).
Failures of the healthcare system can be thought of as occurring whenever there is a failure to deliver maximum value to patients, on a consistent basis. System failures may result in direct harm to patients, but also lead to problems with sustainability.  Importantly, pathologists may be well placed to see these system failures.  System failures may manifest to pathology services in a number of ways:

• Variability in test requesting between users
• Unexpected changes in demand
• Clinically inappropriate test requesting
• Data from other areas (eg. referrals / admissions / prescribing) where inappropriate testing has ‘shifted the burden’

In future blogs, we will discuss a number of examples in which pathology services have identified system failures, and then worked with primary care practitioners, and other health professionals, to develop diagnostic frameworks that support key decision steps and deliver high levels of value to the patient.