Scripted consultation

Scripted consultations are being seen as a good way of delivering information to patients by non-experts. I suspect they are also a very good way of teaching the non-expert. They have the benefit of defining 'norms' for the non-expert, making them more confident in imparting information. Here's a draft scripted consultation draft for 'no antibiotic' consultation. Probably too long... Elicit information • What do you think is going on? (e.g. afraid it is pneumonia) • What did you want to have happen at this visit? Provide information • Your illness has the characteristics of a viral infection, so antibiotics will do nothing to help you recover, and they do not prevent complications. • We worry about using antibiotics when they are not definitely needed because : • Antibiotic use can result in the bacteria you always have in your body becoming resistant to antibiotics. Bacteria that cause disease can pick up this resistance, and this may make more serious infections (when antibiotics can be life saving) harder to treat • Resistant bacteria can spread in the community and this may put other people with life-threatening conditions at risk. • Antibiotics often cause unpleasant side effects, like diarrhoea and rashes • Some times these side effects can be very serious, like some allergic reactions. • The latest research suggests that antibiotics will kill off a lot of your friendly bugs that live in your guts, and some of these may never come back • We don’t really know what this means, but these bugs may keep us healthy in lots of ways so we need to try to look after them o They produce vitamins o They may prevent allergies o They may stop other intestinal disease, like coeliac disease o They may reduce the risk of some cancers o They may produce substances that keep our brains healthy o They may even help stop us getting fat • There is also new research that suggests antibiotics may affect the bits of our cells that produce energy. Again, we don’t know what this means to our patients, but it is another good reason to try to avoid antibiotics unless we are sure you really need them. Safety net • I have a handout here to help you manage your symptoms, and we can discuss warning signs that you might need to be reassessed. Summarise So, you understand that we won’t give you an antibiotic today? I don’t think it will help, but if you develop any of the concerning symptoms on the list we will have to reassess you. Do you have any questions?

Presenting pathology data to patients - a graphical representation of a haemoglobin result

Traditional pathology results, based on numerical values and strict reference ranges, maybe hard for both patients and doctors to understand. A lot of activity and worry is generated by tests that fall outside reference ranges. We need better ways of representing the 'normality' or otherwise of a result, so that we can have more honest dialogues with patients about meaning.

We recently saw a patient with an incidental finding of a haemoglobin of 108, with the lower end of the reference at 115. This 'low' result has caused anxiety to the GP, who must decide whether to follow guidelines for investigation of anaemia; but prinicipally to the patient, who now worries they may have cancer. 

We assumed that most haemoglobins measured in primary care are in patients with no underlying pathology. We plotted sequential results from women aged 65-75 (the demographic of our patient), to show the context of results we would be expecting. We then plotted the patients result, and used a large data point to represent the uncertainty that is inherent in any result. We added a line showing 2 standard deviations from the mean.

We think that this shows a result in a way that is instantly understandable in context. By showing the population variation as data points rather than in relation to a static mean, or between confidence limits, may give a feel for the dynamic nature of a test which is perhaps lost in traditional reports. Other background 'normal' data sets might be used if available - and this would be essential if there was a high proportion of data from patients with significant pathology.

An alternative way of presenting the data. My feeling is that this does not display the uncertainty of a test in a way that is as meaningful - it still emphasises the abnormality of the result. This may also be beacuse it uses set 'normal' ranges that may not be entirely appropriate for the popultation

Disease registers

James FalconerSmith also talked at today's RCPath day on systems, about disease registers for thyroid disease and health registers to coordinate care of those with mental illness. The general health needs of these patients may be poorly looked after, as they fall between the stools of general medicine and psychiatry. Pathology services maybe in a good place to coordinate this.

Pathology could coordinate care of many similar issues, from high risk conditions (eg lithium, DMARD monitoring, post radio iodine) to the complex (eg albuminurua in patients with diabetes, haematuria, MGUS, recurrent UTI).

These things work best when there is willingness from all stakeholders to work together. The thyroid register in Leicester was set up at the request of the endocrinologists. Labs need to be more confident in giving clinical advice.

We still need to grapple with how we commission this 'value add'. A service which is compared on test cost alone will be tempted to strip away expensive 'luxuries'  that are bundled into test contracts. One option might be for commissioners to require services to act on a certain number of system wide problems, with 'bonus' payment linked to delivery of some meaningful purpose focused measurement. For this to work well there needs to be a large degree of trust between commissioner and provider that the latter will act in the best interest of the patient. Otherwise there is a danger that the whole thing descends into management led performance monitoring of proxy measures, with perpetuation of the gaming that goes with this.

Plate sets for standardised microbiology working

I had a good discussion with Gifford Batstone today about how microbiology will fit into the NLMC. It is very hard to standardise microbiology working and this leads to difficulty in setting standards and comparing labs. I suspect this is mainly because of a lack of clarity of clinical pathways that lead to testing, and uncertainty about the action that should follow a test. I'm not sure if these are possible to reconcile at anything other than a local level. This may be due to local differences in priorities (eg. Detecting multi resistant pathogens, or reducing drivers for antibiotic prescribing) and it may also reflect significant differences in interpretation of a very confused literature. We also give out mixed messages about the role of testing, with, for instance, the national SMI for wound swabs targeting a huge range of organisms, when clinical algorithms refer only to staphs and streps.

One way out of this mess maybe to build up order sets according to the target pathogens only and whether or not sensitivity results would be made available. This would leave labs free to decide exactly which pathogens they would look for, how they would do this in a way that supports the clinical pathway, and what they would do with the results. This would have to be linked to a clinical algorithm which would stipulate the entry into the testing pathway along with scripted actions that would happen with each result.

This is really no different to what we should be doing already. But because the entry into testing is so dirty we have lost sight of the purpose of the microbiology lab in supporting care. There is little point in sorting out testing if we can't take on the mess of the pre analytical pathway and take more responsibility for what happens on the other side of the lab.

Lithium registers

James Falconer-Smith gave an impressive talk on pathology held disease registers in Leicestershire, at today's RCPath day on systems thinking with Muir Gray.

10000pts on lithium register since 1991. Li is high risk for patients and rapidly increasing cause of litigation. Average GP will only have 2 patients on Li and unlikely to have skills to manage. GPs can now refer to pathology held register which will manage everything from coordinating testing to dose management. Since starting service%of patients with TSH>10 has fallen from 9% to 2% and %with no bloods in last year fallen from 19% to 4%. Importantly the pathology service knows who has not been tested and can act accordingly rather than ignore. Also lab can set personalised therapeutic ranges in liaison with psychiatrist. All patients have designated lead clinician who is ultimately responsible for li management. Example shows how pathology can integrate care that currently falls between GP, psychiatry, medicine and pharmacy.

Service relies on good clerical staff. Hard to see how formally commissioned but this is clearly a great example of the value add from pathology.

Previous poor performance often blamed on patient. This may illustrate the point in the last post where the commonest response to being an outlier is to find something else to blame. But the insight from James is that this is a highly motivated group of patients with a lot to lose if things go wrong. To me it shows how the medical profession is quick to stigmatise patients when things don't go right.

Li testing is a significant commitment from patient (weekly bloods until stable then quarterly). We need to be imaginative in supporting this. Is there, for example, a possibility of self phlebotomy where the path lab could mail out test kits, a bit like the bowel cancer screening programme for FOB?

Disease register is a great possibility for research. For example shows that drop in GFR is minimal for most patients. Can integrate with other data eg prescribing.

Commissioning pathology and data

Peter Huntley, now retired from Kent and Medway CCG, talked about the role of the commissioner in setting the direction for pathology. Some persuasive content on how we need to be better at presenting data to clinicians and how we need to start combining data sets eg with prescribing.  Users need to know where they stand in relation to peers.

First of 2 speakers to use lithium monitoring as an example of how pathology can change from test provider to system integrator.

Current lack of standardisation of testing approaches and costing between providers cannot be tolerated. Less than £10/test in one locality to more than £14/test in another. Lack of common currency means hard to know what this means, but commissioners can start to insist we adopt this.

Some personal thoughts
- is practice level data adequate for combining data sets? Do we need integration at patient level to allow data to be turned into coherent narratives, and explore the interaction of behaviours?
-how do we get users to engage with the data? Pathology advisors could have a role here in helping users 'find the feeling'. I doubt shame is enough - most will be motivated by the patient stories behind the data.
-users must be allowed to explore and challenge the data, perhaps with the help of an advisor. Peter gave an example of how more junior GPs request more. There is a danger that this becomes implicit criticism which may evoke a unnecessary defensive response. For example, it may be the higher requestor reflects best practice, or they may be the one  that nurses write down on nurse-driven requesting. Or not. But if we don't go to this level of detail we may not bring people with us.
-basically we need people who are skilled at using data as a tool for quality improvement, and not as a blunt stick for driving compliance against arbitrary standards