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.