Dear Editor

Rao et al. describe a wide range of testing in pathology where targeted effort could improve appropriateness.[1]

One of the blocks to improving use of pathology testing is the limited evidence base. This should not stop us however trying to improve practice.[2] The medical literature contains a large resource of reviews and consensus guidance, some of which has an evidence base, and there are many interventions, both published and unpublished, which have been introduced to attempt to improve use of tests.

Some 95% of primary care tests are contained within a limited repertoire of under 30 investigations across laboratory medicine. These make up half or more of the laboratory activity in many district general hospitals.[3] Standardised general practice activity data also show very large differences in testing activity between practices, and although it is difficult to define optimal testing activity, it is apparent that there is both over-use and under-use of tests and it is important that the pursuit of good practice includes both stimulating the increased use of under-used tests alongside demand control aspects of over-use.

To this end, a cross-laboratory medicine group has recently been established[4] with representation from the Royal College of Pathologists, Royal College of General Practitioners, Association of Clinical Pathologists, PRODIGY, Association of Clinical Biochemists, Association of Medical Microbiologists and British Society for Haematology. The purpose of this group initially is to construct an information resource, bringing together available guidance and evidence to answer a series of everyday questions affecting primary care users, and subsequently to examine ways in which this information can be disseminated and used in interventions.

In order to do this it would be valuable to hear from colleagues initially in the disciplines of clinical biochemistry, haematology, microbiology and immunology, who have set up specific initiatives to improve practice and/or would like to participate in this exercise. Many good ideas are slow to seed across the NHS and it is only by gathering these together and making them widely available, that the profession will be able to help to orchestrate a concerted approach to good practice.

References

(1) RAO GG, Crook M, Tillyer ML. Pathology tests: is the time for demand management ripe at last? J Clin Pathol 2003;56:243-248

(2) Barth JH, Jones RG. Indiscriminate investigations have adverse effects (letter) BMJ 2003;326:393.

(3) Smellie WSA, Galloway MJ, Chinn D. Benchmarking general practice use of pathology services: a model for monitoring change. J Clin Pathol 2000;53:476–80.

(4) Smellie WSA. Demand Management in primary care pathology. Bull R Coll Path 2003;122:16-19.

Dear Editor

I fully support the view that the time is ripe for demand management of pathology tests.[1] The NHS cannot continue to provide an open access pathology service which is used indiscriminately. The service should be evidence-based. If we received specimens for culture which we believe are irrelevant we withhold culture and return a report with the comment:
"Culture of this specimen is not likely to be useful. Discuss with Consultant Microbiologist if indicated".

And since we cannot respond to a demand for "C & S" with a relevant report unless clinical data are provided, the comment "We were unable to process this specimen and produce a relevant report due to the lack of supporting data. Please repeat or discuss with the Consutlant Microbiologist" is used when such specimens are received. We do of course make telephone enquiries if we feel the specimen cannot be repeated.

Although I agree in principle with the recommendations made by Dr Gopal Rao et al, I note with dismay that I disagree with some of the specific recommendations regarding inappropriate microbiology specimens. This is due in part to local variations in the use of the laboratory but further debate of this issue is indicated.

Reference

(1) G Gopal Rao, M Crook, and M L Tillyer. Pathology tests: is the time for demand management ripe at last? J Clin Pathol 2003;56:243-248.