Publication - Progress report

National Demand Optimisation Group (Ndog) – Phase 3 Report

Published: 24 Mar 2021

The National Demand Optimisation Group (NDOG) is a Scottish Government commissioned group. Its main objective is to reduce unwarranted variation in laboratory diagnostic testing, contributing to improved patient outcomes The group has recently completed its third phase of work.

National Demand Optimisation Group (Ndog) – Phase 3 Report
10 Appendices

10 Appendices

10.1 Appendix A Phase III NDOG Membership

Specialism Covered Membership
Chair of the Group Dr Bernie Croal, Consultant Chemical Pathologist, NHS Grampian.
Scottish Government Sponsor Catherine Ross, Chief Healthcare Science Officer Karen Stewart, Healthcare Science Officer
Scottish Government Lead Mike Gray, Service Manager, Laboratory Medicine, NHS Lothian
NHS National Services Scotland Dr David Stirling, Director of Healthcare Science
NSS Programme Management / Programme Support Liz Blackman, Senior Programme Manager, NSD Dr Niove Jordanides, Programme Manager, NSD Claire Lawrie, Senior Programme Manager, IMS Gavin Hallford, Data Analyst, IMS Dr Karl Hope, Programme Support Officer, NSD
General Practice Dr Ben Hall, GP and Scottish Clinical Leadership Fellow
Biochemistry Dr Janet Horner, Consultant Biochemist Dr Sara Jenks, Consultant Clinical Scientist Dr Rebecca Pattenden, Consultant Biochemist
Microbiology/Virology Linda Mulhern, Operational Science Manager, Microbiology
Pathology Dr Fiona Payne, Consultant Pathologist David Topping, Clinical Lab Manager/Lead BMS
Haematology Dr Alastair Hart, Consultant Haematologist Robyn Gunn, Healthcare Science Manager Sonja Wright, Clinical Scientist
Clinical Immunology Dr Liz Furrie, Clinical Scientist Dr Charu Chopra, Consultant Immunologist
Genetics/Molecular Pathology Consortia Dr David Baty, Consultant Clinical Scientist Caroline Clark, Consultant Clinical Scientist
Transfusion Dr Alastair Hart, Consultant Haematologist

10.2 Appendix B List of tests included in the Atlas

AGPCA

Albumin:creatinine ratio

ANA

ANCA

Anti-Cardiolipin

B12

Beta 2 glycoprotein

Bilirubin

BNP

C3/C4

CA125

Calcium

Calprotectin

Catheter specimen of urine (CSU)

CCP

CEA

Cholesterol

Coagulation Screens

C-reactive protein

CRP

CTDS/ENAS

D Dimer

Ds DNA Ab

Electrophoresis/ immunofixation/ immunosubtraction

ESR

FBC

Ferritin

Folate

Follicle Stimulating Hormone

Free T3

Free T4

Glucose (including fasting glucose)

HbA1c (glycated haemoglobin)

HDL-Cholesterol

High Vaginal Swab (HVS)

IF

IgA TTG

IgE - Aspergillus

IgE - Birch

IgE - Cat

IgE - Dog

IgE - Egg

IgE - Grass

IgE - HDM

IgE - Milk

IgE - Peanut

IgE - Total

IgE - Wheat

IgM RF

IgG/IgA/ IgM

Liver autoantibody - AMA

Liver autoantibody - ASM

Liver autoantibody - LKM

Mid-stream sample of urine (MSSU)

MPO

Plasma Viscosity

PR3

Prostate-specific antigen

Protein Electrophoresis

Rheumatoid Factor

Serum Free Light Chains

Sodium

Testosterone

Thrombophilia Screen

Thyroid stimulating hormone

TPO

Triglyceride

Urine - other

Urine Bence Jones Proteins

Vitamin D

10.3 Appendix C Stakeholder engagement

Steering Groups
  • Diagnostics in Scotland Strategic Group
  • Demand Optimisation Group
  • Scottish Microbiology and Virology Network (SMVN)
  • Scottish Pathology Network (SPAN),
  • Scottish Clinical Biochemistry Network (SCBN)
  • Haematology and Transfusion Scotland network (HaTS)
Education events
  • SCBN Education Event
  • SPAN Education Event
  • HaTS Education Event
Other interest groups
  • Clinical Immunology
  • Genetics / Molecular Pathology consortia
  • Scottish National Blood Transfusion Service
Scottish Government Realistic Medicine team
  • Realistic Medicine Atlas Development Subgroup
Scottish Government Primary Care Team
  • Primary Care advisory group
Primary care cluster groups
  • Lothian Primary Care Laboratory Interface Group
  • Dumfries and Galloway Clinical Optimisation Group
ISD Local Intelligence Support Team (LIST)
Roadshow events
  • NHS Ayrshire and Arran
  • NHS Lanarkshire
  • NHS GG&C
  • NHS Grampian
  • NHS Dumfries and Galloway
  • NHS Western Isles
NHS Scotland Events
  • Healthcare Science event
  • NHS Scotland Event 2019
  • NHS Scotland Event 2020 – abstract submitted, delayed until further notice
Association for Clinical Biochemistry (ACB) focus
  • 2019
  • 2020 Abstract accepted, meeting delayed until further notice

10.4 Appendix D Flash report

Thyroid function testing in primary careTFTs are requested for the diagnosis and monitoring of thyroid disease.

Example of a Flash Report showing variation in Thyroid Function Testing in Primary Care in an unidentified NHS Board

Appropriate indications for requesting TFTs in primary care3
Indication Recommended frequency
Patient with signs and symptoms of thyroid disease (Including new presentations of atrial fibrillation, hyperlipidaemia, osteoporosis and oligoamenorrhea)
Patient's stabilised on T4 therapy 2 yearly TSH check for males/post-menopausal females Annually for women of child bearing age
Treated hyperthyroidism Annually
Type 1 diabetes Annually
Type 2 diabetes At diagnosis only (check annually if TSH >2.0mU/L & anti-TPO Ab +ve)
Down's syndrome & Turner's syndrome Annually
Lithium and amiodarone therapy 6 monthly intervals
Pregnancy and known thyroid disease Preconception and at various intervals during pregnancy
(see refhelp guidelines2)
Subclinical hypothyroidism (Free T4 normal, TSH high) Repeat at 3 months to exclude transient rise in TSH. After this if not requiring therapy monitor annually and pre-conception

When not to test

Repeat testing of normal TFTs is not indicated unless the clinical picture changes or the patient is at high risk e.g. type 1 diabetes1.

Do not routinely request annual monitoring in type 2 diabetes, hypertension, atrial fibrillation, osteoporosis

For asymptomatic male/post-menopausal females stable on T4 therapy a 2 yearly TSH check is sufficient

For additional data on individual practice laboratory test requesting please see the National Atlas of Variation in Laboratory testing.

References/Further reading

1. Cook Rob, Fortescue-Webb Duncan, Taft Rachel. Repeat thyroid function tests for healthy older people are not needed BMJ 2019; 364 :l805

2. https://apps.nhslothian.scot/refhelp/guidelines/ResourcesLinks/Endocrine%20-%20Thyroid%20Function%20Testing%20in%20Pregnancy%20Guidance%20Lothian%20Jan%2023.01.20.pdf

3. https://apps.nhslothian.scot/refhelp/guidelines/ResourcesLinks/ENDO%20THY%20-%20%20Thyroid%20Function%20Testing%20in%20Primary%20Care%20Guidance%202017%20PLIG%20approved.pdf https://www.british-thyroid-association.org/sandbox/bta2016/uk_guidelines_for_the_use_of_thyroid_function_tests.pdf

10.5 Appendix E Feedback from event

Twitter engagement following GP Lothian event 23rd January and PC leads meeting 29th January

Screenshot of Twitter engagement following events to promote this work in January 2020

10.6 Appendix F Quality Improvement Initiatives

Network/ Specialty QI initiative
SCBN iLFTs- Fully operational across NHS Tayside. Conducting a survey across all health the other boards to determine uptake.
SCBN Standardising Lipid requesting- Document has been sent to the Scottish Lipid forum for an opinion.
SCBN Minimal requesting interval recommendations- Approved by the network and published on the SCBN website.
SCBN AKI alerts- Reviewing the current status of AKI alerts in each health board.
SCBN NHS GG&C- Reduction in Vitamin D requesting- Have installed a new ICE interface at point of requesting for GPs and started a trial in March 2020 to reduce Vitamin D requesting.
SCBN Guidance- Have produced guidelines on Thyroid testing.
HaTS Guidance- Have produced laboratory and GP guidelines for B12. Re-developing Ferritin guidelines to take into account pre-op anaemia pathway.
SMVN NHS A&A - Reduction of High Vaginal Swabs- Have a protocol to follow and have been granted approval from GUM to proceed. Anticipated start date of April 2020.
SMVN NHS Fife - Reduction of urine samples- The current guidance has been presented to the PLIG meeting held in January and plan to progress the initiative shortly.
SMVN NHS Lothian - Reduction of leg ulcer swabs- Have a protocol that can be used to manage urine.
SPAN Placenta and gastric biopsy survey- A survey across all health boards highlighted differences in practice, leading to decisions to review differing practices.
SPAN NHS Lanarkshire - Endoscopy guidance- Have formed a new governance group to implement the recommendations.
SPAN Cancer tracking of endoscopy samples review- NHS Fife have an overarching cancer group that have established criteria for how to remove people from the cancer tracker. Cancer tracking practices are to be reviewed in other health boards.
Immunology National Diabetes Testing- NHS Lothian were the first Board to conduct Triple Antibody testing and are in progress of analysing the outcomes.
Immunology Auto-immune Hepatitis Testing- Identifying method to triage auto immune hepatitis testing for liver screening to primary care.
Immunology ANCA screening- Three of the 4 immunology laboratories have moved from immunofluorescence to using ELISA's, which provides a quicker result and is more cost and time efficient.

Contact

Email: Julie.Townsend@gov.scot