National Demand Optimisation Group (Ndog) – Phase 3 Report

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.

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

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.