Introduction
The NHS is under significant financial stress and there is an important responsibility to make savings when possible.1 Immunology tests, including autoantibody testing and measurement of immunoglobulins, are expensive and may be requested without their results impacting upon patient management. As part of the Royal College of Physicians Learning to make a difference project, a quality improvement project (QIP) which aimed to improve efficiency associated with follow-up immunology testing, was initiated.2
Method
Immunology tests requested for a grab sample of 30 patients attending the lupus and connective tissue disease (CTD) clinics at Central Manchester Foundation Trust in May 2010 were reviewed in order to establish the baseline use of these requests. Included subjects had an established diagnosis of systemic lupus erythematosus (SLE), Sjögren's syndrome, scleroderma, adult idiopathic myositis or antineutrophil cytoplasmic antibody-associated vasculitis which had been made prior to May 2008. All tests requested between May 2008 and May 2010 were recorded and cross-referenced with clinic letters from each appointment.
A literature review did not identify any existing guidelines for requesting follow-up immunological tests in such patients. Using the consensus expertise of clinicians within the department, a guideline for ‘appropriate testing’ in clinically stable patients (Table 1) was developed. The results of the initial data collection with these guidelines were compared, and the frequency and cost of ‘unnecessary’ tests calculated.
The first intervention was to present these initial results to the rheumatology department. Individual costs for each test were provided and, by discussing cases, debate was stimulated and the rationale for the guideline was clarified. Requests made for a further grab sample of 30 patients attending the clinic were recorded. The agreed guidelines and test costs were disseminated to the department using email and displays within each clinic room. The requests for a further 30 patients were reviewed following this second intervention.
Manchester Guidelines for immunological testing in stable patients with established connective tissue disease and vasculitis. ACL = anticardiolipin antibodies; ANA = anti-nuclear antibodies; ANCA = anti-neutrophil cytoplasmic antibodies; CCP = cyclic citrullinated protein; CTD = connective tissue disease; ENA = extractable nuclear antigen; IP = inflammatory polyarthritis; LAC = lupus anticoagulant; SLE = systemic lupus erythematosus.
Results
Baseline results for the first 30 patients, extrapolated across the whole year, suggested that the rheumatology department requested approximately 6,880 immunological tests for patients with established SLE and CTDs per year, at an estimated cost of £57,840 for 1,200 patient visits. Applying the guidelines, it was estimated that 51% of these tests could be classified as ‘unnecessary’. This represented a potential for saving £29,760 per year.
Following the interventions, the frequency of ‘unnecessary’ tests requested for the last sample of 30 patients reduced from 20 to seven, equivalent to a 70% reduction. The total cost of these tests was reduced from £186 to £51. These reductions can be extrapolated to represent a saving of approximately £21,427 per annum. This efficiency will be maintained by altering computerised requesting systems and ongoing education within the department including adding this guidance to our induction portfolio.
Conclusion
Educational intervention for this QIP achieved the aim of improving the efficiency of follow-up immunological test requesting. Clear guidelines and simple educational interventions lead to significant savings. These interventions are transferable to all areas of medicine and represent an easy way to make savings in the current economic climate. The adoption of these guidelines by other rheumatology, immunology and medical departments is recommended in order to improve efficiency. The adoption of these guidelines by other rheumatology, immunology and medical departments is recommended in order to improve efficiency, and a project to extend these local guidelines regionally is currently underway.
Footnotes
Letters not directly related to articles published in Clinical Medicine and presenting unpublished original data should be submitted for publication in this section. Clinical and scientific letters should not exceed 500 words and may include one table and up to five references.
- © 2011 Royal College of Physicians
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