Whaddon Medical Centre in Milton Keynes has set up its own cardiology diagnostics and is able to test patients for suspected heart failure (HF), acute coronary syndrome (ACS) and deep vein thrombosis (DVT). The practice recognised that a significant proportion of hospital referrals could be avoided with point of care testing (POC) in primary care. POC also ensures that patients are diagnosed rapidly and appropriate treatment can be initiated without delay.
The cardiology service started with D-dimer testing for suspected DVT in 2008, but now conducts a range of diagnostic tests, including NT-proBNP for patients with suspected heart failure, and Troponin T tests in recent non-specific acute chest pain. All three tests are carried out using the cobas h232 from Roche Diagnostics.
As well as bringing clinical benefits for patients, the diagnostic equipment allows the Centre to serve a large patient population efficiently.
What we did
From February to November 2008, Whaddon Medical Centre conducted a pilot to diagnose and treat DVT on site, using the practice-based commissioning innovation fund. The results demonstrated that primary care testing for DVT using the D-dimer test saved unnecessary hospital admissions, speeded up the initiation of appropriate treatment and allocated Clinical Decision Unit (CDU) admissions to those at high risk only.
The practice has found the point of care diagnostic testing straightforward to implement. GPs refer their patients to three healthcare assistants, already employed by the practice, who then run the tests. Training in how to use the meter and conduct tests was provided free by Roche Diagnostics.
GP referral occurs via choose and book, paper and fax channels. All training is provided externally and the equipment is considered user-friendly, and can be used for a range of diagnostic tests.
D-dimer testing for suspected DVT
Having demonstrated that the DVT testing service could be carried out on site, in July 2009 Milton Keynes PCT appointed Whaddon Medical Centre as the lead practice in a Local Enhanced Service, (LES) with the remit of signing up the 27 practices in Milton Keynes for DVT D-dimer testing.
Practice manager, Toni Fisher, says: ‘As the lead practice, we are responsible for providing training and advice to GPs, nurses and healthcare assistants, negotiating with the CDU on pathways and pathway development, and monitoring the performance of the Local Enhanced Service. We support the practices in using point of care equipment including holding spare kit, validating equipment and ensuring test strips and other consumables are available for use.'
So far, eight practices have taken up the LES and now carry out D-dimer testing for DVT. Each practice which is contracted to provide the D-dimer service is able to claim £65 per patient according to the 2009-2010 protocol. Where low molecular Heparin is administered to enable a delayed CDU attendance, the practice may claim an additional fee of £15.
NT-proBNP testing for suspected heart failure
The Centre also started to test for NT-proBNP in patients with suspected heart failure in 2008 and now has the experience and capability to offer this service to a population of 240,000.
The NT-proBNP test has a high negative predictive value ( > 97%), which enables exclusion of heart failure in symptomatic patients,and helps to confirm the presence of heart failure, giving confidence to begin appropriate treatment. It also provides an alternative assessment to echocardiograms (ECHO), reducing pressure on waiting lists. NT-proBNP testing can also be used as a valuable triage tool to determine how urgent an ECHO is, and whether a patient needs to receive this immediately or whether the procedure can wait a week or two. The higher the reading, the worse the prognosis and the more urgent is the ECHO.
Dr Naguib Hilmy, the lead GP with a special interest in cardiology said: ‘It's a sensitive test which enables diagnosis of systolic and diastolic ventricular dysfunction, even in mild and asymptomatic cases of heart failure. We have found it particularly useful as a prioritising and triaging tool, to determine if breathlessness is due to respiratory problems or heart failure.
‘To ensure we make the most accurate diagnosis, we use clinical assessment to listen to the patient, understand their history, listen to their heart and combine this with the NT-proBNP test.
‘The test is easily interpreted and results are available within minutes. This helps to improve practice efficiency. This means that we can make an appropriate diagnosis during one consultation without the need for repeat consultation or referral, and the need for referral for specialist heart failure assessment can be reduced so resources can be focused on patients who need them most.'
Troponin T testing for diagnosing acute coronary syndromes
In November 2009, the cardiology centre started using the cobas h232 diagnostic equipment to carry out Troponin T testing for patients arriving at the surgery with complaints of chest pain that occurred between six hours and two weeks earlier. The Troponin T test result is incorporated into the TIMI (Thrombolysis In Myocardial Infarction) score to assess patients' risk. Patients with a positive Troponin T test need to be referred to hospital for emergency treatment of acute coronary syndrome – even if ECHO or other cardiac markers have been tested normal. Therefore, the test significantly speeds up care.
Lessons learned
Initially there were concerns raised about using near-testing machines, and about doing different activity in addition to the normal accepted day job of healthcare practice, as laid down by the practice guidelines. These were overcome by presenting the evidence of the value of such a service and such tests, and by the reassurance of using the external independent quality control measures provided by National External Quality Assessment Service (NEQAS). The service started small to allow for careful management and practice, which was the right approach. The attitude of the Trust has been very positive, welcoming the innovative approach taken.
Outcomes
Whaddon Medical Centre is responsible for providing a DVT testing service for 20,000 patients, including their own patients and those of another practice nearby. An audit of 234 patients indicated 58% were negative and ruled out, thus saving the NHS significantly on hospital admissions.
Of the first 365 patients who attended the heart failure service, 175 (48%) did not require an echo, helping reduce waiting times and costs associated. Regarding the Troponin T test, being able to diagnose a case of chest pain in a matter of minutes is reassuring for the patient and can help determine appropriate treatment or whether they need to be transferred to the care of the local hospital. Between November 2009 and September 2011, 150 patients have had a Troponin T test as part of this pathway. Of these, only 12 required admissions to CDU.
In summary, since the service began in 2008, the Centre has seen approximately 357 patients for suspected DVT (D-dimer),over 500 patients for heart failure (NT-proBNP), and since November 2009, over 150 patients for the Troponin T test for chest pain.
Based on an admission cost of just under £700 per patient and considering the impressive reduction in referrals witnessed, significant cost savings have been realised whilst speeding up diagnosis and treatment thereby improving patient outcomes.
The future
With the ongoing need for the NHS to find cost-savings, the hope is that this service will be extended across the whole of the Milton Keynes area, and this is currently being looked into by the new Clinical Commissioning Group and the PCT.
60 SECOND SUMMARY
Initiative: A cardiology diagnostic service, in which patients can be tested for suspected heart failure (HF), acute coronary syndrome (ACS) and deep vein thrombosis (DVT) in a practice setting.
Start up costs: Cobas h232 meter costs about £1,100; cost for NEQAS independent external quality control is £130 a year.
Staffing: Three healthcare assistants already employed by practice trained to use equipment
Savings: Service has achieved significant savings in the secondary care setting by treating patients in primary care.
Outcomes: Use of point of care diagnostics has led to speedier diagnosis and treatment, resulting in better outcomes for patients.
Contact info: Toni.Fisher@mkpct.nhs.uk
Sponsorship Statement: This case study was provided by Munro & Forster Communications, on behalf of Roche Diagnostics.
