National Demand Optimisation Group (Ndog) – Phase 3 Report

11 Addendum: Phase IV Update on Pandemic Monitoring

Lab Activity as a Metric for Pandemic Healthcare Trends

The National Demand Optimisation Group (NDOG) for Laboratory Medicine has developed a monitoring tool that tracks diagnostic activity during the pandemic and into recovery. This information is a direct surrogate metric for associated clinical activity and can be used to identify healthcare gaps, monitor recovery, and enable better informed prioritisation decisions.

Background

The NDOG was established in 2016 as a collaborative initiative aimed at developing a programme of work to optimise the use of laboratory testing to reduce unwarranted variation in the delivery of healthcare. The group has developed an interactive Atlas of Variation (AoV) for laboratory tests that tracks lab test use at regional, board, cluster, and GP practice levels. This allows unwarranted variation to be identified and targeted via peer comparison and educational interventions.

During the COVID-19 pandemic, emphasis has shifted towards using the same data collection and AoV structure to develop dashboard intelligence on lab test trends. Given the integral importance of lab testing throughout healthcare, these trends are an indirect marker for diagnosis, monitoring and treatment modalities throughout the pandemic period and into the recovery phase. Such information may be vital at identifying reductions in diagnoses and treatment of specific malignancies and other disease pathways such as diabetes, heart disease and chronic conditions.

Pathology and Cancer

Pathology specimens serve as a robust marker of healthcare activity associated with the diagnosis and treatment of various malignancies and other serious diseases. Figure 1 shows the total number of pathology requests, received by Scottish labs during the pandemic, adjusted to the 2019 average for each health board. Similar trends are seen when specific specimen types are looked at in isolation.

Interactive Dashboard Development

An AoV style Tableau dashboard (Figure 2) has been created that allows interrogation of the data to focus on specific health boards, specimen types and even complexity of specimen requests by virtue of the number of blocks and slides generated.

Blood Sciences and Diabetes

Blood tests are a good measure of healthcare activity within both Primary and Secondary care. Significant reductions in blood test requesting have been observed throughout the pandemic because of reduced activity (out-patients, GP led clinics) and significant phlebotomy capacity issues in the community due to social distancing measures and staff pressures.

The diagnosis and monitoring of diabetes is crucially dependent upon blood testing for HbA1c. Figure 3 shows Primary Care HbA1c requesting trends during the pandemic period adjusted to the average 2019 activity. The significant reductions observed in HbA1c testing are likely to have significant clinical consequences for both new diagnoses and the adequate monitoring of existing diabetic patients.

Interactive dashboards are being created for HbA1c and other key blood markers, including those related to cancer diagnosis and monitoring. These will allow trend interrogation by health board down to GP practice level.

Data Collection and IT Limitations

Data collection of laboratory test use on a national basis is difficult because of outdated lab IT systems, inconsistent coding systems and a lack of interoperability between health boards. Automated collection on a national basis is therefore not possible but must rely on manual downloads from individual health boards. Data collection is therefore patchy and will depend upon IT resource availability within the boards, which is under intense pressure due to the pandemic. If lab test trend analysis is important then consideration should be given to provide additional resource allocation to assist data collection by local IT personnel.

Potential Uses of the NDOG Lab Activity Dashboard

As a result of the pandemic, established metrics of healthcare activity/demand have become unreliable due to the huge shift away from traditional modes of care, referral, waiting list accumulation and reluctance of patients to seek direct medical input. The Lab Activity dashboard can therefore serve as a useful surrogate metric for healthcare activity across cancer and other chronic conditions. Specific uses could include:

1. Phlebotomy Capacity – using blood sciences data to identify demand and shortfall in phlebotomy provision across Primary/Secondary care and monitor the impact of developing Community Phlebotomy Hubs.

2. Cancer – using pathology and blood sciences data to identify gaps in the screening, diagnosis and monitoring of specific malignancies.

3. Chronic Disease Pathways – Similarly, focus in on specific disease pathways to identify healthcare gaps from health board down to individual GP practice level.

4. Recovery Targeted Prioritisation – identified healthcare gaps can be assessed and prioritised at health board level during recovery programmes.

5. Targeting and Reducing Unwarranted Variation – Ensuring appropriate lab test use is tracked and optimised – especially important during post pandemic recovery period.

6. Laboratory Resource Allocation – Much of the gap lab activity will likely return, and with the inevitable enhanced recovery initiatives to enable catch up, this will likely put huge pressures on lab services – especially within pathology, given the predicted consultant shortfall.

Recommendations

The Scottish NHS has faced a huge crisis associated with the COVID-19 pandemic. As we hopefully emerge from the second wave, another healthcare crisis associated with the missed diagnoses, delayed treatments, and the continuing impact of COVID-19 long term, will require focus – both to identify the gaps and to prioritise scarce resource. The NDOG Lab Activity dashboard will be an important tool going forwards and the following should be considered:

• Awareness – Scottish Government, Health Boards, Chief Executives, Remobilisation Groups and Lab Services should be aware of this potentially valuable resource in identifying pandemic driven healthcare gaps and enabling targeted prioritisation of resource moving into the post-pandemic recovery period.
• Collaboration – Clinical groups should consider working alongside the NDOG to develop specific lab metric bundles linked to their patient pathways.
• Resource – Additional resource input should be considered to allow the NDOG/ISD and local lab IT provision to deliver this initiative.
• Lab Services – Careful resource planning to enable lab services to cope with likely enhanced activity they will face as services recover and overshoot normal capacity - especially given the existing shortfall in Consultant pathologist capacity across the UK.

Dr Bernie Croal on behalf of the NDOG

February 2021