The Laboratory Investigation of. Tiredness. Clinical Audit. better medicin

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1 The Laboratory Investigation of Tiredness Clinical Audit bpac nz better medicin e

2 Clinical Audit The tired patient in general practice Claiming MOPS credits This audit has been endorsed by the RNZCGP as a CQI Activity for allocation of MOPS credits. General practitioners taking part in this audit can claim credits in accordance with the current MOPS programme. This status will remain in place until January To claim MOPS credits, you can indicate completion of the audit on the annual claim sheet, or alternatively you can go to the RNZCGP website, and claim your credits at MOPS online. As the RNZCGP frequently audit claims, you should retain the following documentation in order to provide adequate evidence of participation in this audit: A summary of the data collected (included as Appendix one). Continuous Quality Improvement Activity summary sheet (included as Appendix two). A certificate of participation, if this is an organisational activity. Prepared by Rachael Clarke bpac nz Level 8, 10 George Street P.O. Box 6032 Dunedin Phone PAGE 1

3 Introduction Tiredness can be a complex complaint for doctors to investigate. In many situations the tiredness may be just tiredness, or the result of psychosocial or lifestyle causes. But less frequently, tiredness will be the indication of a serious clinical diagnosis. The challenge for the GP is to be able to diagnose significant disorders without over investigating minor conditions. Causes of tiredness Causes of tiredness presentation can be usefully divided into three overlapping groups. Many presentations will not fit into these groups and the cause will remain unknown. Lifestyle Unknown Psychosocial Physical Lifestyle causes may be the result of: Significant life stresses The demands of occupation or family Diet excessive food or diet fads Alcohol and street drugs Exercise over or under exercise Sleep disorders Psychosocial causes often overlap with lifestyle causes of tiredness. Anxiety, stress and interpersonal difficulties affect quality of life and are often amenable to intervention. Depression needs early identification because of the morbidity and threat to life associated with untreated depression. Physical causes can also make someone tired. These physical causes may not always be obvious. They may include: Co-morbidities Medications many drugs cause tiredness New conditions presenting as tiredness PAGE 2

4 A suggested clinical framework A step-by-step approach is recommended when investigating tiredness. STEP 4 Focused laboratory tests STEP 3 Focused examination STEP 2 Focused symptom review STEP 1 Define the problem from the patient s viewpoint STEP 1 Defining the problem from the patient s viewpoint People mean different things by tiredness, and exploring this will help to clarify the problem. The following questions may be a useful staring point: What does the patient mean by tiredness? Is tiredness the only issue? How is it affecting their life? What do they believe is causing it? What are their concerns? STEP 2 Focused symptom review The focus of additional symptom review, especially looking for red flags, is determined by patient demographics and past history. For example women will need to be asked about menstrual symptoms; elderly people about weight loss, appetite and bowel disturbance; and smokers about cough. STEP 3 Focused examination The focus of the examination will be determined by patient demographics and findings from the history. Clearly a 65 year-old man with tiredness and weight loss will need a different examination to an 18 year-old that presents with one week of fatigue and is clearly under stress and sleeping poorly. STEP 4 Focused laboratory tests Similarly, we suggest a focused approach to laboratory investigations of tiredness, determined by clinical findings. When there are no other clinical findings we suggest an approach based on demographics, the presence of risk factors and the duration of the tiredness. This is a consensus approach that has been suggested, because there are few clinical trials that assess laboratory testing using patient benefits as outcomes. Use focused laboratory investigations for tiredness when there are no other clinical findings PAGE 3

5 In a study performed in Australia (Gialamas, 2003), of 345 patients who presented to their GP with tiredness, 189 patients (55%) went on to have 1183 pathology tests performed. Of these tests 84% were considered normal. Of the 345 patients, 12 (4%) had a significant clinical diagnosis made because of an abnormal pathology test. The most common diagnoses made from the tests were anaemia, diabetes mellitus, and hypothyroidism. The diagnostic challenge when investigating tiredness is to detect physical causes and serious disease without burdening the patients with excessive medical investigation. Use focused laboratory investigations for tiredness when there are no other clinical findings Patients under 50 years without other risk factors: Tests: CBC Ferritin Comments: Searching for iron deficiency, macrocytosis, significant infections and leukaemias. Patients over 50 years or tiredness lasting over one month Tests: CBC CRP Ferritin, iron saturation LFT Creatinine with egfr Electrolytes Calcium, phosphate TSH Fasting glucose Urinalysis ANA Comments: This wide range of tests reflects the increased risk that older people have of many diseases and the difficulty of reaching a diagnosis in chronic tiredness. Patients under 50 years with additional risk factors may require the following extra tests: Type 2 diabetes Thyroid dysfunction Renal impairment Liver disease Body fluid transfer Fasting glucose TSH Creatinine with egfr Electrolytes Urinalysis LFTs HIV Hepatitis B & C serology PAGE 4

6 Focus of this audit This audit focuses on female patients who are of menstruating age. This group of patients may become tired due to a variety of causes, which include lifestyle, psychosocial and physical factors. Anaemia will frequently be investigated as a physical cause of tiredness in this group, due to the demands of blood loss from menstruation. Iron deficiency is the most likely cause of anaemia and the most appropriate test for iron deficiency in this situation is ferritin. Megaloblastic anaemia as a result of vitamin B12 or folate deficiency is much less common and rare in the presence of a normal blood count. Therefore vitamin B12 and folate tests should only be requested following an abnormal full blood count. This audit focuses on: The choice of tests of iron status when investigating iron deficiency And If vitamin B12 and folate tests are requested following an abnormal full blood count. References Gialamas, A et al. (2003), Investigating tiredness in Australian general practice. Do pathology tests help in diagnosis? Australian family physician, 32, BPAC Guide 14: The Laboratory Investigation of Tiredness, 2006 PAGE 5

7 Plan Indicators Patients eligible for audit can be identified. Ferritin is the sole test of iron status in eligible patients. Vitamin B12 and folic acid are only requested in eligible patients following an abnormal complete blood count. Criteria The age, gender and indication for blood tests are recorded in the patient notes. Patient notes demonstrate that ferritin is the sole blood test of iron status for eligible patients. In patients for whom vitamin B12 or folate deficiency is tested, the patient notes demonstrate that was in response to an abnormal complete blood count. Standards The age, gender and indication for blood tests are recorded in 100% of patients notes. In patients in whom iron deficiency is investigated, ferritin is the sole blood test of iron status in 80% of patients. 3. In patients for whom vitamin B12 or folate deficiency is investigated, requests for vitamin B12 and folate tests were in response to an abnormal complete blood count in 80% of patient. PAGE 6

8 Data Which patients are included? This audit should include women between 15 and 50 years of age who have blood tests to determine either iron status or vitamin B12 and folate status. Identifying patients You will need to have a system that allows you to identify women between 15 and 50 years of age who have had requests for Iron studies, Ferritin, Vitamin B12 or Folate. Many practices will use a PMS system that allows them to search for all results of a particular blood test. You can use this approach to identify patients for this audit. Sample size and type Number of eligible patients will vary according to your practice demographics. It would be optimal to identify patients for each criteria. If you identify more, take a random sample of patients whose notes you will audit. What data should be collected? The following question should be answered: Were your patients identifiable through a system that recorded age and gender? In eligible patients having blood tests for iron deficiency, was ferritin the sole test of iron status? In eligible patients having tests for vitamin B12 and folate, had they initially had a complete blood count suggestive of megaloblastic anaemia? The answers to these questions can be recorded in the data sheet included as Appendix One. Data analysis Use the data sheet to record your data. Calculate: The number of patients who had ferritin only measured as a percentage of all patients who had iron status tests The percentage of patients who had a vitamin B12 and folate performed who initially had an abnormal complete blood count. Compare these percentages to the standards set in advance by the practice team. Standards are suggested in this audit but may also be set at a practice/practitioner level. Discussion amongst peers may be useful in establishing standards. PAGE 7

9 Taking Action The first step in taking action is to identify the criteria where gaps exist between expected and actual performance and decide on priorities for change. Once priority areas for change have been decided on, an action plan should be developed to implement any changes. The plan should assign responsibility for various tasks to specific members of the practice team and should include a timeline. It is important to include the whole practice team in the decision-making and planning process. It may be useful to consider the following points when developing a plan for action (RNZCGP 2002). 1. Problem solving process What is the problem or underlying problem(s)? Change it to an aim. What are the solutions or options? What are the barriers? How can you overcome them? 2. Overcoming barriers Identifying barriers can provide a basis for change. What is achievable find out what the external pressures on the practice are and discuss ways of dealing with them in the practice setting. Identify the barriers. Develop a priority list. Choose one or two achievable goals. 3. Effective interventions No single strategy or intervention is more effective than another and sometimes a variety of methods are needed to bring about lasting change. Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour. PAGE 8

10 Review Monitoring change and progress It is important to review the action plan against the timeline at regular intervals with the practice team. It may be helpful to discuss the following questions: Is the process working? Are the goals for improvement being achieved? Are the goals still appropriate? Do you need to develop new tools to achieve the goals that have been set? Following the completion of the first cycle, it is recommended that practices complete the first part of the RNZCGP clinical audit summary sheet (a copy of which is attached as Appendix two). Undertaking a second cycle In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance. It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended practices complete the remainder of the clinical audit summary sheet. General Practitioners claiming credits Once a year a credit claim sheet is sent out by RNZCGP to GPs. On this you can indicate what you have completed, or alternatively you can go to the college website, and enter your points/claim through MOPS online at General Practitioners claiming credits towards MOPS will be required to complete the summary sheet (Appendix Two) in this audit but it is not required to send the summary sheets to RNZCGP, or bpac nz. You should retain the summary as it will allow you to provide adequate evidence of participation should the RNZCGP audit claims. Those undertaking this audit but not claiming credits towards MOPS are strongly recommended to complete the summary sheet as it will provide them with a succinct review of the audit process. PAGE 9

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12 Appendix One: Data Sheet Cycle one Patient Number Were tests of iron status* requested? Was ferritin the sole iron status test? Patient Number Were tests for B12 and folate performed? Were B12 and folate requested following the results of a CBC? Total Total Percent Percent *tests of iron status = iron studies, Iron, saturation, ferritin PAGE11

13 Appendix One: Data Sheet Cycle two Patient Number Were tests of iron status* requested? Was ferritin the sole iron status test? Patient Number Were tests for B12 and folate performed? Were B12 and folate requested following the results of a CBC? Total Total Percent Percent *tests of iron status = iron studies, Iron, saturation, ferritin PAGE 12

14 Appendix Two: RNZCGP Summary Sheet CQI Activity Doctor s name: The activity was designed by, please tick appropriate box: ü RNZCGP Organisation e.g. IPA (name of organisation) Individual (self) bpac nz Topic: Laboratory Investigation of Tiredness Describe why you chose this topic (relevance, needs assessment etc.): First cycle (15 credits) Data: Information collected. Date of data collection: Please attach: A summary of data collected or If this is an organisation activity, attach a certificate of participation. Check: Describe any areas targeted for improvement as a result of the data collected. Action: Describe how these improvements will be implemented. PAGE 13

15 Monitor: Describe how well the process is working. When will you undertake a second cycle? Second cycle (15 credits) Data: Information collected. Date of data collection: Please attach: A summary of data collected or If this is an organisation activity, attach a certificate of participation. Check: Describe any areas targeted for improvement as a result of the data collected. Action: Describe how these improvements will be implemented Monitor: Describe how well the process is working. Will you undertake another cycle? Additional comments: PAGE 14