Should we abandon routine blood tests?
BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2091 (Published 03 May 2017) Cite this as: BMJ 2017;357:j2091
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I agree with the authors that “routine” blood tests should be abandoned.
It is common place for clinicians to order blood tests as part of clinical practice.
However, I often receive outpatient referrals from our colleagues in primary care (GPs, ANPs). If blood tests had already been organised, tests like vitamin B12 and folate levels are appended. Such requests are perhaps easily done when a computerised system is in utilised. Megaloblastic anaemia is uncommon in paediatric practice and such tests are a waste of scare resource.
On the other hand, when a patient reattends, tests like full blood count, electrolytes, liver and kidney and function tests, iron studies and bone profile may be re-ordered by another practitioner who may not have had a look at the previously requested tests. This represents unnecessary duplication (unpublished results). Likewise, in secondary and tertiary care, I urge clinicians to be mindful that all requests do have a cost attached to them and, therefore, we need to move away from and stop using the term “routine bloods”, but justify why a particular test is being requested. “Baseline” bloods may be justified if a particular condition needs monitoring pre- and post- intervention.
By being cognisant of these already entrenched ways of working, a culture change is well overdue and we have a duty to impact these onto our younger colleagues and by so doing, we will be able to limit unnecessary procedures like venepunctures and “routine” blood requests and these in turn will save the NHS a whole lot of money.
Competing interests: No competing interests
Should we abandon routine blood tests? No, not when hereditary erythrocytopathy poses a real problem in a so-called multi-racial population!
WEST AFRICANS NEED ERYTHROPATHIC TESTS BUT ONCE
The name “K Siau” [1] sounds Ghanaian from Kwahu Tribe, while the initial K could stand for any of the 7 Ghanaian Male Day-Names: Kwesi – Sunday to > Kwame – Saturday. [Our Kofi Annan was Friday-born]. If Siau is Ghanaian, then he may well be one of the “1 in 3 West Africans” who have inherited the abnormal haemoglobin gene ‘S’ or ‘C’, from one parent, not to mention the 1 in 4 males with Glucose 6 Phosphate Dehydrogenase (G6PD) Deficiency [2 3]. Millions of healthy West Africans in the UK have one gene for hereditary erythrocytopathy (abnormal haemoglobin S or C, plus or minus G6PD Deficiency) [4 5]. Routine blood tests performed just once can discern these [5]. UK is no longer entirely Caucasian therefore doctors need to unmask erythrocytopathy.
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PROFESSOR MALCOLM MILNE AND THE CAUCASIAN’S SHOULDER
Orthopaedic Trainee Dr Alastair Faulkner [6] may have read my account [7] of a postgraduate ward round many years ago. After being asked to examine a white patient I gave my Clinical Impression: “This jaundiced Greek patient with pale nails, scars on one shoulder and right hypochondrium, and with limited straight leg elevation of right leg has avascular necrosis of the shoulder, avascular necrosis of one femoral head, and has had gall stones removed because of chronic haemolysis from Sickle Cell beta-Thalassaemia” [7] Duly impressed, Professor Milne produced laboratory results confirming my diagnosis proving that NOT ONLY BLACK PEOPLE SUFFER FROM SICKLE CELL DISEASE. In Greece, around Lake Kopais, the 30% incidence of sickle cell trait was higher than anywhere in Ghana [8-10]. Any new patient I ever had - Black, White, Hebrew, Asian or Indian must routinely have Haemoglobin Electrophoresis and G6PD test done and be given a Certificate of the findings.
PROBLEM WITH NHS TESTS
Dr Sam Lewis [11] mentions the “nit-picking rejection of lab requests” in the NHS. When Clinicians request certain tests, NHS Pathologists often decide which to accept and reject. While Locum Consultant Physician in a London Hospital I requested Haemoglobin Electrophoresis on a woman, only for the Pathologist to send a report: “Sickling Test Negative”. I protested I never asked for a Sickling Test; could I have Haemoglobin Electrophoresis, please? The Haematologist asked why if sickling test was Negative I wanted Haemoglobin Electrophoresis? I then told him I had in Ghana the largest collection of Homozygous Haemoglobin C Disease patients (CC) in the world (all sickling negative) and that it was a common cause of miscarriage in pregnant women [12] The Pathologist still refused to do the test so I sent the lady to a Private Lab where Haemoglobin CC Phenotype was confirmed. As husband was Sickle Cell Trait (AS) I counselled them, advising that they should expect to have Sickle Cell Disease (SC) and Haemoglobin C Trait (AC) offspring. [13]
DO ROUTINE TEST FOR GLUCOSE 6 PHOSPHATE DEHYDROGENASE DEFICIENCY
Do not wait till patients complain of “passing urine like coca cola”. Always testing new patients for Abnormal Haemoglobins and G6PD Deficiency was how we discovered that G6PD Deficiency was not just a haemolysis problem, but could aggravate the course of typhoid fever, renal failure, muscle pain, duration of coma from any cause, and the prognosis of sickle cell disease. [2 3 14 -20]. That was how we discovered the first ever African with zero G6PD enzyme in his red cells – a phenomenon thought only to exist in Mediterranean Caucasians. [21 22]. Ringelhann [23], Beutler [24], James Bowman and Robert Murray [25] confirmed high levels of G6PD Deficiency in Blacks on both sides of The Atlantic. Luzzatto, examining 100 “SS” males found 16% to be G6PD Deficient [26]. As salmonellosis is common in sickle cell disease [27 28], and Chloramphenicol is contraindicated in G6PD Deficiency, this test requires doing for all sickle cell disease patients [19].
QUANTIFICATION TESTS BETTER THAN QUALITATIVE BUT NOT CHEAP
Relying only on G6PD Colour Tests would have missed our zero-enzyme patients. Quantification is vital for both Abnormal Haemoglobin and G6PD enzyme. That was how we knew that Sickle Cell Traits have 3 modes of Haemoglobin S (20-25%, 30-35%, 36-39.5%) [29] which fact enables us to distinguish the true Sickle Cell Trait (“AS” with S less than 40%) from Sickle Cell beta-plus Thalassaemia Disease (2 abnormal genes) with Sickle gene product way above 50% [28 29 30].
WHO and International Atomic Energy Agency grants funded our tests. [5 28].
SHOULD ANYONE BE REFUSED THESE ONCE ONLY ROUTINE TESTS?
I have described a white Englishman (Hb D Trait) married to a Ghanaian lady (Hb S Trait) and their 2 sickle cell disease daughters (Ref 28, Illustrative Case History 133). If NHS budget is unable to sustain such a routine test burden shall we not ask enquirers to go Private for their health’s sake? Dr K Siau believes while we needed to “avoid unnecessary repetition of blood tests” [1] some routine tests “should be considered part of holistic Medicine …” [1]. Three out of every 100 West Africans in the UK have inherited TWO ABNORMAL HAEMOGLOBIN genes causing hereditary disease capable of showing up in any Clinical Discipline [See the 133 Illustrated Case Histories in Reference 28] not to mention the non-haematological complications of G6PD Deficiency [2 3 20 28 29]. I once expressed disappointment when a seven-part series on genetic epidemiology by “three white professors began in The Lancet on September 10, 2005” [30] only for the series to end without once mentioning the genetic burden of west Africans in the UK. [29]. Will Dr K Siau now add our West African statistics to those of the “4000 Danish patients” he produced [1]? As I said in 1982, we needed to “unearth the hundreds of cases of SC sickle cell disease, some of whom are bread winners, before they are brought in dying or dead in their first crisis for 10 years” [31]
Conflict of Interest: My Parents Heterozygote for Abnormal Hbns (“AC” & “AS”) had 11 children: 3 Sickle Cell Disease “SC”, 2 Heterozygotes “AC”, 2 Heterozygotes “AS”, 4 Homozygotes “AA” [32].
felix@konotey-ahulu.com Twitter@profkonoteyahul
F I D Konotey-Ahulu MD(Lond) FRCP(Lond) FRCP(G) DTMH(L’pool) FGCP FWACP FTWAS
Kwegyir Aggrey Distinguished Professor of Human Genetics, University of Cape Coast, Ghana. Former Consultant Physician/Genetic Counsellor in Sickle & Other Haemoglobinopathies, Korle Bu Teaching Hospital, Accra, Ghana and at 9 Harley Street, London WIG 1AA. [ www.sicklecell.md ]
References
1 Siau K. Should we abandon routine blood tests? BMJ Rapid Response 8 May 2017. http://www.bmj.com/content/357/bmj.j2091/rr-6
2 Owusu SK. Glucose 6 Phosphate Dehydrogenase Deficiency in the causation of disease in Ghana. Ghana Med J 1974; 13: 168-170.
3 Konotey-Ahulu FID. Glucose 6 Phosphate Dehydrogenase Deficiency and Disease Causation in Ghana. (Editorial) Ghana Medical Journal 1974; 13: 155-158.
4 Ringelhann B, Dodu SRA, Konotey-Ahulu FID. Lehmann H. A survey for haemoglobin variants, thalassaemia, and Glucose 6 phosphate dehydrogenase deficiency in northern Ghana. Ghana Med J 1968; 17: 120-124.
5 Ringelhann B, Konotey-Ahulu FID. Hemoglobinopathies and thalassaemias in Mediterranean areas and in West Africa: Historical and other perspectives 1910 to 1997 - A Century Review. Atti dell’Accademia dell Science di Ferrara (Milan) 1998;74: 267-307
6. Faulkner Alastair, Reidy Mike, McGowan James. Should we abandon routine blood tests? BMJ 2017; 357: j2091 www.bmj.com/content/357/bmj.j2091?sso=
7 Konotey-Ahulu FID. Hip pain and radiographic signs of osteoarthritis: Sickle cell and other haemoglobinopathy differential diagnosis. BMJ Rapid Response 8 January 2016 http://www.bmj.com/content/351/bmj.h5983/rr-2
8 Choremis G, Sickle cell anaemia in Greece. Lancet 1951; 1: 1147.
9 Choremis G. Sickle cell trait and blood groups in Greece. Lancet 1953; 2: 901-911.
10 Delyannis GA, Tavlarakis N. Sickling phenomenon in Northern Greece. BMJ 1955; 2: 299-301.
11 Lewis Sam. Should we abandon routine blood tests? BMJ Rapid Response May 4 2017 www.bmj.com/content/bmj.j2091/rapidresponses
12 Konotey-Ahulu FID. Homozygous Haemoglobin C Disease. In FID Konotey-Ahulu. The spectrum of phenotypic expression of clinical haemoglobinopathy in West Africa. New Istanbul Contribution to Clinical Science 1978 Dec; 12(3-4): 246-257.
13 Konotey-Ahulu FID. SICKLE CELL DISEASE: The Case for Family Planning. Astab Books Ltd., Accra Ghana 1973.
14 Owusu SK. Clinical manifestations of glucose 6 phosphate dehydrogenase (G6PD) deficiency in Ghana. Ghana Medical J 1978; 17: 235-239.
15 Owusu SK, Foli AK, Konotey-Ahulu FID, Janosi M. Frequency of Glucose 6 Phosphate Deficiency in typhoid fever in Ghana. Lancet 1972; 1: 320.
16 Adu D, Anim-Addo Y, Foli AK, Yeboah ED, Quartey JKM. Acute renal failure and typhoid fever. Ghana Medical Journal 1975; 14: 172-174.
17 Owusu SK, Addy JH, Foli AK, Janosi Marianne, Konotey-Ahulu FID, Larbi EB. Acute reversible renal failure associated with glucose 6 phosphate dehydrogenase deficiency. Lancet 1972; 1: 1255-1257.
18 Konotey-Ahulu FID. Glucose 6 phosphate dehydrogenase deficiency and sickle cell anaemia. New Eng J Med 1972; 287: 887-888.
19 Acquaye CTA, Gbedemah KA, Konotey-Ahulu FID. Glucose 6 phosphate dehydrogenase deficiency incidence in sickle cell disease in Accra. Ghana Med J 1977; 16: 4-7.
20 Konotey-Ahulu FID. G6PD Deficiency in Ghanaians: How to recognize it. http://blog.konotey-ahulu.com/blog/_archives/2008/1/16/3458557.htmlJan. 16 2008.
21 Owusu SK. Absence of glucose 6 phosphate dehydrogenase (G6PD) in red cells of an African. BMJ 1972; 4: 25-26
22 Owusu SK, Opare-Mante A. Electrophoretic characterization of glucose 6 phosphate dehydrogenase (G6PD) enzyme in Ghana. Ghana Medical Journal 1972; 11: 304
23 Ringelhann Bela. A simple laboratory procedure for the recognition of the A (African Type) G6PD Deficiency in acute haemolytic crisis. Clin. Chim. Acta 1972; 36: 272-274.
24 Beutler E. Genetic Disorders of Red Cell Metabolism. Medical Clinics of North America 1969; 53: 813-826.
25 Bowman James E, Murray Robert F. Genetic Variation and Disorders in Peoples of African Origin. The Johns Hopkins University Press Ltd, London 1990, pp 171-190.
26 Luzzatto Lucius. G6PD Deficiency frequency and sickle cell association on the African continent. INSERM 1975; 44: 229.
27 Konotey-Ahulu FID, Kuma Eunice. Skeletal crumbling in sickle cell anaemia complicated by Salmonella Typhi infection. British J Clin Practice1965; 575-578.
28 Konotey-Ahulu FID. The Sickle Cell Disease Patient. Natural History from a clinico-epidemiological study of the first 1550 patients of Korle Bu Hospital Sickle Cell Clinic. T-A’D Company Watford 1996 [First Published 1991 & 1992 The Macmillan Press Ltd., London and Basingstoke] – 643 pages. [This book has 133 Illustrated Case Histories not found elsewhere]
29 Konotey-Ahulu FID. Alpha-Thalassaemia nomenclature and abnormal haemoglobins. Lancet 1984; 1: 1024-1025.
30 Weatherall DJ, Clegg JB. The Thalassaemia Syndromes 1981. Third Edition, Blackwell Scientific. Oxford.
31 Konotey-Ahulu FID. Survey of sickle cell disease in England and Wales. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495623/pdf/bmjcred00588-00...
BMJ 1982; 284: 111 (January 9)
32 Konotey-Ahulu FID. Sickle Cell Disease in Successive Ghanaian Generations for Three Centuries (Manya Krobo Tribe) Chapter 2 Reference 28 pp 6-20, and FID Konotey-Ahulu in The Human Genome Diversity Project: Cogitations of An African Native. Politics and The Life Sciences (PLS) 1999; Vol 18: No 2, pp 317-322 [Invited Commentary on Professor David Resnik’s article: The Human Genome Diversity Project: Ethical Problems and Solutions]
Competing interests: My Parents Heterozygote for Abnormal Hbns (“AC” & “AS”) had 11 children: 3 Sickle Cell Disease “SC”, 2 Heterozygotes “AC”, 2 Heterozygotes “AS”, 4 Homozygotes “AA” [32].
We read with interest the article by Faulker et al as well as the responses on BMJ.com on abandoning routine blood tests. It is apparent that the view on this topic varies from specialty to specialty. Ultimately, we feel that it is the responsibility of individual departments to assess the local incidence of routine blood tests and their implications. In an elective surgical specialty with a high turnover such as Urology, there are no official guidelines on which patients should have post-operative blood tests. A 3-month audit of all patients undergoing Grade 1-3 urological procedures in a district general hospital revealed that 55% of patients underwent post-operative blood tests including LFTs and clotting screens. No patient received an unplanned blood transfusion or suffered from TUR syndrome. The total annual cost of performing these tests was £3416.08 and >90% of results were reported after 11am thus delaying patient discharge (1). When reasons for this were explored, it became apparent that often the junior team were unsure as to whether blood tests were required and would request them "just in case". Following issuance of clear local guidelines emphasised in departmental induction, re-audit revealed a 75% reduction in the incidence of these tests (unpublished data). Operating surgeons adopted a patient-specific approach based on intra-operative judgement and clinical assessment as to whether a patient would need post-operative tests. This amounted to significant savings for the Trust both in terms of laboratory requirements and patient flow whilst maintaining safe practice. It is therefore apparent that an individualised approach is key to assessing and changing practice within different departments particularly in the current NHS climate of limited resources.
References:
1. Post-operative blood tests in patients undergoing urological surgery. Ravindra P, Lam G and Miller MAW. Journal of Clinical Urology 2016, Vol. 9(1S) 9–77
Competing interests: No competing interests
I read with great interest the article written by Dr Faulkner et al. Perhaps the authors went a little too far in abandoning the routine blood test. There are numerous disorders -- thyroid disease, renal impairment, lipid profile, diabetes, to name but a few -- that would only have been picked up on routine blood testing as they have no symptoms.
It's the daily blood draw in Hospital that needs immediate medical attention!
Drawing blood on a daily basis is an necessary physiologically in patients, but adds to the cost and in terms of consumables and doctors' time. There is always a danger that these results could lead to unwarranted attempts to correct an minor imbalance that otherwise would not have affected the patient’s outcome.
Perhaps the question should be rephrased: "Should we abandon unnecessary routine blood tests"?
Competing interests: No competing interests
I commend the article written by Dr Faulkner et al. and agree with it.The benefits of preventing unnecessary blood tests are so obvious but at the same time the circumstances and challenges the requesting clinicians are facing should also be appreciated. Furthermore, clinical signs and symptoms and clinical evaluation guide clinicians to request the right tests, but there are still clinical conditions which are not clinically overt and only blood tests will reveal their presence.
Having said this, we should still endeavour to reduce unnecessary tests and although the authors focus quite rightly on the colleagues i.e. initiators of these investigations in terms of emphasising to request for only tests that will influence their management to the patients concerned, but the laboratory can also be instrumental in the reduction of such blood tests.
If the laboratory , which is a clinical service led by clinicians, is provided with the bare minimum necessary clinical information on the request form by the requesting clinician, then the laboratory will only proceed with the relevant tests and avoid any other clinically irrelevant tests or even proceed with additional tests when appropriate.
Another additional approach to ensure optimal blood testing is to conduct on-going joint audits ( between the users and the laboratory ) to establish whether the blood tests conducted by the relevant speciality are appropriate , including whether there are benefits in conducting these tests, or not and if not then necessary actions are jointly undertaken in order to close the loop.
At our hospital we always welcome doctors in training at their induction programme to train them in optimal use of laboratory services in a practical and interactive manner at the Department of Laboratory Medicine.
Competing interests: No competing interests
Faulkner and colleagues address a point I feel is becoming ever more important in clinical practice. Of course, when ordering any test, we as doctors must consider the question: "will it change this patient's management?" In the context of many blood tests considered "routine", the answer to this will be "No". We have entered a culture of checking blood tests merely "because we can" or "just to check". The result of this is an abandoning of reliance upon our own interpretation of the patient in front of us - opting instead to rely on numbers to guide us.
I feel that the main issue needing addressed here is: why are these tests being ordered? On most in-patient wards, the individual ordering the bloods will be the one with the least experience, and indeed perhaps the least confidence. Requesting bloods is most often falls to the house officer - for whom the task of ordering blood tests for patients (whom they may not have seen or examined themselves) on a busy surgical admission unit can be a daunting task, and ordering the "full battery" of tests can be somewhat of a comfort to them. Perhaps what is required is better education for Foundation Year doctors regarding the validity of routine blood tests, and greater guidance by senior doctors as to the reasons for requesting certain tests in certain presentations.
Competing interests: No competing interests
How very interesting that a time when a BMJ article advocates abandoning "routine tests", we learn that they are strong predictors of mortality risk !!
"In 271 465 admissions for which complete data existed (53.9% of the total), these test results strongly and independently predicted 30 day mortality. The study found that adjustment for 15 routinely measured haematology and biochemistry test results accounted for 33% of the excess mortality on Saturdays and 52% of the excess mortality on Sundays."
References
Walker S, Mason A, Quan T, et al. Mortality risk associated with emergency admissions during weekends and public holidays: an analysis of electronic health records. Lancet2017;(May). doi:10.1016/S0140-6736(17)30782-1.
Competing interests: No competing interests
I hope many other doctors also bemoan the title "clinical lead" that sadly has replaced the more human "leader" in the NHS's official panoply of jargon. To me, a "clinical lead" is a diagnostic clue, not a person who leads a team of professionals. The shorter "lead" is an electrical cord waiting to be plugged in to energize an appliance, or perhaps a piece of rope to restrain a barking dog, or even the hidden keel weight that keeps a sailing boat upright and steady. While any of these meanings might be metaphorically applied to professional colleagues who take on often-challenging administrative roles, I am sure they too would mostly prefer to be known as leaders, not inanimate leads.
Competing interests: No competing interests
The essential message behind the article is the need to make our services leaner. Whilst lean thinking has slipped out of fashion in recent years, I believe it has always been a part of clinical thinking. If you take a speciality like Paediatrics for example, a “full house” of bloods is very rarely done on first presentation. In fact, a child can present with a LRTI and not receive any invasive investigations (such as bloods or CXR) at all. That same patient when they are a few years older, however, could present to an adult A&E with similar symptoms and receive a battery of tests.
There is certainly something to be said for bringing this thinking back to adult medicine. However, one big issue with lean (‘lean is mean’) is that is often over looks the humans at the centre of the process. How would patients feel if we do fewer samples on them – do we know how they feel now about the number we take?
I’d recommend the ‘Lean Thinking for the NHS’ booklet produced by the Lean Enterprise Academy UK in 2006 for an insight into the peak of lean thinking.
[1] http://www.leanuk.org/media/37654/Lean-Thinking-in-the-NHS-Daniel-T-Jone...
Competing interests: No competing interests
Re: Should we abandon routine blood tests?
Red blood cell wastage and sugar mismatch
Why do we pour blood down the drain?
If you a paediatric patient and you present to your primary care physician with lethargy, you are very likely to get a series of blood tests ordered, including vitamin B12, folate level and HbA1c. I often wonder how many GPs have children with megaloblastic anaemia on their registers. Without the appropriate history to point to such diagnoses, these haematological deficiencies are infinitely rare, even in general paediatric practice1. The use of technology interfaces that makes it easy to tick box and order such blood tests should be discouraged across all levels of patient care.
Ditto, another blood test that is often requested in such scenarios is HbA1c. This is not necessary and is the wrong test if type 1 diabetes in being considered. The diagnosis in paediatric diabetes is based on appropriate history and confirmed by random plasma glucose more than 11mmol/litre. HbA1c is used for monitoring and not for diagnosis of diabetes in children and young people2. It is also important that the patient should also be referred to secondary care on the same day of the diagnosis..
I call on my learned colleagues to think of the necessity, reason and of course, the cost that is attached to any test that is ordered.
Like had been previously been mentioned and published3, the term” routine bloods” should be consigned into the past and any bloods requested should be justified.
It is also paramount that medical students are armed with the knowledge that such tests do cost money and that they should desist from such a tick box culture that seems to be embedded in our everyday patient care.
Competing interests: No competing interests