NICE impact diagnostic pathology

Why focus on diagnostic pathology?

Diagnostic pathology impacts on all areas of healthcare. In particular, pathology tests play an important role in the prevention and early detection of cancer. Early detection improves the chances of successful treatment, saves lives and is more cost effective for the NHS.

• 1.2 billion pathology tests are estimated to be carried out each year in England
• around 95% of clinical pathways rely on access to pathology services.

Key findings from the report

This page gives a summary of the uptake of 5 NICE-recommended pathology diagnostics. Two of these were originally identified by the AAC as rapid uptake products:

• high-sensitivity troponin tests
• placental growth factor (PIGF)-based tests for suspected pre-eclampsia.

We've included insights from Dr Michael Osborn, president of the Royal College of Pathologists, as well as shared learning examples from a number of NHS Trusts.

High-sensitivity troponin tests

Key points

• Hospital emergency departments use these tests when someone has acute chest pain. The tests show if someone is having a heart attack, the type of heart attack and the treatment needed. Older-style troponin tests take 10 to 12 hours, so people need to be admitted while they wait for the results.
• We recommend tests to help rule out a type of heart attack called a non-ST-segment-elevation myocardial infarction (NSTEMI) in 20 minutes or less. We also recommend a second test for people at low risk if the first test is positive.
• High-sensitivity tests can mean people with normal troponin levels do not need to be admitted to hospital, and those with a confirmed NSTEMI can get earlier treatment.
• 86% of eligible people had access to high-sensitivity troponin tests (estimated by the Accelerated Access Collaborative in 2019/20).

• We have produced an adoption support resource for high-sensitivity troponin testing. This provides practical information and advice to NHS organisations on adopting these tests.

Placental growth factor (PlGF)-based tests for suspected pre-eclampsia

Key points

• Pre‑eclampsia can be a serious pregnancy complication. It can need a referral to a specialist and hospital admission.
• Our updated guideline on hypertension in pregnancy, along with our diagnostics guidance on PlGF-based testing recommend a blood test for pregnant women with suspected pre-eclampsia who are between 20 weeks and 34 weeks plus 6 days. This could result in a faster and more accurate diagnosis of pre‑eclampsia. It could also allow pregnant women who have had pre‑eclampsia ruled out to return to community care instead of being admitted to hospital for observation.
• Only 1 hospital had access to PlGF-based tests in 2018/19 compared with 60 who had access to the tests in 2019/20.

• The rapid increase in uptake of PIGF-based tests means:
  • quicker and more accurate diagnosis
  • fewer unnecessary admissions
• This leads to reduced costs for the NHS.

Faecal immunochemical test (FIT) for colorectal cancer

Key points

• Our diagnostics guidance on faecal immunochemical tests helps primary care clinicians decide who to refer for a colonoscopy.
• We have produced an adoption support resource for faecal immunochemical testing.
• In June 2019 FIT became the primary test used in the bowel cancer screening programme for people aged 60 to 74 in England.
• Uptake of the screening test increased from 56% in 2015/16 to 66% in 2019/20.
• The NHS Long Term Plan highlights that use of the FIT has improved uptake rates. This includes groups with low participation rates such as men, people from black, Asian and minority ethnic groups, and people living in more deprived areas.

Prenatal testing for fetal RHD genotype

Key points

• A new prenatal test for fetal RHD genotype will help to ensure that only pregnant women who need anti-D prophylaxis receive it.
• Routine antenatal anti‑D prophylaxis for all women who are rhesus D negative is current practice in most NHS maternity services. However our diagnostics guidance on high-throughput non‑invasive prenatal testing (NIPT) for fetal RHD genotype states that about 40% of women who are rhesus D negative carry a rhesus D negative baby. Where the rhesus D status of the baby can be determined, anti‑D prophylaxis will not be needed.
• NIPT will prevent unnecessary treatment and protect stocks of anti-D immunoglobulin.
• We have produced an adoption support resource for prenatal testing for fetal RHD genotype to provide practical information and advice to maternity services.

Natriuretic peptide testing for heart failure

Key points

• Natriuretic peptide testing - B‑type natriuretic peptide (BNP) or N‑terminal pro‑B‑type natriuretic peptide (NT‑proBNP) is an important tool for rapidly assessing adults presenting with possible heart failure.
• It can be used to rule out a diagnosis of heart failure or to decide if further investigation with echocardiography is needed.
• It can save time and distress for people presenting with suspected heart failure.
• Our guideline on chronic heart failure recommends that people with suspected chronic heart failure should have NT‑proBNP measured. In addition, our guideline on acute heart failure and quality standard on acute heart failure recommend measuring either BNP or NT‑proBNP in people presenting with new suspected acute heart failure.
• There is a lack of uptake data. The British In Vitro Diagnostics Association have data showing a rapid increase in the sales of BNP tests. This suggests an increase in use. But our discussions with stakeholders and local data collection says that availability is variable.
• We published a chronic heart failure: diagnosis visual summary to help clinicians decide which tests to offer when diagnosing heart failure. We will continue to focus our implementation efforts on increasing uptake of NT-proBNP in primary care.

We would like to thank Dr Michael Osborn for his contributions. We would also like to thank The British In Vitro Diagnostic Association and NHS Blood and Transplant.