NICE Guideline (NG23), Menopause: diagnosis and management, was published in November 2015 and made clear recommendations about the use of laboratory tests in the diagnosis of menopause. The guideline recommended laboratories actively discourage follicle-stimulating hormone (FSH) requesting in women over the age of 45yrs.
This project used data from the laboratory information system to audit local requesting of FSH in female patients over 45yrs. Strategies to reduce inappropriate requesting were implemented, namely a GP information sheet, a pop-up message added to the electronic pathology ordering system (ICE) and coded comments added to reports. A re-audit was then conducted to assess the effectiveness of these strategies in reducing inappropriate requests for FSH in female patients over 45yrs.
Example
Aims and objectives
The aim of this project was to assess local compliance of FSH requesting against NG23 and measure the effectiveness of strategies to discourage inappropriate FSH requesting in female patients over the age of 45 years.
Reasons for implementing your project
Before this project started, there were no restrictions on FSH requesting by GPs for our laboratory and no educational resources on use of laboratory tests to diagnose menopause available to local GPs.
The baseline audit in 2016 revealed 819 requests for FSH in female patients over 45yrs during a three-month period and a significant proportion of these (>40%) were for diagnosis of menopause. FSH measurement costs approximately £6.50 per test in our laboratory so the annual cost of FSH testing in female patients over 45yrs is estimated locally as approximately £21,300.
Audit findings were shared with our local GP Pathology Demand Optimisation group which consists of laboratory professionals, CCG representatives and local GPs. York Teaching Hospital NHS Foundation Trust serves a community of approximately 800,000 people living in and around York, North Yorkshire, North East Yorkshire and Ryedale. Women over the age of 45yrs probably represent about ¼ of this total population.
How did you implement the project
A GP information sheet on using FSH to diagnose menopause was produced and uploaded to the laboratory medicine website. A link to this information sheet was added to FSH results issued to GP surgeries in female patients over 45yrs along with an automatic interpretative comment stating: “Women aged >45yrs should not have FSH requested to diagnose menopause, NICE guideline NG23”.
The GP electronic pathology requesting system was modified and a question was added to FSH requests in female patients “Is this a request to aid in diagnose of menopause in a patient >45yrs?”.
If the requestor answered “Yes” then the request was cancelled and a link was provided to the NICE Clinical Knowledge Summary on diagnosing menopause.
There has been little or no negative feedback from GPs in response to these changes and they were all within the power of the laboratory to implement.
Key findings
At 6 months following the changes, FSH requests in female patients >45yrs had reduced by 34% and this was sustained at 12 months following the change which equates to a ~£7500 saving in FSH testing in one year. The most recent data from 2019 suggests a 52% reduction from the 2016 baseline data in FSH requests in female patients over 45yrs.
Key learning points
Key learning from this project was that demand management strategies for FSH requesting can produce modest cost savings and that the approach suggested in the NICE guideline of GP education coupled with changes to GP requesting systems is effective.
If this project were being attempted again then engagement with secondary care clinicians and perhaps a joint protected learning time (PLT) session for GP with Obstetrics and Gynaecology would have been helpful.
It is clear that many GPs continue to request FSH to aid diagnosis of menopause in patient’s age 45yrs so a targeted approach for larger GP surgeries or frequent GP requestors may be effective in achieving further reductions. No attempt was made to audit oestradiol requesting in patients over 45yrs in the original project and this is something highly recommended to others undertaking similar projects.
Others conducting similar projects may wish to consider slightly more but not completely restrictive GP electronic requesting prompts, recognising that there are patients over 45yrs in who measurement of FSH may be appropriate.