Reducing inappropriate testing in the diagnosis of the menopause and peri-menopause

Introduction

The menopause is universally experienced as women age. Due to increasing female life expectancy, women can expect to spend roughly a third of their lives in the post-menopausal phase. As women complete the menopausal transition, 85% report symptoms and this results in 10% of women consulting their health-care provider. ¹ Women experiencing menopausal symptoms may be tested for follicle stimulating hormone (FSH) levels, often requesting the test themselves. Natural variations in the level of FSH lead to difficulty in defining diagnostic thresholds and make the test an unreliable indicator of the menopause. The measurement of FSH, along with luteinising hormone and oestradiol is recommended to confirm diagnosis in women suspected of having a premature or early menopause, and it is now recognised in accordance with recent NICE guidelines, that the menopause in women aged 45 and over should be diagnosed based on clinical symptoms, not FSH testing. ²

Diagnostic testing in the NHS has been increasing by 15% annually; however, it is estimated that 25% of the tests requested are inappropriate. ³ Inappropriate testing not only costs the NHS, but also results in a further consultation to discuss the result, delayed diagnosis, delayed treatment and prolonged anxiety. As part of a demand optimisation programme to identify and decrease inappropriate testing, this study aimed to quantify and reduce the number of inappropriate FSH tests requested for the investigation of menopausal women in Dumfries and Galloway.

Methods

Data were collected from Dumfries and Galloway Royal Infirmary laboratory using pre-defined inclusion and exclusion criteria. FSH blood tests ordered for female patients aged 45 years and over were included in the data set. Clinically appropriate FSH tests for specific situations were excluded. FSH tests to assess the need for contraception in women aged 50 and over, who were amenorrhoeic due to progestogenic contraception were excluded, as were tests for the investigation of suspected endocrine and neuroendocrine conditions. Educational interventions were implemented to discourage FSH testing and to promote the clinical diagnosis of the menopause. Relevant clinicians were sent an educational message by e-mail. This was reinforced by laboratory staff, who returned inappropriate tests with an educational message including reference to guidance on the menopause, accessible via the Health Board Intranet.

Results

In the month of May 2015, the lab received 83 inappropriate FSH test requests, with the majority being requested from primary care. Following our educational interventions, only 38 inappropriate FSH tests were requested during July 2015, a 54% reduction from May. The educational interventions implemented have also shown a sustainable decrease. Analysis of data from October showed a 70% reduction in inappropriate testing in comparison to May (Figure 1). OPEN IN VIEWER

Discussion

Educating clinicians encourages sustainable reductions in testing; however, maintaining change is often difficult. With the advent of more electronic-based laboratory requesting systems, it may prove easier to block test requests at source. Doctors attempting to submit inappropriate tests online could be blocked before the test is sent or is even conducted, with a notification educating the clinician for future practice.

This study has demonstrated the success of simple educational interventions in reducing inappropriate laboratory test requests. In addition to saving laboratory costs, this is also likely to improve the provision of care for menopausal patients by eliminating additional consultations and allowing immediate diagnosis and management. Finding similar clinical scenarios and applying the same interventions used in this study could help save costs and improve delivery of care to patients in a wide range of medical specialties.