the clinical practice committee: the view from both · pdf filethe clinical practice...
TRANSCRIPT
1
The Clinical Practice Committee: The
view from both sides
Dr Emma Parry
Clinical Director Maternal Fetal Medicine
Auckland District Health Board
• Selective Fetoscopic Laser
Photocoagulation
– Preparation
– Score
– Implementation
• RAST type tests for Food Allergies
– Review
– Presentation
– Disinvestment
2
Selective Fetoscopic Laser Coagulation
(SFLC)
• For the treatment of Twin to Twin Transfusion Syndrome (TTTS)
• Twins 1-2% all pregnancies
• 25% are Monochorionic
• 10-15% Monochorionic Twins
• 95% mortality if untreated
• Significant risk Cerebral Palsy in Survivors
• New treatment in Australia
• Better outomes and ‘Gold standard’
Video Clip
3
Selective Fetoscopic Laser Coagulation
(SFLC)
• A Business Case and Submission to ADHB CPC management support
• February 2009 presentation to CPC
• SPINHIA?
• Highest score at the time (80)
• RCTs and significant increase in QALYs
Selective Fetoscopic Laser Coagulation
(SFLC)
• Liaison with Sydney based team
• Funding from MoH and ADHB
• National based service at ADHB
• First case may 2009
• 29 cases thus far
• Ongoing review and follow-up of children age 2 and 5 years
4
RAST testing for Food Allergies
• July 2012
• Identified significant increase in RAST
testing with associated costs of over $1 to
Lapplus and ADHB
• One fulltime technician employed to run
tests
• Is this best use of our ADHB health dollar?
• Disinvestment...
Total sIgE testing at LabPlus
Is ordering with within hospital or from community
5
What are the sources of requests for sIgE testing?
2010/11
Community sIgE 77,130
“GP” 16,140
GP’s request 21% of all community tests
4-5% of tests are within hospital so 75% of testing is by
allergy specialists in the community
Number of sIgE tests per practitioner:
(in hospital and community) 2010/11
6
Individual allergens – by individual allergist
Jul-Dec 2011
0
100
200
300
400
500
600
700
800
900
Series1
Series2
Series3
Series4
Series5
Individual allergens – by individual allergist
Jul-Dec 2011
0
100
200
300
400
500
600
700
800
900
Series1
Series2
Series3
Series4
Series5
7
RAST testing for Food Allergies
• Reviewers identified
• CPC manager met with the Clinical
Immunologists to look at current pathways
to testing
• Identification of different opinions and lack
of clear agreed pathway
• Eventual agreement on the question to be
asked
RAST testing for Food Allergies
• Food allergies are relatively common in children
(4-5%). Less common in adults (2-3%)
• In children and adults with atopic symptoms food
allergy maybe suspected
• Testing has traditionally been with skin prick
testing (SPT) in vivo
• Newer in vitro testing is available examining
levels of IgE
• Useful when in vivo testing high risk for
anaphylaxis or skin condition
8
Further questions
• How quickly does clinical allergy and/or IgE
senitisation subside? Is there any evidence for
potential harm to patients by limiting to annual
tests?
• What is the ideal frequency of testing for
allergens? Is there a case for testing less
frequently than annually for a particular food
allergen or in particular age groups?
Further questions
• What proportion of children have or develop
concurrent allergies and what kind of testing
strategy (if any) is appropriate to identify them? Is
there any evidence to support ‘fishing’ for more
allergens when one is known.
9
RAST testing for Food Allergies
• Reviewers and Clinicians prepare review
and presentation
• Meeting prior to CPC
• CPC
– Clinicians present
– Visitors leave the meeting
– Reviewers present
– Discussion
– Conclusion
– Letter to CMO after emails