The SHIELD program for Hodgkin lymphoma in patients 60 years of age or older, prospectively evaluated clinical features and outcome in a large patient cohort (n ‫؍‬ 175). The central element was a phase 2 study of VEPEMB chemotherapy (n ‫؍‬ 103, median age 73 years) incorporating comorbidity assessment. A total of 72 other patients were treated off-study but registered prospectively and treated concurrently with: ABVD (n ‫؍‬ 35); CLVPP (n ‫؍‬ 19), or other (n ‫؍‬ 18). Of VEPEMB

Aims: The National Pathology Alliance benchmarking review has completed five years of data collection and analysis of the workload and organisation of haematology laboratories in the UK. This study analyses variation in practice in how laboratories respond to a request to determine whether or not a patient has folate deficiency. Methods: A three year analysis of workload data on the number of serum/plasma folate and red cell folate assays performed on an annual basis for the period 1 April 1999 to 31 March 2002. Results: Three diagnostic testing strategies were found, namely: serum/plasma folate only, red cell folate only, and both serum/plasma folate and red cell folate. Conclusion: Evidence from the literature indicates that serum folate measurements provide equivalent information to red cell folate measurements when attempting to determine whether folate deficiency is present. There seems to be no basis for the routine testing of all samples for serum/plasma folate and a red cell folate.T he National Pathology Alliance benchmarking review has now completed five annual cycles of data collection and analysis of the workload and organisation of haematology departments in the UK.1 When the benchmarking study was started there was no agreed national definition of what constituted a test and a request in haematology and blood transfusion. Therefore, a major part of the first two years' reports was to establish a national definition of tests and requests in haematology and blood transfusion, because without this no comparative assessment of a department's performance can be undertaken. In haematology, this has been achieved, with over 95% of departments now using the standard definition of tests and requests when completing the workload section of the questionnaire. Over the past two years, increasing attention has focused on the variation in diagnostic testing strategies used in different laboratories. This report analyses variation in practice in how laboratories respond to a clinical request to determine whether or not a patient has folate deficiency.''We analysed the variation in practice of different diagnostic testing strategies that laboratories have established to determine whether or not a patient is deficient in folate'' Folate values can be measured using either a serum/plasma folate or a red cell folate assay. National guidelines indicate that a negative folate balance seen in hospital patients can result in a low serum folate value without folate deficiency.2 Therefore, low red cell folate, thought to indicate tissue deficiency, may be more important than a low serum folate in the diagnosis of folate deficiency. However, no references were given in these guidelines to substantiate this view.Therefore, we analysed the variation in practice of different diagnostic testing strategies that laboratories have established to determine whether or not a patient is deficient in folate. We have also reviewed the literature to determine the appropriate diagnostic testing strategy in this situation. METHODSThe metho...

Aims: To examine whether variations in pathology test requesting between different general practices can be accounted for by sociodemographic or other descriptive indicators of the practice. Method: This was a comparative analysis of requesting patterns across a range of pathology tests representing 95% of those requested in general practice, in 22 general practices in a single district, serving a population of 165 000. Spearman correlation coefficients were calculated and both the top and bottom fifths of activity were displayed graphically to detect trends at the extremes of the ranges. Results: The proportion of women of childbearing age, median practice Townsend scores, or the existence of specialist miniclinics within the practice did not have a demonstrable impact on requesting patterns. A weak correlation was found between the proportion of elderly patients and creatinine/electrolyte testing but not for the other two tests examined for this patient group. Conclusions: The large differences observed in general practice pathology requesting probably result mostly from individual variation in clinical practice and are therefore potentially amenable to change.A lthough the relation between sociodemographic parameters, morbidity rates, and the use of medical services on a large scale is well established, 1 2 we are not aware of similar reports for the use of pathology services, either on a broad population basis or within individual health localities. Clinical practice is often assumed to account for differences in the use of pathology tests, but there is little published evidence to support this.Recently, we have published details of a simple model that may be used to monitor test requesting activity in general practice across different tests in pathology.3 This model produced stable results over time, and showed considerable differences between the test requesting activity of 22 general practices. In a context of primary care groups being able to use this type of model in a clinical governance setting, it is important to exclude potential confounding variables that could explain these differences, to provide credibility for any intervention designed to change practice."Clinical practice is often assumed to account for differences in the use of pathology tests, but there is little published evidence to support this"To examine whether these variations could be explained by differences in the general practices themselves, or in the general practice catchment area, we have considered several individual factors in the cohort of 22 general practices studied.We had previously shown that adjusting the overall rankings of requesting numbers for age and sex to produce standardised requesting ratios for each practice did not alter the unadjusted rankings of request activity.3 However, most practices in these distributions lie within a broad modal band of requesting, and it is possible that age and sex adjustment of overall activities may not detect particular extremes of activity for certain tests. Therefore, we set ou...

Prompt diagnosis and treatment of malignant disorders is generally regarded as improving outcomes. There is good evidence for this in the most common solid tumours, bronchus, breast and large bowel. It might be expected that delays in diagnosis of lymphoma could affect the outcome of treatment, as well as causing dissatisfaction among patients and relatives. However it would be difficult to obtain definite evidence for this as a randomised trial of delay is an unethical proposition. The recently introduced National Priorities Guidance (NPG) Cancer Targets require that all new patients with suspected cancer should see a specialist within two weeks of referral by their General Practitioner (GP). There is no good evidence to support this requirement in lymphoma, but we decided to audit delays at different stages of the process of diagnosis and initial treatment of lymphoma as a base line to assess current performance, identify possible shortcomings and set achievable standards amenable to further audit.

Aims-To identify a model to assess general practitioner use of pathology services that could be applied to assess specific interventions designed to promote best practice. Methods-A database containing standardised requesting data for 22 general practices was constructed. The database contained 28 tests covering 95% of general practitioner activity, distributed across pathology, and it was evaluated during two sequential six month periods. A comparison of ranks of requesting activity between diVerent time periods was undertaken by calculating Pearson rank correlation coefficients. Requesting numbers were also adjusted for patients' age and sex distributions within the 22 practices for a sample of three high volume tests. The eVects of distributing requesting guidelines and details of requesting activity were assessed during two sequential three month periods. Results-Requesting activity was extremely stable during the two baseline periods for most tests (r > 0.80 for 20 of the 28 tests). Several less discriminatory tests were identified. Age and sex adjustment had minimal impact on the ranks of requesting activity. Requesting activity during the two three month periods after distributing guidelines and comparative details of individual requesting activity showed little change (overall correlation coeYcient, 0.844 between baseline and intervention periods). Conclusion-Ranking general practitioners requesting activity adjusted for practice list size provides a reproducible means of measuring requesting activity for most pathology tests performed in general practice. Activity was not influenced by age or sex of patients on the practice list. Distributing requesting guidelines and individual requesting activity on their own do not have any measurable impact on requesting activity. More innovative (possibly multiple) interventions might be required to influence general practitioner requesting practice. (J Clin Pathol 2000;53:476-480)