Title: Developing evidence based optimal testing strategies to monitor long term conditions in primary care
Funder: Department of Health and Social Care

Abstract: BACKGROUND Most patients with long term conditions (LTC) are managed in primary care; regular blood tests assess disease progression, treatment response, complications, and associated diseases. There is no robust evidence to inform recommendations on selection of tests, or test frequency for people with LTC. AIMS AND OBJECTIVES To optimise testing to monitor LTC (hypertension, T2DM and CKD) in primary care by developing evidence-based testing strategies (EBTS) and accompanying patient and clinician materials. METHODS WP 1: Develop evidence-based testing panels for people with LTC: Rapid reviews and clinical practice research datalink (CPRD) analysis to develop evidence-based recommendations on which tests people with LTC should have to monitor their condition. A consensus meeting of advisory panel members of will select tests for inclusion, exclusion or further analysis. WP 2: Develop evidence-based recommendations on frequency of monitoring Combination of rapid review methods, CPRD analysis and cost-effectiveness modelling using a linked evidence approach to determine optimal testing panels and frequency. Value of information analysis to assess value of further research. WP 3: Explore patient, clinician and commissioner views on testing to monitor people with LTC Following the person-based approach (PBA) to developing and implementing interventions, we will use qualitative interviews to understand patient, clinician and commissioner views on testing. We will interview patients with LTC who do not regularly attend for monitoring to understand barriers to engagement. WP 4: Produce information materials for patients and clinicians to facilitate implementation Development of an intervention package, including patient and clinician resources, to support implementation of the new testing strategy at a practice level. WP 5: Clinical and cost-effectiveness of EBTS to monitor LTC with current practice: efficient design cluster randomised controlled trial (CRCT) We will use a CRCT with randomisation at the GP practice level to compare our EBTS to standard care. Initial feasibility work will assess whether: EBTS developed is sufficiently different to routine care; sufficient CCGs and GP practices consent to take part; EBTS implementable at GP practice level; outcomes fully defined and collectable from routine data. A report describing progress on the programme, with particular emphasis on the feasibility work, together with the protocol will be sent to NIHR for approval at 30 months. The full trial will be carried out in 190 GP practices with outcome data collected via CPRD. The EBTS will be implemented through electronic test ordering systems. TIMELINES FOR DELIVERY 5 years from 1 January 2021. Key milestones: WP1 (June 2021-May 2023); WP2 (December 2022-May 2024); WP3 (December 2021-May 2023); WP4 (June 2023-May 2024); WP5 feasibility (June 2022-May 2024); finalise progression criteria (31/5/2023); interim report to NIHR (30/11/2023); WP5 CRTC (June 2024-May 2026); report production (June 2025-May 2026). ANTICIPATED IMPACT AND DISSEMINATION This programme of work has the potential to change how LTCs are monitored in primary care, ultimately improving patient outcomes and leading to more efficient use of NHS resources. Results will be reported in peer-reviewed journals, academic and public presentations and social media. We will discuss findings with patient groups to help with dissemination to patients.

Lay abstract: What is the problem? The number of blood tests performed in the NHS is increasing. Over half of these blood tests take place in general practice to monitor long-term conditions (LTC). Testing blood can be unnecessary, may cause distress and lead to further tests and treatments that may not be needed. However, not testing may miss things that might be wrong. Current guidelines on what tests people with LTC should have to monitor their condition are based on expert opinion rather than research evidence. What are we trying to find out? We want to develop evidence-based testing strategies to monitor people with high blood pressure, diabetes and chronic kidney disease in general practice. This will let patients, doctors and nurses know which are the best tests for these conditions, how often to test patients, and how to use the results. It has the potential to free up resources from general practice, reduce unnecessary testing for patients and improve overall management of LTC. What are we going to do? We are proposing a 5-year programme consisting of 5 integrated work-packages (WP): WP1 and WP2 will involve reviews of existing research evidence and analysis of data from GP practices. We will build mathematical models to look at whether tests improve patient outcomes (WP1) and how often they should be used (WP2). In WP3, we will interview patients, GPs and nurses about their views on testing and how they would feel about changing testing practice. WP4 will involve work with patients, doctors and nurses to produce information in the form of leaflets or online guides to support those using the new testing strategy. WP5 will evaluate our new testing strategy by implementing it in a range of GP practices and comparing with those following their usual testing practice. We will compare the testing rates between the GP practices to see how the new policy has been adopted. We will also look at patient outcomes such as hospital visits and GP consultations to check that patients are not experiencing a deterioration in their condition due to changes in the testing system. Patient and public involvement Three patient representatives have been involved in the design of the programme and will continue to be involved. We have recruited a patient advisory group which will oversee the project and meet twice a year over the five years. Sharing our findings All results will be reported in peer reviewed health care journals and a summary of findings will be disseminated to people involved in the delivery and organisation of health care for long term conditions. Relevant patient groups, and our patient advisors, will help us communicate our findings to patients.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: METABOLIC AND ENDOCRINE;RENAL AND UROGENITAL;CARDIOVASCULAR