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Coeliac disease is the name of the genetic condition which causes a person’s immune system to react abnormally to gluten, causing small bowel damage. If left undiagnosed, it can have serious and far-reaching consequences.

Coeliac Australia estimate that 1 in 70 Australians have the disease – significant, but a far cry from the huge numbers of people going gluten free.

Dr David Clift, a pathologist from Geelong specialising in gastrointestinal conditions, warns that people who decide they need to go gluten-free but do not seek medical advice or proper testing could be risking their health, in some cases with cancer;

“Poorly managed Coeliac Disease can lead to a variety of issues including osteoporosis or certain cancers. 1 in 20 people with Coeliac Disease who routinely consume gluten (sometimes unknowingly) will develop a form of lymphoma with a poor prognosis. It amazes me that so many are willing to ‘wing it’ with such a serious condition.”

The symptoms of coeliac disease can be similar to other gut conditions so it’s important to know that you’re getting the correct treatment. And gluten can be present in unexpected foods like processed meats, marinades and spices, so medical support is vital to help people with the disease adhere to the strict diet.

A study published by Monash University Professor Peter Gibson in 2011 proposed the existence of ‘gluten sensitivity’ – a ‘coeliac lite’ version causing symptoms in people without Coeliac Disease. This was seized upon by the burgeoning wellness market but in 2015 Gibson followed up his findings with two much larger studies that disproved gluten sensitivity existed. Dr Clift adds;

“There is more speculation than evidence about diet on the internet. Some people attribute an improvement in digestive symptoms to a gluten-free diet. But by cutting out gluten, you are reducing processed foods and additives that may be the real cause of gut pain.

Coeliac disease is not a sliding scale – you either have it or you don’t and it is a shame this myth persists. The only way to know for sure is to get tested.”

But is there a problem with going gluten free if you don’t have coeliac disease?

Well your bank account might think so. On average a gluten-free diet for a family of four will be 17% more expensive than a routine diet.¹

Not to mention, unnecessarily restricting your diet may have negative effects on your health.

Removing grains from the diet can reduce intake of vital nutrients. In children this may interfere with growth. And if you don’t have symptoms, there is no evidence that a gluten-free diet will provide you with any health benefits. Coeliac Australia estimate that 80% of Australians with coeliac disease are currently living undiagnosed. Their advice? If you have symptoms, get tested.

1. Lambert et al “Cost and affordability of a nutritionally balanced gluten-free diet: Is following a gluten-free diet affordable?” Nutrition and Dietetics Feb 2016

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THE Australian health system is under pressure to deliver more for less with an ageing population and growing burden of chronic disease.

The role of efficient and effective medicine has never been more important, but in the case of pathology, value is difficult to articulate.

Pathology is a vital part of medicine. However, it is mostly hidden behind laboratory doors and typically struggles to demonstrate its worth, because it is often considered in purely cost terms.

This is why Pathology Awareness Australia launched the Know Pathology Know Healthcare initiative, which aims to raise awareness of pathology’s value and integral role throughout healthcare. It is an approach which other countries should also embrace.

In my own work, I look at ways in which a change in approach can help pathology realise its full potential and show its value to the health system, both in terms of cost savings and improved patient outcomes.

Although there may be areas within pathology that can be improved to reduce spend, the idea that massive savings are available via automation is misguided. It is difficult to imagine improving health expenditures meaningfully when all of pathology costs a mere 3% of the healthcare budget.

Pathology’s appearance in the interim results of the MBS review is focused on over-testing.  Although some over-testing clearly exists, data suggests that under-testing is more than twice as prevalent (20.6% vs 44.8%¹) and the absence of necessary diagnostic information is likely to harm patients and cost more than any savings from over-testing. Yet under-testing is rarely considered an area of concern.

There are also some excellent examples of how pathology labs have become more actively involved in patient care with fantastic benefits for patients and financial savings.

One of these is a U.S lab that identified a pharmacogenomic test that could help patients needing anti-clotting medication (Clopidogrel). The drug may not be effective for all patients, meaning some could be at risk of adverse events (stroke) with the associated financial cost to the health system.

The lab showed that using this test for these patients would prevent 60 adverse events and save $1.5m annually.

A further example is a lab that reviewed high creatinine results where patients had not had follow-up testing. Working with care providers they pursued a number of patients resulting in the identification of 1,000 cases of undiagnosed kidney disease.

Although pathology teams know their worth, the demonstration of this value and the realisation of the full benefit labs can provide to patients requires a shift in thinking, both from within pathology and from the wider medical profession.

A lab’s mission should not just be to provide accurate, timely, low-cost test results. The clinical lab’s mission should be to efficiently enable the accurate diagnosis of conditions, the selection of appropriate treatments and the effective monitoring of health status.

Fostering more input from pathology professionals into patient care would better address all these issues, demonstrating that collaboration and appropriate pathology use is better (and cheaper) than driving down pathology costs in isolation of patient needs.

^{1 Zhi M, Ding EL, Theisen-Toupal J, Whelan J, Arnaout R (2013) The Landscape of Inappropriate Laboratory Testing: A 15-Year Meta-Analysis. PLoS ONE 8(11): e78962. oi:10.1371/journal.pone.0078962}

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Pathology testing saves lives and money according to a new report released today. Half the Australian population had a pathology test in the last 12 months. According to the report a third of the rise in tests requests is from doctors as they seek to prevent or minimise the impact of disease.

Pathology testing is central to controlling important, growing chronic diseases including diabetes. Managing diabetes without pathology has been compared to trying to drive a car without a steering wheel.

One in two GP visits involves a request for pathology tests. 60% of GP referrals for pathology relate to preventative health strategies and management of chronic illness. The report notes that 32% of the increase in clinical demand for pathology is due to preventative health treatments.

The Economic Value of Pathology is a meta-analysis conducted by the Centre for International Economics that examines three key health areas: diabetes, heart attack and colorectal cancer. Pathology is practiced in laboratories and is a largely unseen area of healthcare. The report was commissioned by Pathology Awareness Australia to quantify the value of investment in pathology.

70% of medical decisions rely on information from pathology testing and all cancer diagnosis is made by pathology investigations.

Pathology includes tests on blood, urine, swabs and biopsies, and provides detailed information to doctors. The report says Australia has among the highest quality pathology in the world and results produced by a workforce of 35,000 underpin the standards of overall healthcare.

Enhanced diagnostic technologies combined with the ageing population and an increasing focus on prevention, has spurred growth. Men over 75 in particular now access more testing for chronic disease management and preventative health strategies.

The total cost of delivering 500 million pathology tests per year across the community and in hospitals is estimated at 3 per cent of total health spending.

Report author Sarina Lacey from the Centre for International Economics says the findings highlight the need to invest appropriately in pathology:

“Pathology offers tremendous return on investment. With so many people with and projected to develop diabetes and other chronic conditions, it’s important to make smart, cost-effective decisions before health problems become expensive to manage. Getting health expenditure in the right areas makes good economic sense and pathology can make this happen.”

Pathology testing a defence against ballooning diabetes treatment costs

Diabetes related testing accounts for 10.5% of the growth in requesting from general practice and 6% of all GP orders for pathology.

1.7 million Australians have diabetes and this is forecast to rise to 3.5 million within 17 years. Diabetes complications account for 14% of preventable hospitalisations, 67% of Australian adults with diabetes have high blood pressure, and 68% die of heart disease or stroke.

Pathology tests are integral to diabetes prevention programs. The report notes that Type 2 diabetes prevention programs can save between $2,600 and $5,300 per life year.

The Haemoglobin A1c (HbA1c) blood test indicates the level of long-term blood sugar control. Proactive action on regular HbA1c results can help keep levels normal in people with diabetes. A small sustained decrease can reduce the cumulative incidence over five years in: end stage kidney disease by 40%; amputation by 21%; advanced eye disease by 43%; and heart attack by 16%.

Pathology Awareness Australia Ambassador A/Prof Graham Jones is a Pathologist at Sydney’s St Vincent’s Hospital. He specialises in testing for diabetes and says,

“Pathology underpins most of healthcare – you can’t do without it. Diabetes is defined by pathology tests – we have no other tools to see if we’re winning against the condition. Trying to manage diabetes without pathology is like trying to drive a car without a steering wheel!”

Sturt Eastwood, CEO of Diabetes NSW says,

“Diabetes is a significant, expensive problem that continues to grow at an alarming rate. Helping people prevent diabetes or reduce their complications is a win for the individuals involved and for the economy as a whole. Pathology testing is a vital part of diabetes management.”

$167 million per year can be managed down by ruling out heart attacks in Emergency Departments

Patients with chest pain account for approximately 10% of Emergency Department (ED) presentations. Approximately 1 in 5 cases will be for heart attack with the remainder for more benign conditions. At current ED attendance rates, $167 million per year is required to triage chest pain patients prior to hospital admission or direct discharge.

The Troponin blood test is an essential tool to diagnose and rule out heart attack. Recent advances in Troponin tests have allowed costs to be partially managed down. Newer Troponin tests may allow 40% of chest pain patients to be discharged earlier if used to their full potential.

Smart testing matches patients with the best therapies

Personalised medicine has revolutionised cancer care, and is only possible because of pathology. Pathology can now test the genetic characteristics of cancer to determine if a treatment will work on a patient.

Smart tests can match the patient with the appropriate drug therapy. The report notes that the KRAS and RAS mutation gene tests have been found to provide net cost savings to the Australian Government by ruling out treatment for patients that won’t respond well, and reducing harm and improving outcomes for patients that will.

This has underpinned dramatic improvements in survival and reductions in deaths from colorectal cancer over the past decade, with the 5–year survival rate for metastatic colorectal cancer having risen dramatically up to 67 per cent.

Download the full Value of Pathology report or an infographic including key pathology facts.

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