Rob Brown

To think about how we can save money in the lab.

To discuss how Haemochromatosis testing has changed and developed over time in Newcastle and how this has improved efficiency and reduced costs.

To encourage Genetic Technologists and Healthcare Practitioners to take a lead role in suggesting and implementing changes that drive efficiency and money saving.

Money is tight.

Things could get worse.

Savings to be made in 2012/13 and beyond.

Are we as efficient as we can be?

Can we save money without reducing quality and therefore continue to ensure efficient and effective use of resources in delivery of patient care?

Hereditary Haemochromatosis testing in Newcastle is a good example of how becoming more efficient has not only reduced costs but has generated income for the department.

By reviewing the last 5 years we can observe how the testing process has changed, how the number of referrals have increased and where efficiencies and savings have been achieved.

What I want you to think about is…

Is there more we could do to improve efficiency?

Are there further savings that can be made?

Can the model presented here be applied to other disorders or to testing in other labs?

• Autosomal recessive• HFE gene• chromosome 6p21.3

characterized by high absorption of iron by the gastrointestinal mucosa, resulting in excessive storage of iron in the:- liver

- skin- pancreas

- heart- joints- testes

Early symptoms include:

▪ Abdominal pain▪ Weakness▪ Lethargy▪ weight loss.

Advanced symptoms include:

▪ increase in skin pigmentation

▪ diabetes mellitus▪ congestive heart failure▪ liver cirrhosis with an

increased risk of liver cancer.

~95% of HFE related Haemochromatosis cases are caused by homozygosity for the C282Y mutation.

Penetrance of this mutation is predicted to between 2% and 50%.

Therefore many people who are homozygous for the C282Y mutation will never develop symptoms.

The compound heterozygote (C282Y/H63D) genotype has an even lower penetrance with approximately 0.5%-2% of patients developing clinical symptoms.

Homozygosity of the H63D mutation can lead to mild iron overload but has an even lower penetrance than compound heterozygotes and very rarely leads to clinical symptoms.

Causative mutations: c.845G>A p.Cys282Tyr (C282Y) & c.187C>G p.His63Asp (H63D)

Clinical detection and treatment:

Individuals showing symptoms of Haemochromatosis undertake a biochemical test to determine transferrin-iron saturation and/or serum ferritin levels.

Patients with raised transferrin-iron saturation and/or serum ferritin levels are referred for genetic testing.

Treatment for symptomatic patients with a positive genotype is therapeutic phlebotomy.

Lifestyle factors such as diet should be taken into consideration to prevent iron overload i.e. reduction of red meat consumption.

C282Y 50μl PCR reaction - 2.5hrs -3hrs. Overnight restriction enzyme digest Rsa1 at 37°C. Run PCR products and enzyme digest products in adjacent lanes

on a 2.5% 3:1 agarose gel for 3 hrs and stain with ethidium bromide.

H63D Reflex test for CY result or for patients with a known family

history 50μl PCR reaction - 2.5hrs -3hrs. Overnight restriction enzyme digest Mbo1 at 37°C. Run PCR products and enzyme digest products in adjacent lanes

on a 2.5% 3:1 agarose gel for 3 hrs and stain with ethidium bromide.

Jeffrey et al. (1999) Nature Genet. 22: 325-329.

Laborious and time consuming.

Only possible to process small numbers and batches.

Drew heavily on the resources of the scientist and/or the technician.

PCR and melt curve analysis on the Lightcycler LC480.

Hyb-Probe HFE genotyping – labelled probe and meltcurve analysis (closed system).

Results analysed on Lightcycler software.

Reflex test for heterozygous individuals.

Automated PCR set-up.

Automated DNA extraction.

Homogeneous Multiplex Genotyping of Haemochromatosis Mutations with Fluorescent Hybridisation Probes. Bernard, P.S., et al.,(1998). Am J Pathology, 153: 1055-1061

Overall time taken for testing significantly reduced.

Capacity increased (i.e., after DNA extraction testing for up to 100 samples can be done in one afternoon).

Reflex test can be set up the next day for heterozygous individuals.

Significant reduction in technician/scientist resources required per sample.

Cost per sample reduced.

Luna Probe HFE Genotyping

From this year our laboratory has performed HFE genotyping using the Luna probe assay on the Light Scanner.

The Luna probe approach is a diplex reaction in which both the C282Y and H63D mutation sites are co-amplified and subject to melt curve analysis.

Unlabelled probe approach.

Assay based on the analysis of the melt curve profile from probe hybridized to the target region.

Results analysed using Light Scanner software.

Cost of unlabelled probe approach 50% cheaper than labelled Lightcycler probes.

Assay for C282Y and H63D run concurrently so consumables are reduced.

Technician/practitioner time saved because reflex test is integrated with the original test.

Overall time for testing equal to that of Lightcycler, therefore the above savings justify the change of method.

Year Number of samples

2006 951

2007 1102

2008 1948

2009 4622

2010 4558

2011 (to date)

4412

Total (2006 – Present)

17593

Number of samples referred has increased.

DNA extraction method is now fully automated.

Paperwork retention and filing has been streamlined.

PCR setup has become automated.

Shift in lab work from scientist to technician.

Shift towards analysis and reporting from scientist to technician.

Time limitations introduced for DNA storage (i.e., DNA sample discarded after specified time period).

Automated processes introduced.

Significant increase in capacity.

Reduction in cost of consumables per sample processed.

Reduction in technician/practitioner or scientist time per sample processed.

More responsibility to the technician/practitioner saves time for the more expensive scientist.

Amount of storage required reduced.

We all need to think about saving money.

Even tests that are efficient could possibly be tweaked or changed to save more money.

Small savings add up, especially when the numbers of samples are increased.

Genetic Technologists and Healthcare Practitioners should take a lead in lab based savings.

Greater responsibility in the laboratory is excellent for developing career pathways for Genetic Technologists and Healthcare Practitioners.