Charting the course of medical laboratories in a changing environment

Fibrin clot interference in a human chorionic gonadotrophin assay causing a false Down syndrome screening result

Serum samples are generally used for the measurement of human chorionic gonadotrophin (hCG) to calculate second-trimester maternal screening results. Lower hCG concentrations correlate with a lower calculated risk of Down syndrome (DS). Hence, erroneously low hCG results due to fibrin clot may lead to misinterpretation. We present a 23-year-old woman with a pregnancy of 17+3 weeks. Blood was taken into the Becton-Dickinson (BD) vacutainer SST-II Advance tube (Ref: 367955). The hCG test was performed on Immulite 2000 XPi analyser (Siemens Healthcare Diagnostics Inc, Tarrytown, USA) with original reagents. The results of the same sample were found as 2566 U/L, 18,153 U/L, and 7748 U/L. Three consecutive results after removal of the small fibrin clot and recentrifugation were 18,878, 20,255, and 22,339 U/L. The risk of DS and MoM for the concentration of 2556 U/L hCG was < 1/10,000 and 0.14, respectively. For a hCG concentration of 20,255 U/L, these values were 1/5632 and 1.13, respectively. Laboratory professionals and technicians should be aware that erroneously low hCG results can be measured with the Immulite 2000 XPi due to interference from small fibrin clots. Falsely underestimated hCG values reduce the MoM values and thus the calculated risk of DS.

The role of laboratory hematology between technology and professionalism: the paradigm of basophil counting

Starting from the discussion topics triggered by Hoffmann about the past and current basophil counting, a broader view of the role and future of laboratory hematology, passing through some general considerations concerning the idea of laboratory medicine in the healthcare pathway between technology and professionalism, is here provided.

Something's Lost and Something's Gained: Seeing Reference Laboratory Quality from Both Sides, Now

Growing regulatory burdens, payment model changes, and increased complexity in laboratory medicine have contributed to an increased reliance on reference laboratories. Although reference laboratories often offer rapid, low cost, high quality testing, outsourcing laboratory tests can create quality and patient safety vulnerabilities particularly in the pre-analytic and post-analytic phases of the test cycle. Disconnects in governance, policy, and information technology between the reference laboratory and the referring provider conspire to increase risk. Laboratory leaders seeking to reduce risk and improve quality must ensure clear and collaborative oversight, monitor meaningful quality metrics, and integrate feedback from ordering providers.

Towards a Comprehensive Knowledge Management Improvement Model for Medical Laboratories

Medical laboratories are complex facilities in which managing knowledge could impact patients’ lives. This paper presents a comprehensive and phased framework for knowledge management (KM) developed and applied within the Research and Medical Analysis Laboratory of the Gendarmerie Royale in Morocco. The model is built according to the PDCA wheel, and the four pillars of methodology are: leadership, knowledge core process, performance evaluation, and finally elements for its continuous improvement. This KM framework will help identify the knowledge needs and expectations of the medical laboratory’s relevant interested parties, support medical laboratory professionals with the decision-making process, and therefore enhance the quality of the services they provide.

Driving the route of laboratory medicine: a manifesto for the future

The role of laboratory medicine is essential in healthcare, since in vitro diagnostic testing represents now an unavoidable part of reasoning and clinical decision making. Laboratory tests are an essential part of most care pathways, aimed at optimizing resource utilization and improving patient outcome. The activity of laboratory professionals is interconnected with all medical disciplines, and provides a crucial support for ordering the right test, for the right patient and at the right time, but also helps interpreting and using laboratory data. Although recent advancement in laboratory medicine, catalyzed by technical innovations and development of innovative tests, have promoted a substantial revolution in the organization of clinical laboratories, the future of this profession seems still ambiguous. We have hence developed a "manifesto" of laboratory medicine, meant to promote an innovative prospect of our discipline and encouraging the establishment of a new generation of laboratory professionals and managers.

Clinical laboratory: bigger is not always better

Laboratory services around the world are undergoing substantial consolidation and changes through mechanisms ranging from mergers, acquisitions and outsourcing, primarily based on expectations to improve efficiency, increasing volumes and reducing the cost per test. However, the relationship between volume and costs is not linear and numerous variables influence the end cost per test. In particular, the relationship between volumes and costs does not span the entire platter of clinical laboratories: high costs are associated with low volumes up to a threshold of 1 million test per year. Over this threshold, there is no linear association between volumes and costs, as laboratory organization rather than test volume more significantly affects the final costs. Currently, data on laboratory errors and associated diagnostic errors and risk for patient harm emphasize the need for a paradigmatic shift: from a focus on volumes and efficiency to a patient-centered vision restoring the nature of laboratory services as an integral part of the diagnostic and therapy process. Process and outcome quality indicators are effective tools to measure and improve laboratory services, by stimulating a competition based on intra- and extra-analytical performance specifications, intermediate outcomes and customer satisfaction. Rather than competing with economic value, clinical laboratories should adopt a strategy based on a set of harmonized quality indicators and performance specifications, active laboratory stewardship, and improved patient safety.

The 2013 symposium on pathology data integration and clinical decision support and the current state of field

Background:

Pathologists and informaticians are becoming increasingly interested in electronic clinical decision support for pathology, laboratory medicine and clinical diagnosis. Improved decision support may optimize laboratory test selection, improve test result interpretation and permit the extraction of enhanced diagnostic information from existing laboratory data. Nonetheless, the field of pathology decision support is still developing. To facilitate the exchange of ideas and preliminary studies, we convened a symposium entitled: Pathology data integration and clinical decision support.

Methods:

The symposium was held at the Massachusetts General Hospital, on May 10, 2013. Participants were selected to represent diverse backgrounds and interests and were from nine different institutions in eight different states.

Results:

The day included 16 plenary talks and three panel discussions, together covering four broad areas. Summaries of each presentation are included in this manuscript.

Conclusions:

A number of recurrent themes emerged from the symposium. Among the most pervasive was the dichotomy between diagnostic data and diagnostic information, including the opportunities that laboratories may have to use electronic systems and algorithms to convert the data they generate into more useful information. Differences between human talents and computer abilities were described; well-designed symbioses between humans and computers may ultimately optimize diagnosis. Another key theme related to the unique needs and challenges in providing decision support for genomics and other emerging diagnostic modalities. Finally, many talks relayed how the barriers to bringing decision support toward reality are primarily personnel, political, infrastructural and administrative challenges rather than technological limitations.

Managing national and international priorities: a framework for low-income countries

CONTEXT

Capacity-building programmes in low-income countries (LICs) are subject to a tension between the requirement to best train workers to fulfil national needs and the requirement to meet international expectations of their students, academics and institutions. This paper presents a theoretical framework developed from a case study of an undergraduate degree programme in Malawi and explores how national needs and international expectations can be managed in health profession settings in LICs to ensure successful curriculum development.

METHODS

An inductive qualitative methodology, grounded theory, combined with open-ended interviews with students, graduates, tutors and external stakeholders in the programme, was used to develop a theoretical framework.

RESULTS

A total of 22 interviews were performed; their analysis conceptualised the tension between national needs and international expectations, and resulted in 12 codes, in four categories: competing and advancing agendas; processes of collaboration; developing a programme or professional identity, and perceptions of programme change.

CONCLUSIONS

This study describes a conceptual framework highlighting three particular areas for analysis to aid in understanding how to best manage competing agendas. These areas refer to, respectively, the significance of international expectations, the organisational climate, and the development of a professional identity.

The brain-to-brain loop concept for laboratory testing 40 years after its introduction

Forty years ago, Lundberg introduced the concept of the brain-to-brain loop for laboratory testing. In this concept, in the brain of the physician caring for the patient, the first step involves the selection of laboratory tests and the final step is the transmission of the test result to the ordering physician. There are many intermediary steps, some of which are preanalytic, ie, before performance of the test; some are analytic and relate to the actual performance of the test; and others are postanalytic and involve transmission of test results into the medical record. The introduction of this concept led to a system to identify and classify errors associated with laboratory test performance. Errors have since been considered as preanalytic, analytic, and postanalytic. During the past 4 decades, changes in medical practice have significantly altered the brain-to-brain loop for laboratory testing. This review describes the changes and their implications for analysis of errors associated with laboratory testing.

Challenges of Laboratory Medicine: European Answers

Medical laboratories play a vital role in modern healthcare, and qualified specialists in Clinical Chemistry and Laboratory Medicine are essential for the provision of high-quality preanalytical, analytical and consultative services. Laboratory medicine has undergone major transformations during the last decade. Ongoing technological developments have considerably improved the productivity of clinical laboratories. Information on laboratory services is globally available, and clinical laboratories worldwide face international competition and there is a huge pressure to reduce costs. To be prepared for the future, clinical laboratories should enhance efficiency and reduce the cost increases by forming alliances and networks, consolidating, integrating or outsourcing, and more importantly create additional value by providing knowledge services related toin vitrodiagnostics. Therefore, business models that increase efficiency such as horizontal and vertical integration are proposed, based on collaborative networks for the delivery of clinical laboratory services. Laboratories should cooperate, consolidate and form strategic alliances to enhance efficiency and reduce costs. There is a growing conflict between the science and the art of clinical practice and on the role of the biomedical sciences in medical practice. We have a dehumanizing effect on medical care. Disease is defined at the level of sick molecules and cells and curative medicine is being replaced by the preventive care of the disease. Undoubtedly all those questions will raise considerable problems and challenges for the medical educators.

Evaluating laboratory diagnostic tests and translational research

In laboratory medicine, the evaluation of an assay is reasonably straightforward and allows broad applicable standards to be established. In contrast, the evaluation of a test is more complex and inherently less susceptible to standardization. The term "test" refers to the use of an assay in the context of a particular disease, in a particular population, and for a particular purpose. Therefore, the true evaluation is to demonstrate its effectiveness in helping a clinician achieve a correct diagnosis or improve patient clinical outcomes. The debate on the current weak framework used for evaluating laboratory tests has been stimulated by recent technological developments, in particular "omics" tests. Currently, consensus has been achieved concerning the proposal to use a model based on at least four steps to be investigated. These are analytical and clinical validity, clinical usefulness and, finally, any ethical, social and legal implications, including economic implications. As the pace of technological advancements in laboratory medicine accelerates, it is time to discuss the role of laboratory testing, and the related role of clinical laboratories. In particular, we should consider whether they should evolve as focused factories of numbers and results, or as knowledge services with an emphasis on improving appropriateness in test requesting, and the interpretation and utilization of laboratory information.

Computerized provider order entry systems - Research imperatives and organizational challenges facing pathology services

Information and communication technologies (ICT) are contributing to major changes taking place in pathology and within health services more generally. In this article, we draw on our research experience for over 7 years investigating the implementation and diffusion of computerized provider order entry (CPOE) systems to articulate some of the key informatics challenges confronting pathology laboratories. The implementation of these systems, with their improved information management and decision support structures, provides the potential for enhancing the role that pathology services play in patient care pathways. Beyond eliminating legibility problems, CPOE systems can also contribute to the efficiency and safety of healthcare, reducing the duplication of test orders and diminishing the risk of misidentification of patient samples and orders. However, despite the enthusiasm for CPOE systems, their diffusion across healthcare settings remains variable and is often beset by implementation problems. Information systems like CPOE may have the ability to integrate work, departments and organizations, but unfortunately, health professionals, departments and organizations do not always want to be integrated in ways that information systems allow. A persistent theme that emerges from the research evidence is that one size does not fit all, and system success or otherwise is reliant on the conditions and circumstances in which they are located. These conditions and circumstances are part of what is negotiated in the complex, messy and challenging area of ICT implementation. The solution is not likely to be simple and easy, but current evidence suggests that a combination of concerted efforts, better research designs, more sophisticated theories and hypotheses as well as more skilled, multidisciplinary research teams, tackling this area of study will bring substantial benefits, improving the effectiveness of pathology services, and, as a direct corollary, the quality of patient care.

Laboratory medicine: challenges and opportunities

Technologic innovations have substantially improved the productivity of clinical laboratories, but the services provided by clinical laboratories are increasingly becoming commoditized. We reflect on how current developments may affect the future of laboratory medicine and how to deal with these changes. We argue that to be prepared for the future, clinical laboratories should enhance efficiency and reduce costs by forming alliances and networks; consolidating, integrating, or outsourcing; and more importantly, create additional value by providing knowledge services related to in vitro diagnostics.

Non-invasive assessment of chronic liver and gastric diseases

BACKGROUND

In patients with both chronic liver diseases and dyspepsia there is the need for non-invasive, inexpensive and effective laboratory tests. These tests should not substitute but complement and integrate the information derived from invasive techniques such as liver biopsy and esofagogastroduodenoscopy. Natural history studies indicate that advanced fibrosis and cirrhosis develop in about 20%-40% of patients with chronic hepatitis B or C, and in a similar proportion of those with alcoholic or non-alcoholic steatohepatitis. In these patients, precise definition of the hepatic fibrosis stage is the most important parameter to assess the risk of disease progression and to decide for an immediate and appropriate antiviral therapy.

METHODS

Liver biopsy represents the gold standard for evaluating the presence, type and stage of liver fibrosis but a body of evidence has been accumulated to demonstrate the limitations of this technique, including inter- and intra-observer variations, sampling errors and variability. In recent years there has been an increasing interest in the possibility of identifying and describing liver fibrosis by using non-invasive, surrogate markers measurable in blood. Many studies have been dedicated to the evaluation of "direct" markers of fibrogenesis, while a second approach is based on the evaluation of single or combined biochemical parameters that reflect the stage of liver disease. Upper gastrointestinal symptoms are common in developed countries and this makes impossible the use of esofagogastroduodenoscopy in all patients with dyspepsia. The Maastricht 2-2000 Consensus meeting has suggested screening and treating Helicobacter pylori infection in dyspeptic patients in primary health care as the first line of therapy for newly onset dyspepsia.

CONCLUSIONS

Combination panels of biomarkers have been demonstrated to improve the accuracy of the single tests and with the use of algorithms based on sequential combination of non-invasive biomarkers a high diagnostic accuracy has been achieved for liver fibrosis. This, in turn, translates in a reduction by >50% in the need of taking liver biopsies. A biochemical panel which includes the measurement of serum pepsinogen I and II, gastrin G-17 and anti-H. pylori antibodies for patients with gastric disease, due to its high negative predictive value, appears to be a valuable approach to screen patients <55 years and with no alarm features, assuring safety and cost-effectiveness.

Recommendations for detection and management of unsuitable samples in clinical laboratories

A large body of evidence attests that quality programs developed around the analytical phase of the total testing process would only produce limited improvements, since the large majority of errors encountered in clinical laboratories still prevails within extra-analytical areas of testing, especially in manually intensive preanalytical processes. Most preanalytical errors result from system flaws and insufficient audit of the operators involved in specimen collection and handling responsibilities, leading to an unacceptable number of unsuitable specimens due to misidentification, in vitro hemolysis, clotting, inappropriate volume, wrong container or contamination from infusive routes. Detection and management of unsuitable samples are necessary to overcome this variability. The present document, issued by the Italian Inter-society SIBioC-SIMeL-CISMEL (Society of Clinical Biochemistry and Clinical Molecular Biology-Italian Society of Laboratory Medicine-Italian Committee for Standardization of Hematological and Laboratory Methods) Study Group on Extra-analytical Variability, reviews the major causes of unsuitable specimens in clinical laboratories, providing consensus recommendations for detection and management.

Clin Chem Lab Med 2007;45:728–36.

Errors in laboratory medicine and patient safety: the road ahead

The Institute of Medicine (IOM) report,

Clin Chem Lab Med 2007;45:700–7.

Venous stasis and routine hematologic testing

Prolonged venous stasis, as generated by a long tourniquet placement, produces spurious variations in several measurable analytes. To verify to what extent venous stasis influences routine hematologic testing, we assessed routine hematologic parameters, including hemoglobin, hematocrit, red blood cell count (RBC), main cell hemoglobin (MHC), main cell volume (MCV), platelet count (PLT), main platelet volume (MPV), white blood cell count (WBC) and WBC differential on the Advia 120 automated hematology analyzer in 30 healthy volunteers, either without venous stasis (no stasis) or after application of a 60 mmHg standardized external pressure by a sphygmomanometer, for 1 (1-min stasis) and 3 min (3-min stasis). Although the overall correlation between measures was globally acceptable, the mean values for paired samples were significantly different in all parameters tested, except MCV, MHC, PLT, MPV, eosinophils, basophils and large unstained cells after 1-min stasis and all parameters except MCV, MHC, MPV and basophils after 3-min venous stasis. As expected RBC, hemoglobin and hematocrit displayed a significant trend towards increase, whereas WBC and the WBC subpopulations were decreased. Difference between measurements by Bland and Altman plots exceeded the current analytical quality specifications for desirable bias for WBC, RBC, hemoglobin, hematocrit, lymphocytes and monocytes in samples collected after either 1- and 3-min stasis. These results provide clear evidence that venous stasis during venipuncture might produce spurious and clinically meaningful biases in the measurement of several hematologic parameters, prompting further considerations on the usefulness of adopting appropriate preventive measures for minimizing such influences.

Proteomics: the next revolution in laboratory medicine?

BACKGROUND

The identification of specific genetic alterations and protein profiles associated with disease offers a unique opportunity to develop proteomics-based assays for early diagnosis. By identifying proteins in serum/plasma, a minimally invasive tool is used to assess the presence of disease and to monitor response to treatment and/or disease progression. The potential clinical applications of this tool are broad-based, including the diagnosis not only of cancer but also cardiovascular and neuromuscular diseases, organ transplantation associated conditions, and infertility.

METHODS

A number of competing chromatographic techniques have been proposed for overcoming the complexity and labor-intensive manipulations associated with the traditional technique for proteomic analysis, which is based on two-dimensional gel electrophoretic techniques. However, mass spectrometry has now assumed a central role in most proteomic workflows, and several combinations of ionization sources, analyzers and fragmentations devices have been described and developed.

RESULTS

Thanks to proteomic applications in the diagnosis of cancer, several research groups have identified proteomic patterns associated with ovarian, prostatic, colorectal and other cancers. While the sensitivity and specificity of these patterns are highly satisfactory, there are still some open questions concerning the standardization, reproducibility, and inter-laboratory agreement of these data.

CONCLUSIONS

Proteomics, and, in particular, serum mass spectroscopic proteomic pattern diagnostics, is a rapid expanding field of research. The plasma proteoma has an important position at the intersection between genes and diseases, and clinical laboratories must adapt to a new era of tests based on proteomics and genomics. In the future, mass spectrometry will become an essential tool in the clinical laboratory.

Evidence-based laboratory medicine as a tool for continuous professional improvement

BACKGROUND

Evidence-based medicine (EBM), defined as "the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of patients," seems a tool (a "new paradigm") able to meet individual clinical experience with robust observations. EBM has been driven by the need to manage information overload by cost control and by public request for the best in diagnostics and treatment.

METHODS

The application of EBM in laboratory medicine or evidence-based laboratory medicine (EBLM) is aimed to advance clinical diagnosis by researching and disseminating new knowledge, combining methods from clinical epidemiology, statistics, and social science with the traditional pathophysiological molecular approach.

RESULTS

EBLM, by evaluating the role of diagnostic investigations in the clinical decision-making process with emphasis on measurable outcome, can help both in improving the quality of new scientific findings and in translating the results of good-quality research into everyday practice.

CONCLUSIONS

Since there is a need to integrate many educational tools to focus the strategy on promoting the implementation of best practices, the STARD proposal for robust diagnostic test primary studies, the presence of systematic reviews of high quality, and the development of valid guidelines based on the best scientific evidence may be useful to promote an a evidence-based culture for appropriateness, efficiency, and effectiveness in laboratory medicine.