Application of the principles of evidence-based medicine to laboratory medicine

Effectiveness of Practices to Support Appropriate Laboratory Test Utilization: A Laboratory Medicine Best Practices Systematic Review and Meta-Analysis

Objectives

To evaluate the effectiveness of practices used to support appropriate clinical laboratory test utilization.

Methods

This review followed the Centers for Disease Control and Prevention (CDC) Laboratory Medicine Best Practices A6 cycle method. Eligible studies assessed one of the following practices for effect on outcomes relating to over- or underutilization: computerized provider order entry (CPOE), clinical decision support systems/tools (CDSS/CDST), education, feedback, test review, reflex testing, laboratory test utilization (LTU) teams, and any combination of these practices. Eligible outcomes included intermediate, systems outcomes (eg, number of tests ordered/performed and cost of tests), as well as patient-related outcomes (eg, length of hospital stay, readmission rates, morbidity, and mortality).

Results

Eighty-three studies met inclusion criteria. Fifty-one of these studies could be meta-analyzed. Strength of evidence ratings for each practice ranged from high to insufficient.

Conclusion

Practice recommendations are made for CPOE (specifically, modifications to existing CPOE), reflex testing, and combined practices. No recommendation for or against could be made for CDSS/CDST, education, feedback, test review, and LTU. Findings from this review serve to inform guidance for future studies.

Appropriateness of diagnostics tests

The evolution of the concept of 'appropriateness', in the three past decades, from 'no harm' and 'no waste' to 'medical decision-making' and 'determining outcomes' highlights two main points: its foundation is evidence-based medicine, and it is a quality of every phase of the total testing process, not only for the selection of tests. Nevertheless, appropriateness in Laboratory Hematology, as well as in Laboratory Medicine, is an elusive concept: 'Appropriateness' interplays with 'patient's safety', 'healthcare costs', 'clinical decision-making', and 'effectiveness', and the criteria for appropriateness, mainly adherence to clinical guidelines, are often not evidence-based and not always consensus-based. Moreover, practising appropriateness is a complex issue because of the ambiguity of the criteria and targets, the never-ending work of implementing guidelines and their audit, and the uniqueness of the clinical situation of the individual patient. Authors agree on some practical rules: establishing a multidisciplinary and multiprofessional team, choosing carefully clinical targets, finding or building evidences, sharing guidelines with clinicians, choosing adequate tools for changing, working hard on implementation, identifying the 'right' laboratory methods and processes, checking progress indefinitely, providing information, interpretations, and consultations, and promoting feedback and audits. The success depends on the 'right' combination of educational, operative, and reinforcing interventions. Competences in organization, in implementation science, and in interpersonal relationship management are essential as well as knowledge and experience in Hematology, not only in Laboratory Hematology.

The pathology informatics curriculum wiki: Harnessing the power of user-generated content

BACKGROUND

The need for informatics training as part of pathology training has never been so critical, but pathology informatics is a wide and complex field and very few programs currently have the resources to provide comprehensive educational pathology informatics experiences to their residents. In this article, we present the "pathology informatics curriculum wiki", an open, on-line wiki that indexes the pathology informatics content in a larger public wiki, Wikipedia, (and other online content) and organizes it into educational modules based on the 2003 standard curriculum approved by the Association for Pathology Informatics (API).

METHODS AND RESULTS

In addition to implementing the curriculum wiki at http://pathinformatics.wikispaces.com, we have evaluated pathology informatics content in Wikipedia. Of the 199 non-duplicate terms in the API curriculum, 90% have at least one associated Wikipedia article. Furthermore, evaluation of articles on a five-point Likert scale showed high scores for comprehensiveness (4.05), quality (4.08), currency (4.18), and utility for the beginner (3.85) and advanced (3.93) learners. These results are compelling and support the thesis that Wikipedia articles can be used as the foundation for a basic curriculum in pathology informatics.

CONCLUSIONS

The pathology informatics community now has the infrastructure needed to collaboratively and openly create, maintain and distribute the pathology informatics content worldwide (Wikipedia) and also the environment (the curriculum wiki) to draw upon its own resources to index and organize this content as a sustainable basic pathology informatics educational resource. The remaining challenges are numerous, but largest by far will be to convince the pathologists to take the time and effort required to build pathology informatics content in Wikipedia and to index and organize this content for education in the curriculum wiki.

Symptomatic comparison in efficacy on patients with benign prostatic hyperplasia treated with two therapeutic approaches

Objectives

A randomised controlled trial was performed to compare the symptomatic effects on patients with benign prostatic hyperplasia (BPH) treated by two therapeutic approaches – the Western medicine (WM) and traditional Chinese medicine (TCM).

Methods

Four primary outcome measures, namely the quality of life (QOL), maximum urine flow ratio (UFR), International Prostate Symptom Score (IPSS) and prostate volumes, as well as four urethra-related and 35 non-urethra-related symptoms, were investigated to evaluate the effects on 31 BPH patients subjected to WM (Terazosin Hydrochloride Hytrin, THH) and 30 cases to TCM (herbal Saxifrage tablet, HST). The effects of both treatments are compared by the two-sample Kolmogorov–Smirnov test. The contributions of symptoms for four assessments are analysed by the logistic regression model and the Chow test.

Results

The effect of TCM is weaker than that of WM in the assessment of the IPSS score (p < 0.05), and both treatments are similar in the prostate volumes, the maximum UFR and the QOL assessments (p > 0.05), as well as in the effective number of urethra-related or non-urethra-related symptoms before and after treatment (p > 0.05). By comparing the linear regression models, different urethra-related and non-urethra-related symptom patterns associated with TCM and WM therapies are detected for four assessments, especially for the prostate volume assessment (p < 0.01).

Conclusion

TCM (HST) is a potentially effective treatment in improving the QOL, prostate volumes and maximum UFR for patients with BPH, though it is less effective in ameliorating the IPSS score when compared with WM (THH). The non-urethra-related symptoms experienced by BPH patients might be one of the parameters to further achieve the tailored diagnosis and treatment for BPH.

The laboratory approach to the diagnosis of autoimmune diseases: is it time to change?

Array technology and proteomics are about to launch the era of multiplexed analysis, which allows simultaneous detection of numerous autoantibody specificities and the possibility of defining broad autoantibody profiles. This will probably improve disease staging, risk stratification, prognosis and treatment. However, although these technologies are very promising, they are still in their infancy, and therefore need to undergo strict analytical and clinical validation processes. The latter should involve clinicians and pathologists in prospective, multicentric studies conducted on large numbers of patients to define the specific significance of the various autoantibody profiles. Establishing common standards for the publication and sharing of microarray-generated data will be important for this purpose. Only when these studies have been completed will these new technologies find a place in clinical laboratories. Although we are entering a decade which will probably see a radical change in the diagnostic approach to autoimmune diseases, we do not yet have sufficient knowledge to apply proteomic technologies on a large scale. For the time being, therefore, it is advisable to continue using well-established approaches and diagnostic algorithms such as those reported in the international guidelines, which have been prepared in accordance with the principles of appropriateness and evidence-based medicine.

A simple, focused, computerized query to detect overutilization of laboratory tests

CONTEXT

Although there is nearly universal agreement that laboratory tests are overutilized, the degree of overutilization in a given institution is difficult to quantify and monitor across time.

OBJECTIVE

To detect and clearly document repetitive daily ordering of a commonly ordered laboratory test (serum sodium) by employing a simple, focused, computerized query of a test result database followed by chart review and validation.

DESIGN

A retrospective computerized query of our clinical data repository was performed to find inpatients who displayed normal serum sodium test results on 4 or more consecutive days, without any abnormal values during the same admission. The search was limited to a 1-month period. A subset of these patients was selected for chart review.

RESULTS

One hundred sixteen patients met our criteria, and the tests ordered for those patients comprised 5.1% of the monthly volume of serum sodium tests ordered in our institution. Chart review revealed a consistent lack of documentation of medical necessity for repeat testing as well as persistence of repeat serum sodium orders until the end of the patients' hospital course.

CONCLUSIONS

We conclude that a focused query of data derived from a clinical data repository can detect and document overutilization of a common laboratory test in a convincing fashion within a given institution.