Change of pathology request forms can reduce unwanted requests and tests

Disruption vs. evolution in laboratory medicine. Current challenges and possible strategies, making laboratories and the laboratory specialist profession fit for the future

Since beginning of medical diagnostics, laboratory specialists have done an amazing job, continuously improving quality, spectrum and speed of laboratory tests, currently contributing to the majority of medical decision making. These improvements are mostly of an incremental evolutionary fashion, meaning improvements of current processes. Sometimes these evolutionary innovations are of a radical fashion, such as the invention of automated analyzers replacing manual testing or the implementation of mass spectrometry, leading to one big performance leap instead of several small ones. In few cases innovations may be of disruptive nature. In laboratory medicine this would be applicable to digitalization of medicine or the decoding of the human genetic material. Currently, laboratory medicine is again facing disruptive innovations or technologies, which need to be adapted to as soon as possible. One of the major disruptive technologies is the increasing availability and medical use of artificial intelligence. It is necessary to rethink the position of the laboratory specialist within healthcare settings and the added value he or she can provide to patient care. The future of the laboratory specialist profession is bright, as it the only medical profession comprising such vast experience in patient diagnostics. However, laboratory specialists need to develop strategies to provide this expertise, by adopting to the quickly evolving technologies and demands. This opinion paper summarizes some of the disruptive technologies as well as strategies to secure and/or improve the quality of diagnostic patient care and the laboratory specialist profession.

Does admission order form design really matter? A reduction in urea blood test ordering

Introduction

Laboratory blood testing is one of the most high-volume medical procedures and continues to increase steadily with instances of inappropriate testing resulting in significant financial implications. Studies have suggested that the design of a standard hospital admission order form and laboratory request forms influence physician test ordering behaviour, reducing inappropriate ordering and promoting resource stewardship.

Aim/method

To redesign the standard medicine admission order form-laboratory request section to reduce inappropriate blood urea nitrogen (BUN) testing.

Results

A redesign of the standard admission order form used by general internal medicine physicians and residents in two large teaching hospitals in one health zone in Alberta, Canada led to a significant step reduction in the ordering of the BUN test on hospital admission.

Conclusions

Redesigning the standard medicine admission order form-laboratory request section can have a beneficial effect on the reduction in BUN ordering altering physician ordering patterns and behaviour.

Reducing day 3 baseline monitoring bloodwork and ultrasound for patients undergoing timed intercourse and intrauterine insemination treatment cycles

BACKGROUND

In the current context of a global pandemic it is imperative for fertility clinics to consider the necessity of individual tests and eliminate those that have limited utility and may impose unnecessary risk of exposure. The purpose of this study was to implement and evaluate a multi-modal quality improvement (QI) strategy to promote resource stewardship by reducing routine day 3 (d3) bloodwork and transvaginal ultrasound (TVUS) for patients undergoing intrauterine insemination (IUI) and timed intercourse (IC) treatment cycles.

METHODS

After literature review, clinic stakeholders at an academic fertility centre met to discuss d3 testing utility and factors contributing to d3 bloodwork/TVUS in IC/IUI treatment cycles. Consensus was reached that it was unnecessary in patients taking oral/no medications. The primary intervention changed the default setting on the electronic order set to exclude d3 testing for IC/IUI cycles with oral/no medications. Exceptions required active test selection. Protocols were updated and education sessions were held. The main outcome measure was the proportion of cycles receiving d3 bloodwork/TVUS during the 8-week post-intervention period compared with the 8-week pre-intervention period. Balancing measures included provider satisfaction, pregnancy rates, and incidence of cycle cancellation.

RESULTS

A significant reduction in the proportion of cycles receiving d3 TVUS (57.2% vs 20.8%, p < 0.001) and ≥ 1 blood test (58.6% vs 22.8%, p < 0.001) was observed post-intervention. There was no significant difference in cycle cancellation or pregnancy rates pre- and post-intervention (p = 0.86). Treatment with medications, cyst history, prescribing physician, and treatment centre were associated with receiving d3 bloodwork/TVUS. 74% of providers were satisfied with the intervention.

CONCLUSION

A significant reduction in IC/IUI treatment cycles that received d3 bloodwork/TVUS was achieved without measured negative treatment impacts. During a pandemic, eliminating routine d3 bloodwork/TVUS represents a safe way to reduce monitoring appointments and exposure.

The impact of interventions applied in primary care to optimize the use of laboratory tests: a systematic review

Laboratory tests are important tools in primary care, but their use is sometimes inappropriate. The aim of this review is to give an overview of interventions applied in primary care to optimize the use of laboratory tests. A search for studies was made in the MEDLINE and EMBASE databases. We also extracted studies from two previous reviews published in 2015. Studies were included if they described application of an intervention aiming to optimize the use of laboratory tests. We also evaluated the overall risk of bias of the studies. We included 24 studies. The interventions were categorized as: education, feedback reports and computerized physician order entry (CPOE) strategies. Most of the studies were classified as medium or high risk of bias while only three studies were evaluated as low risk of bias. The majority of the studies aimed at reducing the number of tests, while four studies investigated interventions aiming to increase the use of specific tests. Despite the studies being heterogeneous, we made results comparable by transforming the results into weighted relative changes in number of tests when necessary. Education changed the number of tests consistently, and these results were supported by the low risk of bias of the papers. Feedback reports have mainly been applied in combination with education, while when used alone the effect was minimal. The use of CPOE strategies seem to produce a marked change in the number of test requests, however the studies were of medium or high risk of bias.

Reducing vitamin D requests in a primary care cohort: a quality improvement study

Background

Since 2000, vitamin D requests have increased 2–6 fold with no evidence of a corresponding improvement in the health of the population. The ease of vitamin D requesting may contribue to the rapid rise in its demand and, hence, pragmatic interventions to reduce vitamin D test ordering are warranted.

Aim

To study the effect on vitamin D requests following a redesign of the electronic forms used in primary care. In addition, any potential harms were studied and the potential cost-savings associated with the intervention were evaluated.

Design & setting

An interventional study took place within primary care across Leicestershire, England.

Method

The intervention was a redesign of the electronic laboratory request form for primary care practitioners across the county. Data were collected on vitamin D requests for a 6-month period prior to the change (October 2016 to March 2017) and the corresponding 6-month period post-intervention (October 2017 to March 2018), data were also collected on vitamin D, calcium, and phosphate levels.

Results

The number of requests for vitamin D decreased by 14 918 (36.2%) following the intervention. Changes in the median calcium and phosphate were not clinically significant. Cost-modelling suggested that if such an intervention was implemented across primary care in the UK, there would be a potential annual saving to the NHS of £38 712 606.

Conclusion

A simple pragmatic redesign of the electronic request form for vitamin D test led to a significant reduction in vitamin D requests without any adverse effect on the quality of care.

Barriers and facilitators to reduce low-value care: a qualitative evidence synthesis

OBJECTIVE

To assess barriers and facilitators to de-implementation.

DESIGN

A qualitative evidence synthesis with a framework analysis.

DATA SOURCES

Medline, Embase, Cochrane Library and Rx for Change databases until September 2018 were searched.

ELIGIBILITY CRITERIA

We included studies that primarily focused on identifying factors influencing de-implementation or the continuation of low-value care, and studies describing influencing factors related to the effect of a de-implementation strategy.

DATA EXTRACTION AND SYNTHESIS

The factors were classified on five levels: individual provider, individual patient, social context, organisational context, economic/political context.

RESULTS

We identified 333 factors in 81 articles. Factors related to the individual provider (n=131; 74% barriers, 17% facilitators, 9% both barrier/facilitator) were associated with their attitude (n=72; 55%), knowledge/skills (n=43; 33%), behaviour (n=11; 8%) and provider characteristics (n=5; 4%). Individual patient factors (n=58; 72% barriers, 9% facilitators, 19% both barrier/facilitator) were mainly related to knowledge (n=33; 56%) and attitude (n=13; 22%). Factors related to the social context (n=46; 41% barriers, 48% facilitators, 11% both barrier/facilitator) included mainly professional teams (n=23; 50%) and professional development (n=12; 26%). Frequent factors in the organisational context (n=67; 67% barriers, 25% facilitators, 8% both barrier/facilitator) were available resources (n=28; 41%) and organisational structures and work routines (n=24; 36%). Under the category of economic and political context (n=31; 71% barriers, 13% facilitators, 16% both barrier/facilitator), financial incentives were most common (n=27; 87%).

CONCLUSIONS

This study provides in-depth insight into the factors within the different (sub)categories that are important in reducing low-value care. This can be used to identify barriers and facilitators in low-value care practices or to stimulate development of strategies that need further refinement. We conclude that multifaceted de-implementation strategies are often necessary for effective reduction of low-value care. Situation-specific knowledge of impeding or facilitating factors across all levels is important for designing tailored de-implementation strategies.

Prospective audit of blood transfusion request forms and continuing medical education to optimise compliance of clinicians in a hospital setting

OBJECTIVES

The aim of this study was to analyse blood requisition forms sent by clinicians in a tertiary care hospital to the transfusion service to ascertain their completeness and correctness. A secondary objective was to study the effect of continuing medical education (CME) in a hospital setting on clinician's behaviour regarding the importance of details that ought to be mentioned on blood requisition forms.

BACKGROUND

Transfusion audits are useful tools in the evaluation and education of those requesting blood components.

METHODS/MATERIALS

This was a prospective, observational study conducted in the department of Transfusion Medicine at a tertiary-level healthcare centre from June 2019 to December 2019. The study was divided into two phases: pre-CME (P1) and post-CME (P2). In both phases, an audit for assessing completeness and correctness of blood requisition forms, which were divided into four sections, was performed. A scoring system was devised to compare both phases.

RESULTS

In the P1 phase, 45.77% of the blood requisition form entries were complete and correct; 23.45% of incomplete entries were generated by emergency and trauma. In the P2 phase, 76.75% of the blood requisition form entries were complete and correct; 35.09% of the incomplete entries were generated by obstetrics and gynaecology. Complete and correct entries increased from 45.7% (P1) to 76.75% (P2). Scores of P1 were found to be lower than scores of P2 for all four sections. Cumulative mean score for P1 (20687) was found to be significantly lower than the mean score for P2 (30870).

CONCLUSION

Audit and CME regarding different aspects of transfusion medicine practices play a major role in the improvement of transfusion practices in hospitals.

The impact of physician education regarding the importance of providing complete clinical information on the request forms of thrombophilia-screen tests at Tygerberg hospital in South Africa

BACKGROUND

Thrombophilia-screen tests are specialised haemostasis tests that are affected by numerous unique patient variables including the presence of acute thrombosis, the concomitant use of medication and patient demographics. Complete information on the request form is therefore crucial for the haematological pathologist to make patient-specific interpretation of patients' results.

OBJECTIVES

To assess the completeness of thrombophilia-screen test request forms and determine the impact of provision of incomplete information, on the interpretive comments generated by reporting haematological pathologists. To assess the impact of an educational session given to clinicians on the importance of providing all the relevant information on the request forms.

METHOD

Two retrospective audits, each covering 3 months, were performed to evaluate the completeness of demographic and clinical information on thrombophilia-screen request forms and its impact on the quality of the interpretive comments before and after an educational intervention.

RESULTS

One hundred and seventy-one request forms were included in the first audit and 146 in the second audit. The first audit revealed that all 171 thrombophilia-screen request forms had complete patient demographic information but none had clinical information. Haematological pathologists only made generic comments which could not be applied to a specific patient. The second audit, conducted after a physician educational session, did not reveal any improvement in the clinical information provision by the test-ordering physicians. This was reportedly due to the lack of space on the request form. The interpretive comments therefore remained generic and not patient-specific.

CONCLUSION

Physicians' failure to provide relevant clinical information made it impossible for pathologists to make patient-specific interpretation of the results. A single physician education session did not change the practice, reportedly due to the inappropriate design of the test request form. Further studies are required to investigate the impact of an improved request form and the planned electronic test requesting.

Inappropriate use of laboratory tests: How availability triggers demand - Examples across Europe

INTRODUCTION

The appropriate use of laboratory diagnostics is increasingly at stake. The aim of this study was to depict some paradigmatic examples of under- and overutilization, as well as possible solutions across Europe.

METHODS

We collected six examples from five European countries where a rise or decline of orders for specific laboratory parameters was observed after organizational changes but without evidence of changes in patient collective characteristics as source of this variation.

RESULTS

The collected examples were the following: 1-Germany) Switch from a Brain-Natriuretic-Peptide assay to NT-pro Brain-Natriuretic-Peptide assay, resulting in a 374% increase in these analytics; 2-Spain) Implementation of a gatekeeping strategy in tumor marker diagnostics, resulting in a 15-61% reduction of these diagnostics; 3-Croatia) Stepwise elimination of creatine-kinase-MB assay from the laboratory portfolio; 4-UK) Removal of γ-glutamyl transferase from a "liver function" profile, resulting in 82% reduction of orders; 5-Austria) Implementation of a new device for rapid Influenza-RNA detection, resulting in a 450% increase of Influenza testing; 6-Spain) Insourcing of 1,25-(OH)₂-Vitamin D measurements, leading to a 378% increase of these analyses.

CONCLUSION

The six paradigmatic examples described in this manuscript show that availability of laboratory resources may considerably catalyze the demand, thus underscoring that inappropriate use of laboratory resources may be commonplace in routine laboratories all across Europe and most probably beyond. They also demonstrate that the application of simple strategies may assist in overcoming this issue. We believe that laboratory specialists need to refocus on the extra-analytical parts of the testing process and engage more in interdisciplinary patient-care.

Ordering Patterns and Costs of Specialized Laboratory Testing by Hospitalists and House Staff in Hospitalized Patients With HIV at a County Hospital: An Opportunity for Diagnostic Stewardship

Background

Inpatient HIV care often requires specialized laboratory testing with which practitioners may not be familiar. In addition, computerized physician order entry allows for ordering tests without understanding test indications, but it can also provide a venue for education and diagnostic stewardship.

Methods

All charts of HIV-positive patients hospitalized at a tertiary care public safety net hospital in Houston, Texas, between January 1, 2014, and June 30, 2014, were reviewed for a set list of laboratory tests. Appropriateness of test ordering was assessed by 2 providers. Cost estimates for each test were obtained from Medicaid and a national nonprofit health care charge database.

Results

A total of 274 HIV-positive patients were admitted 429 times in the 6-month study period. During the study period, 45% of the study laboratory tests ordered were not indicated. A total of 532 hepatitis serologies were ordered, only 52% of which were indicated. Overall, 71 serum qualitative cytomegalovirus (CMV) polymerase chain reactions (PCRs) and eight CMV quantitative PCRs were ordered, with most (85%) qualitative PCRs ordered for nonspecific signs of infection (eg, fever). Other tests ordered without clear indications included Aspergillus IgE (7), serum Epstein-Barr virus (EBV) PCR (5), parvovirus serology (7), and Toxoplasma IgM (18). Overall, the estimated laboratory cost of inappropriate testing over the study period was between $14 000 and $92 000, depending on which cost database was used.

Conclusions

Many tests ordered in HIV-positive inpatients do not have indications, representing a substantial source of health care waste and cost and potentially leading to inappropriate treatment. Opportunities exist to decrease waste through education of trainees and hospitalists and through implementation of diagnostic stewardship via the electronic medical record.

Are laboratory tests always needed? Frequency and causes of laboratory overuse in a hospital setting

BACKGROUND

Inappropriate utilization of laboratory resources is an increasing concern especially in high-throughput facilities. Until now, no reliable information has been published addressing to which extent laboratory results are actually used for clinical decision-making. Therefore, we aimed to close this gap using a novel retrospective approach including a survey of clinicians and nurses.

METHODS

We retrospectively evaluated the number of re-orders for potassium (K), lactate dehydrogenase (LD), aspartate-aminotransferase (AST), activated partial thromboplastin-time (APTT) and prothrombin-time/INR (PT/INR), after the initial order had to be cancelled due to preanalytical non-conformities. We analyzed subgroups regarding time to re-order, ward and sample priority (urgent vs. routine). Subsequently, we surveyed clinicians and nurses, asking for their estimate of the amount of failed re-orders as well as for possible reasons.

RESULTS

From initially cancelled tests, only ~20% of K, LD, AST and ~30% of APTT and PT/INR tests were re-ordered within 24 h. 70% of the investigated clinical chemistry and 60% of coagulation tests were re-ordered one week after cancellation or not at all. Survey participants quite accurately estimated these numbers. Routine laboratory panels, short stay of out-patients, obsolete test results and avoiding additional phlebotomies were the main reasons for not re-ordering cancelled tests.

CONCLUSIONS

Overall, 60-70% of test results in the investigated assays ordered in a high throughput laboratory are potentially inappropriate or of doubtful clinically importance. Although clinicians and nurses are aware of this situation, it is the duty of laboratory specialists to overcome overutilization in close collaboration with all involved healthcare workers.

The effect of a test ordering software intervention on the prescription of unnecessary laboratory tests - a randomized controlled trial

Background

The way software for electronic health records and laboratory tests ordering systems are designed may influence physicians’ prescription. A randomised controlled trial was performed to measure the impact of a diagnostic and laboratory tests ordering system software modification.

Methods

Participants were family physicians working and prescribing diagnostic and laboratory tests.

The intervention group had a modified software with a basic shortcut menu changes, where some tests were withdrawn or added, and with the implementation of an evidence-based decision support based on United States Preventive Services Task Force (USPSTF) recommendations. This intervention group was compared with usual software (control group).

The outcomes were the number of tests prescribed from those: withdrawn from the basic menu; added to the basic menu; marked with green dots (USPSTF’s grade A and B); and marked with red dots (USPSTF’s grade D).

Results

Comparing the monthly average number of tests prescribed before and after the software modification, from those tests that were withdrawn from the basic menu, the control group prescribed 33.8 tests per 100 consultations before and 30.8 after (p = 0075); the intervention group prescribed 31.3 before and 13.9 after (p < 0001). Comparing the tests prescribed between both groups during the intervention, from those tests that were withdrawn from the basic menu, the intervention group prescribed a monthly average of 14.0 vs. 29.3 tests per 100 consultations in the control group (p < 0.001). From those tests that are USPSTF’s grade A and B, intervention group prescribed 66.8 vs. 74.1 tests per 100 consultations in the control group (p = 0.070). From those tests categorised as USPSTF grade D, the intervention group prescribed an average of 9.8 vs. 11.8 tests per 100 consultations in the control group (p = 0.003).

Conclusions

Removing unnecessary tests from a quick shortcut menu of the diagnosis and laboratory tests ordering system had a significant impact and reduced unnecessary prescription of tests.

The fact that it was not possible to perform the randomization at the family physicians’ level, but only of the computer servers is a limitation of our study. Future research should assess the impact of different tests ordering systems during longer periods.

Trial registration

ISRCTN45427977, May 1^st 2014 (retrospectively registered).

Reduction of Laboratory Utilization in the Intensive Care Unit

Objective:

In our academic intensive care unit (ICU), there is excess ordering of routine laboratory tests. This is partially due to a lack of transparency of laboratory-processing costs and to the admission order plans that favor daily laboratory test orders. We hypothesized that a program that involves physician and staff education and alters the current ICU order sets will lead to a sustained decrease in routine laboratory test ordering.

Design:

Prospective cohort study.

Setting:

Academic closed medical ICU (MICU).

Patients:

All patients admitted to the MICU.

Methods:

We consistently educated residents, faculty, and staff about laboratory test costs. We removed the daily laboratory test option from the admission order sets and asked residents to order needed laboratory test results every day. We only allowed the G3+I-STAT (arterial blood gas only) cartridges in the MICU in hopes of decreasing duplicative laboratory test results. We added laboratory review to the daily rounding checklist.

Measurement and Main Results:

Total number of laboratory tests per patient-day decreased from 39.43 to an average of 26.74 ( P <.001) over a 9-month period. The number of iSTAT laboratory tests per patient-day decreased from 7.37 to an average of 1.16 ( P < .001) over the same time period. The number of iSTAT/central laboratory processing duplicative laboratory tests per patient-day decreased from 0.17 to an average of 0.01 ( P < .001). The percentage of patients who have daily laboratory test orders decreased from 100% to an average of 11.94% ( P <. 001). US$123 436 in direct savings and US$258 035 dollars in indirect savings could be achieved with these trends. Intensive care unit morbidity and mortality were not impacted.

Conclusion:

A simple technique of resident, nursing, and ancillary staff education, combined with alterations in order sets using electronic medical records, can lead to a sustained reduction in laboratory test utilization over time and to significant cost savings without affecting patient safety.

Communication skills in diagnostic pathology

Communication is an essential element of good medical practice also in pathology. In contrast to technical or diagnostic skills, communication skills are not easy to define, teach, or assess. Rules almost do not exist. In this paper, which has a rather personal character and cannot be taken as a set of guidelines, important aspects of communication in pathology are explored. This includes what should be communicated to the pathologist on the pathology request form, communication between pathologists during internal (interpathologist) consultation, communication around frozen section diagnoses, modalities of communication of a final diagnosis, with whom and how critical and unexpected findings should be communicated, (in-)adequate routes of communication for pathology diagnoses, who will (or might) receive pathology reports, and what should be communicated and how in case of an error or a technical problem. An earlier more formal description of what the responsibilities are of a pathologist as communicator and as collaborator in a medical team is added in separate tables. The intention of the paper is to stimulate reflection and discussion rather than to formulate strict rules.

Interventions at the laboratory level to reduce laboratory test ordering by family physicians: Systematic review

OBJECTIVES

To assess the effectiveness of interventions by laboratories and to increase rational and reduce unnecessary family physician test ordering.

DESIGN AND METHODS

MEDLINE [1946-present], EMBASE [1980-present], EBM Reviews [1991-present](Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, - Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Health Technology Assessment, NHS Economic Evaluation Database), PubMed [1966-present], PubMed Central [1900-present], Scopus [1960-present], Web of Science [1900-present] and CINAHL [1982-present] were searched with no language or publication limits. Non-randomised studies were assessed with the Newcastle-Ottawa scale.

RESULTS

The search identified 9282 titles and abstracts, 238 were read in full-text and 3 cohort and 7 before- and after-studies were included. Most focused on changing a few tests and evaluated the interventions over several months. Seven changed laboratory forms (the two largest involved 5.2 million and 3.2 million tests), one negotiated a test ordering protocol with family physicians, and two required laboratory approval. They achieved an average 35% reduction in the 19 targeted tests, with a wide range (0%-100% reduction).

CONCLUSIONS

Ten studies were identified which tested interventions by laboratories to reduce test ordering by family physicians, and achieved an average 35% reduction in the 19 targeted tests. The rationale for choosing specific tests for intervention was often not explained, most studies targeted a few tests for several months, the tests and test volumes differed widely across studies, no author improved the results of previous interventions or asked participants their opinions about the intervention or assessed factors impeding change.

A comparison of different methods of demand management on requesting activity in a teaching hospital intensive care unit

BACKGROUND

Laboratory services in the UK have witnessed an annual increase in requesting activity often with no associated increase in budget. This study evaluated the impact of different demand management strategies on biochemistry test requesting activity from a tertiary Intensive Care Unit (ICU) at a UK teaching hospital.

METHOD

We conducted an observational longitudinal study in which biochemistry requesting activity from the ICU was gathered over five separate six-month periods between 2009 and 2013. During this time, two different strategies aimed at reducing inappropriate biochemistry requesting were in use and the effects of the two strategies were compared.

RESULTS

Implementation of minimum re-testing intervals (MRIs) resulted in an overall 22.7% reduction in total requesting activity in the first year with minor change in clinical workload. In the second year, a 13.3% rise in requesting activity was seen but this was against a background of a 14.6% increase in ICU workload. Removal of the MRIs rules associated with the introduction of an ICU test testing schedule resulted in a 13.4% reduction in total requesting activity in the first year. ICU workload during this year was 1.8% lower than the previous year. In the final year, requesting activity was almost unchanged but ICU workload grew by 6.8%.

CONCLUSION

Implementation of MRIs reduced biochemistry test requesting activity on the ICU. Introduction of an agreed test schedule and removal of the MRIs, however, produced a further reduction in ICU requesting activity. Variation in ICU workload does not account for all the observed changes.

From evidence to best practice in laboratory medicine

Laboratory tests offer value if they provide benefit to patients at acceptable costs. Laboratory testing is one of the most widely used diagnostic interventions supporting medical decisions, yet evidence demonstrating its value and impact on health outcomes is limited. This contributes to wide variations in test utilisation including underdiagnosis, overdiagnosis and misdiagnosis, which may impact the quality and the clinical- and cost-effectiveness of care and patient safety. Therefore implementing evidence into the care of patients is a moral and social imperative to laboratory professionals and all health care staff. This review investigates the reasons research does not get into practice, or only does with a very long delay. Apart from reviewing the common barriers to implementation, it also discusses the drivers of inappropriate test utilisation. By reviewing the theoretical and practical aspects of implementation science, recommendations are made for approaches that are thought to be most effective and that can be adopted to close the gap between evidence and practice, and to facilitate evidence-based laboratory medicine. Passive dissemination of the evidence and educational interventions are insufficient and do not offer sustainable solutions. A multifaceted and individualised implementation strategy, including individually tailored academic detailing, reminder systems, clinical decision support systems, feedback on performance, and participation of doctors and laboratory professionals in quality improvement activities addressing test selection and interpretation and in clinical audits, has greater potential for success. Examples of these initiatives at the laboratory and clinical interface are provided with links to valuable resources.

Managing demand for laboratory tests: a laboratory toolkit

Healthcare budgets worldwide are facing increasing pressure to reduce costs and improve efficiency, while maintaining quality. Laboratory testing has not escaped this pressure, particularly since pathology investigations cost the National Health Service £2.5 billion per year. Indeed, the Carter Review, a UK Department of Health-commissioned review of pathology services in England, estimated that 20% of this could be saved by improving pathology services, despite an average annual increase of 8%-10% in workload. One area of increasing importance is managing the demands for pathology tests and reducing inappropriate requesting. The Carter Review estimated that 25% of pathology tests were unnecessary, representing a huge potential waste. Certainly, the large variability in levels of requesting between general practitioners suggests that inappropriate requesting is widespread. Unlocking the key to this variation and implementing measures to reduce inappropriate requesting would have major implications for patients and healthcare resources alike. This article reviews the approaches to demand management. Specifically, it aims to (a) define demand management and inappropriate requesting, (b) assess the drivers for demand management, (c) examine the various approaches used, illustrating the potential of electronic requesting and (d) provide a wider context. It will cover issues, such as educational approaches, information technology opportunities and challenges, vetting, duplicate request identification and management, the role of key performance indicators, profile composition and assessment of downstream impact of inappropriate requesting. Currently, many laboratories are exploring demand management using a plethora of disparate approaches. Hence, this review seeks to provide a 'toolkit' with the view to allowing laboratories to develop a standardised demand management strategy.

Demand management and test request rationalization

Demand for laboratory testing is increasing disproportionately to medical activity, and the tests involved are becoming increasingly complex. When this phenomenon is seen in parallel with declining teaching of laboratory medicine in the medical curriculum, a need emerges to manage demand to avoid unnecessary expenditure and improve the use of laboratory services: 'the right test in the right patient at the right time.' Various methods have been tried to manage demand, with success depending on the medical context, type of health service and preintervention situation. Because many factors contribute to demand, and the different settings in which these exist, it is not realistic to meta-analyse the studies and we are limited to trying to identify trends in results in particular situations. The studies suggest that education combined with facilitating interventions, such as feedback, prompts and changes to laboratory request forms are the most successful. From the perspective of a whole health service, it is important that results are not exaggerated by assessing benefits in terms of total rather than marginal cost. It would be desirable, although difficult, to include the impact on downstream clinical activity caused or avoided by the interventions. Advances in information and web technology may make the elusive goal of achieving substantial demand control more achievable.

History of bloodletting by phlebotomy

Bloodletting by phlebotomy has been an obsession with medical practitioners for thousands of years, causing countless suffering to patients, initially for unproven indications and more recently for diagnoses. The approach to medical evidence-based phlebotomy has been a triumph for scientifically inclined practitioners. Progress, primarily achieved since the nineteenth century, has been in spite of considerable opposition from the medical establishment. The evaluation of phlebotomy as a useful tool continues and no doubt further myths will be dispelled. The history of bloodletting remains one of the greatest stories of medical progress, not because of new discoveries but mainly by persistent unbiased audit.

Incomplete laboratory request forms: the extent and impact on critical results at a tertiary hospital in South Africa

Background

Research has demonstrated that most laboratory errors occur in the preanalytical phase of testing. In view of the paucity of studies examining preanalytical errors, we evaluated our laboratory request forms for the frequency and impact of incomplete data.

Methods

This study examined all request forms received at our laboratory during a five-day period. The forms were scrutinized for the presence of specific parameters. The impact of abbreviated diagnoses was analysed, as well as how lack of ward or telephone details affects the communication of critical results to clinicians.

Results

A total of 2550 request forms were analysed. Medication(s) used by the patient (89.6%) and doctor’s contact number (61.2%) were the most incomplete parameters. No diagnosis was provided on 19.1% of forms, and when a diagnosis was present it was an abbreviated form in 37.3%. This resulted in 35.5% of diagnoses not being recorded by reception staff. Incomplete ward information was found on 4.9% of forms. In a separate search, the impact of 151 request forms (collected over a period of eight months), with incomplete ward location information and corresponding to critical results was assessed. Critical results were not communicated by telephone to clinicians in 19.9% of cases.

Conclusion

As laboratory data influences 70% of medical diagnoses, incorrect or incomplete data provided to the laboratory could significantly impact the success and cost of overall treatment.

Improving the appropriateness of laboratory submissions for urinalysis from general practice

BACKGROUND

Urine is the most common microbiology laboratory specimen. Submissions increase annually by 5-10%, and many specimens may be unnecessary.

OBJECTIVES

To assess the impact of guidance, implemented by interactive workshops and reinforced with modified request forms, on specimen submission.

METHODS

This was a prospective randomized controlled study with modified Zelen design. The study population comprised five primary care trusts (PCTs) in Gloucestershire/County Durham/Darlington, containing 82 general practices in six geographical clusters. The six clusters were randomly assigned to urine workshop covering submission in the elderly, adults and children or a control workshop. Within these groups, half the practices were randomized to receive modified laboratory forms emphasizing the workshop messages. Practices were not aware of the study.

RESULTS

Workshops lead to a 12% reduction in urine submissions from 16- to 64-year olds, which persisted for the 15 months but had no effect on bacteriuria rate. Workshops had no significant effect in the elderly or children. Modified forms were not associated with any reduction in submissions but were associated with an 11% reduction in detection of significant bacteriuria in 16- to 64-year olds.

CONCLUSIONS

The 12% decrease in urine submissions from 16- to 64-year olds, attained with workshops, may help counter relentlessly rising test submissions. Modified forms are currently not worth pursuing. When educational workshops are used across PCTs to change practice, the change in test submission is smaller than attained in educational initiatives involving volunteers. Workshops may be more effective if they also discuss urine submissions from asymptomatic patients and are directed at high testing practices and care homes.