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Mrazek C, Haschke-Becher E, Felder TK, Keppel MH, Oberkofler H, Cadamuro J. Laboratory Demand Management Strategies-An Overview. Diagnostics (Basel) 2021; 11:1141. [PMID: 34201549 PMCID: PMC8305334 DOI: 10.3390/diagnostics11071141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 01/07/2023] Open
Abstract
Inappropriate laboratory test selection in the form of overutilization as well as underutilization frequently occurs despite available guidelines. There is broad approval among laboratory specialists as well as clinicians that demand management strategies are useful tools to avoid this issue. Most of these tools are based on automated algorithms or other types of machine learning. This review summarizes the available demand management strategies that may be adopted to local settings. We believe that artificial intelligence may help to further improve these available tools.
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Affiliation(s)
- Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, A-5020 Salzburg, Austria; (E.H.-B.); (T.K.F.); (M.H.K.); (H.O.); (J.C.)
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2
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Mairesse A, Wauthier L, Courcelles L, Luyten U, Burlacu MC, Maisin D, Favresse J, van Dievoet MA, Gruson D. Biological variation and analytical goals of four thyroid function biomarkers in healthy European volunteers. Clin Endocrinol (Oxf) 2021; 94:845-850. [PMID: 33107075 DOI: 10.1111/cen.14356] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/30/2020] [Accepted: 10/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Interpretation of thyroid function tests by means of biological variation (BV) data is essential to identify significant changes between serial measurements at an individual level. Data on thyroid parameters in adults are limited. OBJECTIVES We aimed at determining the BV of four thyroid function test (thyroid-stimulating hormone (TSH), free thyroxin (FT4), free triiodothyronine (FT3) and thyroglobulin (Tg)) by applying recent recommendations to acquire BV data on a latest generation of immunoassay. METHODS Nineteen healthy volunteers (8 males and 11 females) were drawn every week during 5 consecutive weeks. Samples were analysed in duplicate on the Cobas 602 analyzer (Roche Diagnostics). After normality assessment, outlier exclusion and homogeneity of variance analysis, analytical variation (CVA ), within-subject biological variation (CVI ) and between-subject biological variation (CVG ) were determined using nested ANOVA. RESULTS CVA , CVI and CVG were 0.9%, 19.7% and 37.6% for TSH; 3.6%, 4.6% and 10.8% for FT4; 2.2%, 6.0% and 8.6% for FT3; and 0.9%, 15.4% and 84.9% for Tg. Index of individuality (II) for all parameters was between 0.2 and 0.7. The percentage above which the change between two measures is truly significant (reference change value) was 54.7% for TSH, 16.2% for FT4, 17.7% for FT3 and 42.8% for Tg. CONCLUSION Based on recent international recommendations, our study provides updated BV data for four thyroid function tests in European healthy volunteers. Reliable BV characteristics, and especially RCV, can facilitate the interpretation of consecutive thyroid function tests in an individual and therefore have the potential to efficiently support clinical decisions regarding thyroid diseases.
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Affiliation(s)
- Antoine Mairesse
- Clinical Biology Department, Cliniques Universitaires St Luc, Université catholique de Louvain, Brussels, Belgium
| | - Loris Wauthier
- Clinical Biology Department, Cliniques Universitaires St Luc, Université catholique de Louvain, Brussels, Belgium
| | - Louisiane Courcelles
- Clinical Biology Department, Cliniques Universitaires St Luc, Université catholique de Louvain, Brussels, Belgium
| | - Urszula Luyten
- Clinical Biology Department, Cliniques Universitaires St Luc, Université catholique de Louvain, Brussels, Belgium
| | - Maria-Cristina Burlacu
- Department of Endocrinology and Nutrition, Cliniques Universitaires St-Luc, Universite Catholique de Louvain, Brussels, Belgium
| | - Diane Maisin
- Clinical Biology Department, Cliniques Universitaires St Luc, Université catholique de Louvain, Brussels, Belgium
| | - Julien Favresse
- Department of Laboratory Medicine, Clinique St-Luc Bouge, Namur, Belgium
- Department of Pharmacy, Namur Research Institute for Life Sciences, University of Namur, Belgium
| | - Marie-Astrid van Dievoet
- Clinical Biology Department, Cliniques Universitaires St Luc, Université catholique de Louvain, Brussels, Belgium
| | - Damien Gruson
- Clinical Biology Department, Cliniques Universitaires St Luc, Université catholique de Louvain, Brussels, Belgium
- Pôle de recherche en Endocrinologie, Diabète et Nutrition, Institut de Recherche Expérimentale et Clinique, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium
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Kilinçarslan MG, Şahi N EM. Who repeats more laboratory tests inappropriately? Surgeons versus physicians. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2020; 32:219-227. [PMID: 33044198 DOI: 10.3233/jrs-200065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Inappropriate repeat testing is an objectively measurable type of health service overutilization which may harm patients. OBJECTIVE To evaluate both the frequency and cost of inappropriate repeat testing in a tertiary hospital in terms of specialties. METHODS This cross-sectional study was conducted in a tertiary hospital. Laboratory results of 26 tests ordered between 1 July 2014 and 30 June 2017 were evaluated retrospectively. Test that were repeated earlier than the minimum re-test interval were accepted as inappropriate repeat testing. After analyzing the descriptive statistics, the cluster analysis method was used to determine whether groups were formed within specialties. RESULTS Specialties form two clusters were found: the first cluster included specialties mostly from surgical science and the second cluster included specialties mostly from medical science. It was found that the cluster that includes mostly surgical specialties repeats laboratory tests at a higher rate but causes a waste of less resources, whereas the cluster that includes mostly medical specialties repeats laboratory tests at a lower rate but causes a waste of more resources due to a higher volume of test orders. CONCLUSION Due to the high rates of inappropriate repeat testing, surgical specialties seem to be the first target of intervention strategies, but medical specialties, which account for a higher volume of inappropriate repeat testing and higher unnecessary cost, should be the primary target of intervention strategies.
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Affiliation(s)
| | - Erkan Melih Şahi N
- Department of Family Medicine, University of Canakkale Onsekiz Mart, Canakkale, Turkey
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Ibarz M, Cadamuro J, Sumarac Z, Guimaraes JT, Kovalevskaya S, Nybo M, Cornes MP, Vermeersch P, Simundic AM, Lippi G. Clinicians' and laboratory medicine specialists' views on laboratory demand management: a survey in nine European countries. ACTA ACUST UNITED AC 2020; 8:111-119. [PMID: 31990661 DOI: 10.1515/dx-2019-0081] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/05/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Laboratory tests are an essential aspect of current medical practice and their use has grown exponentially. Several studies however have demonstrated inappropriate use of laboratory testing. This inappropriateness can lead to delayed or wrong diagnosis, negatively impacting patient safety and an increase in health care expenditure. The aim of the present small-scale survey was to obtain information on the current status of demand management in European laboratories, as well as the opinions of laboratory and clinical professionals in this regard. METHODS Two surveys were developed, one for laboratory specialists and one for clinicians, covering information on current use, knowledge and opinions on the possible impact of different demand management strategies on patient outcome and health care costs. Additionally, we asked for the current state and willingness on collaboration of laboratory specialists and clinicians. RESULTS One hundred and fifty responses, 72 laboratory specialists and 78 clinicians, from nine countries were received. Developing local ordering protocols/profiles in collaboration with clinicians was the most used strategy (80.3% of laboratories). Of clinicians, 85.6% considered measures to ensure appropriate use of tests necessary and 100% were interested in advice/information about their indication. Of the laboratory specialists 97.2% were either already participating or willing to participate in multidisciplinary groups on the appropriateness of test demand as were 60.3% of clinicians, and 85.9% of clinicians were interested in attending activities about laboratory test demand management. CONCLUSIONS The results of our survey show that tools to improve the appropriate use of laboratory tests are already regularly used today. Laboratory medicine specialists as well as clinicians are willing to undertake additional shared activities aimed at improving patient-centered laboratory diagnostic workup.
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Affiliation(s)
- Mercedes Ibarz
- Department of Clinical Laboratory, University Hospital Arnau de Vilanova, IRBLleida, Rovira Roure 80, 25198 Lleida, Spain
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Zorica Sumarac
- Center for Medical Biochemistry, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Pharmacy, Novi Sad, Serbia
| | - Joao Tiago Guimaraes
- Department of Clinical Pathology, Sao Joao Hospital Center, University of Porto, Porto, Portugal.,Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal.,EPIUnit, Institute of Public Health, University of Porto, Porto, Portugal
| | - Svetlana Kovalevskaya
- Clinical Laboratory Diagnostic Department with Course of Molecular Medicine, 1st Pavlov State Medical University, St-Petersburg, Russia
| | - Mads Nybo
- Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Michael P Cornes
- Department of Clinical Biochemistry, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Pieter Vermeersch
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Ana-Maria Simundic
- Department of Medical Laboratory Diagnostics, Clinical Hospital "Sveti Duh", Zagreb, Croatia
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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Cobbaert CM, Arslan F, Caballé Martín I, Serra AA, Picó-Plana E, Sánchez-Margalet V, Carmona-Fernández A, Burden J, Ziegler A, Bechel W. Automated urinalysis combining physicochemical analysis, on-board centrifugation, and digital imaging in one system: A multicenter performance evaluation of the cobas 6500 urine work area. Pract Lab Med 2019; 17:e00139. [PMID: 31649991 PMCID: PMC6804654 DOI: 10.1016/j.plabm.2019.e00139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 09/12/2019] [Accepted: 09/17/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND We evaluated the analytical performance of the fully automated cobas® 6500 urine work area and its automated components-cobas u 601 and cobas u 701. DESIGN AND METHODS The study was conducted at three European centers using un-centrifuged surplus routine urine samples; all measurements were performed within 2 h of sample collection. Precision, sample carry-over, and method comparisons were evaluated per Clinical and Laboratory Standards Institute guidelines. Method comparisons: cobas u 601 versus Urisys 2400 and cobas u 411 urine test strips; and cobas u 701 versus KOVA® visual microscopy and iQ200 analyzer. Operability and functionality were assessed using questionnaires. RESULTS Precision of the entire cobas 6500 system was within predefined acceptance limits and no significant carry-over was observed. Erythrocytes, leukocytes, nitrites, and protein were in good agreement (≥93%) with cobas u 411 reflectometry. High correlation was shown between the cobas u 701 analyzer and KOVA visual microscopy for red blood cells (RBC; slope, 0.89; Pearson's r, 0.95) and white blood cells (WBC; slope, 0.96; Pearson's r, 0.96), demonstrating equivalence of test results. The 97.5% percentile reference values on the cobas u 701 analyzer were 5.3 cells/μL (RBC) and 6.2 cells/μL (WBC). The cobas 6500 system showed good sensitivity for small bacteria (>1 μm) and pathological casts, and the user interface, maintenance wizards, and system design were highly rated by operators. CONCLUSIONS The fully automated workflow, high precision, and high throughput of the cobas 6500 system have the potential to facilitate standardization of urine screening.
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Affiliation(s)
- Christa M. Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, ZA, 2333, the Netherlands
| | - Figen Arslan
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, ZA, 2333, the Netherlands
| | - Imma Caballé Martín
- CatLab, Vial St Jordi S/n, Pol.Ind. Can Mitjans, 08232, Viladecavalls, Spain
| | - Antoni Alsius Serra
- CatLab, Vial St Jordi S/n, Pol.Ind. Can Mitjans, 08232, Viladecavalls, Spain
| | - Ester Picó-Plana
- CatLab, Vial St Jordi S/n, Pol.Ind. Can Mitjans, 08232, Viladecavalls, Spain
| | - Víctor Sánchez-Margalet
- Virgen Macarena University Hospital, University of Seville, Calle Dr. Fedriani, 3, 41009, Seville, Spain
| | - Antonio Carmona-Fernández
- Virgen Macarena University Hospital, University of Seville, Calle Dr. Fedriani, 3, 41009, Seville, Spain
| | - John Burden
- Roche Diagnostics International Ltd., Forrenstrasse 2, CH-6343, Rotkreuz, Switzerland
| | - André Ziegler
- Roche Diagnostics International Ltd., Forrenstrasse 2, CH-6343, Rotkreuz, Switzerland
| | - Walter Bechel
- Roche Diagnostics International Ltd., Forrenstrasse 2, CH-6343, Rotkreuz, Switzerland
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Kılınçarslan MG, Şahin EM, Korkmazer B. Prevalence and associated factors of inappropriate repeat test. Postgrad Med J 2019; 95:596-600. [DOI: 10.1136/postgradmedj-2019-136696] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/03/2019] [Accepted: 07/09/2019] [Indexed: 12/23/2022]
Abstract
BackgroundThe rate of laboratory test utilisation has been increasing unsustainably. Evaluating inappropriately repeated laboratory tests is promising because objective criteria are available to measure the rates while causes can be manipulated easily. In this study, we aimed to evaluate the prevalence, associated factors and financial burden of inappropriate repeat tests.MethodsA cross-sectional study was conducted on the results of 26 types of laboratory tests recorded in a laboratory database of a tertiary hospital between 1 July 2014 and 30 June 2017. Minimum retest intervals were determined from the literature for each type of tests. If the time interval between the two tests was shorter than the minimum retest interval, then the later test was accepted an inappropriate repeat test. Binary logistic regression was performed after univariate analyses.ResultsOf a total of 673 794 tests, 109 370 (16.2%) were inappropriate repeat tests. Male gender, being ≥65 years old, being an inpatient, high-volume test and surgical clinic as the test-requesting clinic were associated with inappropriate repeat tests. Also, it was determined that US$66 761.3 had been wasted on inappropriate repeat tests for 3 years.DiscussionThere are several factors that increase the rate of inappropriate repeat tests. They should be considered during health policy making or planning interventions to reduce inappropriate repeat tests.
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Meidani Z, Mousavi GA, Kheirkhah D, Benar N, Maleki MR, Sharifi M, Farrokhian A. Going beyond audit and feedback: towards behaviour-based interventions to change physician laboratory test ordering behaviour. J R Coll Physicians Edinb 2019. [PMID: 29537404 DOI: 10.4997/jrcpe.2017.407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Studies indicate there are a variety of contributing factors affecting physician test ordering behaviour. Identifying these behaviours allows development of behaviour-based interventions. Methods Through a pilot study, the list of contributing factors in laboratory tests ordering, and the most ordered tests, were identified, and given to 50 medical students, interns, residents and paediatricians in questionnaire form. The results showed routine tests and peer or supervisor pressure as the most influential factors affecting physician ordering behaviour. An audit and feedback mechanism was selected as an appropriate intervention to improve physician ordering behaviour. The intervention was carried out at two intervals over a three-month period. Findings There was a large reduction in the number of laboratory tests ordered; from 908 before intervention to 389 and 361 after first and second intervention, respectively. There was a significant relationship between audit and feedback and the meaningful reduction of 7 out of 15 laboratory tests including complete blood count (p = 0.002), erythrocyte sedimentation rate (p = 0.01), C-reactive protein (p = 0.01), venous blood gas (p = 0.016), urine analysis (p = 0.005), blood culture (p = 0.045) and stool examination (p = 0.001). Conclusion The audit and feedback intervention, even in short duration, affects physician ordering behaviour. It should be designed in terms of behaviour-based intervention and diagnosis of the contributing factors in physicians' behaviour. Further studies are required to substantiate the effectiveness of such behaviour-based intervention strategies in changing physician behaviour.
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Affiliation(s)
- Z Meidani
- D Kheirkhah, Infectious Diseases Research Centre, Kashan University of Medical Sciences, Kashan, Iran.
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Erard Y, Del Giorno R, Zasa A, De Gottardi S, Della Bruna R, Keller F, Clivio L, Greco A, Giannini O, Gabutti L. A multi-level strategy for a long lasting reduction in unnecessary laboratory testing: A multicenter before and after study in a teaching hospital network. Int J Clin Pract 2018; 73:e13286. [PMID: 30339303 PMCID: PMC6587855 DOI: 10.1111/ijcp.13286] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 10/14/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Reducing unnecessary laboratory blood testing in the hospital setting represents a challenge to improve the adequacy of healthcare and a tricky task for teaching hospitals. Our hospital network actively participates in the Choosing Wisely Campaign and is engaged in avoiding unnecessary low value interventions and investigations. We aimed to study whether a multi-level approach combining educational and web-system based interventions, could be effective in reducing laboratory testing and related costs. METHODS Multicenter, proof of concept, prospective, observational, before and after study, in a network of public hospitals in Switzerland. All patients admitted between 1 January 2015 and 31 December 2017 were analyzed. A multi-level strategy based on online continuous monitor benchmarking and educational support was applied in the internal medicine services. The primary outcome was a significant reduction in the number of laboratory tests per patient and per day during the hospital stay. Secondary outcomes were reduction in the blood sample volume taken per patient and per day in laboratory costs. RESULTS Over the 36 months of the study, 33 309 admissions were analyzed. A significant reduction of laboratory tests per patient and per day of hospitalisation was found:-11%, P-value<0.001; -6%, P-value <0.001. The mean monthly blood volume, per patient and per day of hospital stay and laboratory costs per patient was also significantly reduced: -7%, P-value<0.05; -3%, P-value<0.01, and -17%, P-value<0.01, respectively. CONCLUSIONS The obtained reduction in the number of laboratory tests, blood volume withdrawn and related costs, support the idea that an open web-based system, involving all health care providers, coupled with educational interventions, can be helpful in generating awareness of prescriber habits and to catalyze changes in their behaviour. The peer pressure related to the unmasked benchmarking process did probably play a determinant role.
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Affiliation(s)
- Yannick Erard
- Department of Internal MedicineSan Giovanni HospitalEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Rosaria Del Giorno
- Department of Internal MedicineSan Giovanni HospitalEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Anna Zasa
- Department of Internal MedicineSan Giovanni HospitalEnte Ospedaliero CantonaleBellinzonaSwitzerland
- Quality and Patient Safety ServiceLa Carità HospitalEnte Ospedaliero CantonaleLocarnoSwitzerland
| | - Simone De Gottardi
- Department of InformaticsEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Roberto Della Bruna
- Institute of Laboratory MedicineEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Franco Keller
- Institute of Laboratory MedicineEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Luca Clivio
- Department of InformaticsEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Angela Greco
- Quality and Patient Safety ServiceLa Carità HospitalEnte Ospedaliero CantonaleLocarnoSwitzerland
| | - Olivier Giannini
- Department of Internal MedicineBeata Vergine HospitalEnte Ospedaliero CantonaleMendrisioSwitzerland
| | - Luca Gabutti
- Department of Internal MedicineSan Giovanni HospitalEnte Ospedaliero CantonaleBellinzonaSwitzerland
- Institute of BiomedicineUniversity of Southern SwitzerlandLuganoSwitzerland
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Zemlin AE. Errors in the Extra-Analytical Phases of Clinical Chemistry Laboratory Testing. Indian J Clin Biochem 2018; 33:154-162. [PMID: 29651205 PMCID: PMC5891449 DOI: 10.1007/s12291-017-0657-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 04/28/2017] [Indexed: 01/06/2023]
Abstract
The total testing process consists of various phases from the pre-preanalytical to the post-postanalytical phase, the so-called brain-to-brain loop. With improvements in analytical techniques and efficient quality control programmes, most laboratory errors now occur in the extra-analytical phases. There has been recent interest in these errors with numerous publications highlighting their effect on service delivery, patient care and cost. This interest has led to the formation of various working groups whose mission is to develop standardized quality indicators which can be used to measure the performance of service of these phases. This will eventually lead to the development of external quality assessment schemes to monitor these phases in agreement with ISO15189:2012 recommendations. This review focuses on potential errors in the extra-analytical phases of clinical chemistry laboratory testing, some of the studies performed to assess the severity and impact of these errors and processes that are in place to address these errors. The aim of this review is to highlight the importance of these errors for the requesting clinician.
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Affiliation(s)
- Annalise E. Zemlin
- Division of Chemical Pathology, National Health Laboratory Service (NHLS) and University of Stellenbosch, Tygerberg Hospital, Cape Town, 7505 South Africa
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Livingston M, Kalansooriya A, Hartland A, Fryer AA, Gupta J, Heald AH. Reduction of unnecessary N-terminal pro-brain natriuretic peptide (NT-proBNP) tests: A further lesson in demand management. Int J Clin Pract 2018; 72:e13071. [PMID: 29878475 DOI: 10.1111/ijcp.13071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | | | - Andrew Hartland
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - Anthony A Fryer
- Department of Clinical Biochemistry, University Hospitals of North Midlands, Stoke-on-Trent, UK
- Institute of Applied Clinical Sciences, Keele University, Staffordshire, UK
| | - Jayant Gupta
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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Bogavac-Stanojevic N, Jelic-Ivanovic Z. The Cost-effective Laboratory: Implementation of Economic Evaluation of Laboratory Testing. J Med Biochem 2017; 36:238-242. [PMID: 30568540 PMCID: PMC6287218 DOI: 10.1515/jomb-2017-0036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 06/06/2017] [Indexed: 12/12/2022] Open
Abstract
Laboratory testing as a part of laboratory in vitro diagnostic (IVD) has become required tool in clinical practice for diagnosing, monitoring and prognosis of diseases, as well as for prediction of treatment response. The number of IVD tests available in laboratory practice has increased over the past decades and is likely to further increase in the future. Consequently, there is growing concern about the overutilization of laboratory tests and rising costs for laboratory testing. It is estimated that IVD accounts for between 1.4 and 2.3% of total healthcare expenditure and less than 5% of total hospital cost (Lewin Group report). These costs are rather low when compared to pharmaceuticals and medical aids which account for 15 and 5%, respectively. On the other hand, IVD tests play an important role in clinical practice, as they influence from 60% to 70% of clinical decision-making. Unfortunately, constant increases in healthcare spending are not directly related to healthcare benefit. Since healthcare resources are limited, health payers are interested whether the benefits of IVD tests are actually worth their cost. Many articles have introduced frameworks to assess the economic value of IVD tests. The most appropriate tool for quantitative assessment of their economic value is cost-effectiveness (CEA) and cost-utility (CUA) analysis. The both analysis determine cost in terms of effectiveness or utilities (combine quantity and quality of life) of new laboratory test against its alternative. On the other hand, some investigators recommended calculation of laboratory test value as product of two ratios: Laboratory test value = (Technical accuracy/Turnaround time) × (Utility/Costs). Recently, some researches used multicriteria decision analysis which allows comparison of diagnostic strategies in terms of benefits, opportunities, costs and risks. All analyses are constructed to identify laboratory test that produce the greatest healthcare benefit with the resources available. Without solid evidence that certain laboratory tests are cost-effective, laboratory services cannot be improved. Consequently, simple policy measures such as cost cutting may be imposed upon many laboratories while patients will have limited access to laboratory service.
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Affiliation(s)
| | - Zorana Jelic-Ivanovic
- University of Belgrade - Faculty of Pharmacy, Department of Medical Biochemistry, Belgrade, Serbia
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12
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Pema AK, Kiabilua O, Pillay TS. Demand management by electronic gatekeeping of test requests does not influence requesting behaviour or save costs dramatically. Ann Clin Biochem 2017; 55:244-253. [DOI: 10.1177/0004563217707980] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Healthcare budgets face constraints, and laboratories have developed strategies to adapt to the concomitant increase in workload. Some of the tests (7.4%) may be attributed to unnecessary repeat testing. Electronic gatekeeping has been implemented at selected laboratories in South Africa to limit unnecessary repeat testing. We performed a study of chemistry tests subjected to electronic gatekeeping to determine its effectiveness as a sustainable demand management tool. Methods A 22-month retrospective study of chemistry test requests at a Pretoria hospital was performed. Tests violating electronic gatekeeping rules were rejected upon registration before analysis, and cost-savings were estimated from electronic gatekeeping-held tests. The impact of electronic gatekeeping on the test requesting pattern of clinicians was derived from the percentage cost of electronic gatekeeping-held tests. Results The total savings generated from electronic gatekeeping test rejections amounted to $84,380. Greatest savings were generated from high-cost tests: glycated haemoglobin ($14,139), urea ($8661) and thyroid-stimulating hormone ($7514). The average number of electronic gatekeeping-held tests as a percentage of their total requested number over 22 months was 3.18%. Discussion The savings from electronic gatekeeping-held tests were not as dramatic as anticipated, but were modest and may have some impact in a cost-constrained setting. Electronic gatekeeping was concluded not to have a substantial effect on the clinician test requesting pattern, demonstrated by the largely unchanged monthly percentage of electronic gatekeeping-held tests. As a solitary demand management strategy, electronic gatekeeping does not appear to be as effective as anticipated or as demonstrated in other studies.
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Affiliation(s)
- Aarti K Pema
- Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria and National Health Laboratory Service, Tshwane Academic Division, Pretoria, South Africa
| | - Olivia Kiabilua
- Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria and National Health Laboratory Service, Tshwane Academic Division, Pretoria, South Africa
| | - Tahir S Pillay
- Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria and National Health Laboratory Service, Tshwane Academic Division, Pretoria, South Africa
- Division of Chemical Pathology, University of Cape Town, Cape Town, South Africa
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13
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Livingston M, Kalansooriya A, Heald AH. Clinical appropriateness of C-reactive protein requests: Reduction in unnecessary repeats. Int J Clin Pract 2017; 71. [PMID: 28371018 DOI: 10.1111/ijcp.12941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | | | - Adrian H Heald
- Department of Endocrinology, Leighton Hospital, Crewe, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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Gion M, Peloso L, Trevisiol C, Squarcina E, Zappa M, Fabricio ASC. An epidemiology-based model as a tool to monitor the outbreak of inappropriateness in tumor marker requests: a national scale study. Clin Chem Lab Med 2017; 54:473-82. [PMID: 26351929 DOI: 10.1515/cclm-2015-0329] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/15/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND Evaluation of appropriateness of laboratory tests on the basis of individual requests remains a serious problem as the clinical question is usually not reported with the test order. This study explored the comparison of the rate of tumor marker orders with cancer prevalence as a putative indicator of inappropriateness. METHODS Tumor marker orders (2011 and 2012) were obtained from the Ministry of Health and cancer prevalence from the Italian Association of Cancer Registries. The rate of tumor marker orders was matched with demographic data and tumor prevalence and examined by using the confidence interval approach. Region-to-region and year-to-year variations were also examined. Focus was placed on CEA, CA125, CA19.9 and CA15.3. RESULTS Tumor markers ordered in Italy were 13,207,289 in 2012 (221.3/1000 individuals). Given an estimated prevalence of 2,243,953 cancer cases, 7.04 tumor markers appear to be requested for each prevalent case of epithelial cancer per year. The rate of requests of CEA, CA125, CA19.9 and CA15.3 (in aggregate 5,834,167 requests in 2012, 44.2% of total) from the first and the last ranked region (96 and 244/1000 individuals) are significantly different (p<0.01). Region-to-region differences do not correspond to any known variation of prevalence in the different regions. CONCLUSIONS The developed approach provides a proxy indicator of inappropriateness showing that tumor markers are overused in Italy and their ordering pattern is not related to tumor prevalence. The model is suitable to be validated in other laboratory tests used in diseases whose prevalence is known.
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Lee AYS, Hudspeth AR, Adelstein S. The concordance of serial ANA tests in an Australian tertiary hospital pathology laboratory. Pathology 2016; 48:597-601. [PMID: 27600602 DOI: 10.1016/j.pathol.2016.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 05/22/2016] [Accepted: 06/09/2016] [Indexed: 01/23/2023]
Abstract
The antinuclear antibody (ANA) tests are some of the more frequently requested tests for the diagnosis of autoimmunity. Although they are used primarily as diagnostic blood tests, multiple requests on the same patient continue to be encountered in the laboratory. This retrospective analysis of serial ANA testing at one pathology laboratory in Australia is the first study that examines the statistical concordance and possible implications of this on clinical practice. High-titred ANA have quite good repeatability for titre and pattern, and low-titred ANA, which can be non-specific, have poor repeatability. Staining patterns are, in general, almost random in nature on serial tests when compared to the first-obtained ANA pattern for each patient. This study confirms that there is little benefit in serial ANA testing, and only if there is a clear change in the patient's clinical picture would repeat of an initial low-titred ANA be useful. The findings reinforce the need for pathology stewardship to minimise costs, wasted resources and unnecessary referrals.
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Affiliation(s)
- Adrian Y S Lee
- Western Health, Melbourne, Vic, Australia; School of Medicine, University of Tasmania, Hobart, Tas, Australia; Royal Hobart Hospital, Hobart, Tas, Australia.
| | | | - Stephen Adelstein
- Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, NSW, Australia
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Cornes MP, Church S, van Dongen-Lases E, Grankvist K, Guimarães JT, Ibarz M, Kovalevskaya S, Kristensen GB, Lippi G, Nybo M, Sprongl L, Sumarac Z, Simundic AM. The role of European Federation of Clinical Chemistry and Laboratory Medicine Working Group for Preanalytical Phase in standardization and harmonization of the preanalytical phase in Europe. Ann Clin Biochem 2016; 53:539-47. [PMID: 27141012 DOI: 10.1177/0004563216643969] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2016] [Indexed: 11/16/2022]
Abstract
Patient safety is a leading challenge in healthcare and from the laboratory perspective it is now well established that preanalytical errors are the major contributor to the overall rate of diagnostic and therapeutic errors. To address this, the European Federation of Clinical Chemistry and Laboratory Medicine Working Group for Preanalytical Phase (EFLM WG-PRE) was established to lead in standardization and harmonization of preanalytical policies and practices at a European level. One of the key activities of the WG-PRE is the organization of the biennial EFLM-BD conference on the preanalytical phase to provide a forum for National Societies (NS) to discuss their issues. Since 2012, a year after the first Preanalytical phase conference, there has been a rapid growth in the number of NS with a working group engaged in preanalytical phase activities and there are now at least 19 countries that have one. As a result of discussions with NS at the third conference held in March 2015 five key areas were identified as requiring harmonisation. These were test ordering, sample transport and storage, patient preparation, sampling procedures and management of unsuitable specimens. The article below summarises the work that has and will be done in these areas. The goal of this initiative is to ensure the EFLM WG-PRE produces work that meets the needs of the European laboratory medicine community. Progress made in the identified areas will be updated at the next preanalytical phase conference and show that we have produced guidance that has enhanced standardisation in the preanalytical phase and improved patient safety throughout Europe.
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Affiliation(s)
- Michael P Cornes
- Departments of Clinical Chemistry, New Cross Hospital, Wolverhampton, West Midlands, UK
| | | | | | - Kjell Grankvist
- The Department of Medical Biosciences, Clinical Chemistry, Umea University, Umea, Sweden
| | - João T Guimarães
- Department of Clinical Pathology, São João Hospital Center, Department of Biochemistry, Faculty of Medicine, and EPI Unit, Institute of Public Health, University of Porto, Porto, Portugal
| | - Mercedes Ibarz
- Laboratori Clínic Hospital Arnau de Vilanova, Lleida, Spain
| | - Svetlana Kovalevskaya
- Clinical Laboratory Diagnostic Department with Course of Molecular Medicine, First Saint Petersburg Pavlov State Medical University, St-Petersburg, Russia
| | | | - Giuseppe Lippi
- Section of Clinical Chemistry, University of Verona, Verona, Italy
| | - Mads Nybo
- Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Ludek Sprongl
- Central Laboratory, Hospital Sumperk, Sumperk, Czech Republic
| | - Zorica Sumarac
- Center for Medical Biochemistry, Clinical Center of Serbia, Belgrade, Serbia
| | - Ana-Maria Simundic
- Department of Medical Laboratory Diagnostics, Clinical Hospital Sveti Duh, Zagreb, Croatia
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Lippi G, Banfi G, Church S, Cornes M, De Carli G, Grankvist K, Kristensen GB, Ibarz M, Panteghini M, Plebani M, Nybo M, Smellie S, Zaninotto M, Simundic AM. Preanalytical quality improvement. In pursuit of harmony, on behalf of European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working group for Preanalytical Phase (WG-PRE). Clin Chem Lab Med 2016; 53:357-70. [PMID: 25490032 DOI: 10.1515/cclm-2014-1051] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 10/28/2014] [Indexed: 11/15/2022]
Abstract
Laboratory diagnostics develop through different phases that span from test ordering (pre-preanalytical phase), collection of diagnostic specimens (preanalytical phase), sample analysis (analytical phase), results reporting (postanalytical phase) and interpretation (post-postanalytical phase). Although laboratory medicine seems less vulnerable than other clinical and diagnostic areas, the chance of errors is not negligible and may adversely impact on quality of testing and patient safety. This article, which continues a biennial tradition of collective papers on preanalytical quality improvement, is aimed to provide further contributions for pursuing quality and harmony in the preanalytical phase, and is a synopsis of lectures of the third European Federation of Clinical Chemistry and Laboratory Medicine (EFLM)-Becton Dickinson (BD) European Conference on Preanalytical Phase meeting entitled 'Preanalytical quality improvement. In pursuit of harmony' (Porto, 20-21 March 2015). The leading topics that will be discussed include unnecessary laboratory testing, management of test request, implementation of the European Union (EU) Directive on needlestick injury prevention, harmonization of fasting requirements for blood sampling, influence of physical activity and medical contrast media on in vitro diagnostic testing, recent evidence about the possible lack of necessity of the order of draw, the best practice for monitoring conditions of time and temperature during sample transportation, along with description of problems emerging from inappropriate sample centrifugation. In the final part, the article includes recent updates about preanalytical quality indicators, the feasibility of an External Quality Assessment Scheme (EQAS) for the preanalytical phase, the results of the 2nd EFLM WG-PRE survey, as well as specific notions about the evidence-based quality management of the preanalytical phase.
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Elnenaei MO, Campbell SG, Thoni AJ, Lou A, Crocker BD, Nassar BA. An effective utilization management strategy by dual approach of influencing physician ordering and gate keeping. Clin Biochem 2016; 49:208-12. [DOI: 10.1016/j.clinbiochem.2015.11.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 11/03/2015] [Accepted: 11/05/2015] [Indexed: 10/22/2022]
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Mughal Z, Narayanan A, Gupta V, Reay-Jones N. Clinical need-directed blood tests: a step in saving the NHS? Ann Clin Biochem 2016; 53:568-74. [PMID: 26746410 DOI: 10.1177/0004563215617782] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Unnecessary blood tests are estimated to contribute to 25% of wastage in the National Health Service. The aim of this study was to assess the financial implication of clinical need-focused blood tests guided by a senior clinician in a district general hospital. METHODS We conducted an observational longitudinal study over six months with pre- and postanalysis of a vetting intervention. A colorectal firm (Team A) implemented a vetting system that required a registrar or consultant to discuss which blood tests needed to be requested for each in-patient with junior doctors. Another colorectal firm (Team B) with a similar caseload was blinded to the study and was used as a control. RESULTS The vetting initiative demonstrated a reduction of 33% of blood test requests, translating to a cost-saving of £2406 over three months. Following the intervention, the median number of tests requested per patient per day by Team A for C-reactive protein reduced from 0.8 to 0.63 (P = 0.0074), full blood counts reduced from 0.8 to 0.67 (P = 0.0138), liver function tests decreased from 0.8 to 0.6 (P = 0.0021) and urea and electrolytes fell from 0.8 to 0.63 (P = 0.0083). The number of tests per patient per day after the intervention was significantly less than the control group (P < 0.001). The length of hospital stay and admission to critical care were not adversely affected in the group that had less blood tests, P = 0.808 and P = 0.58, respectively. CONCLUSION The direction, by a senior clinician, of the requesting of blood tests by junior doctors to ensure that requests were based on clinical need, reduced the number of inappropriate blood tests and resulted in some reduction in laboratory costs.
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Affiliation(s)
- Zahir Mughal
- Department of General Surgery, Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, UK
| | - Aravindan Narayanan
- Department of General Surgery, Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, UK
| | - Vivek Gupta
- Department of General Surgery, Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, UK
| | - Nick Reay-Jones
- Department of General Surgery, Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, UK
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Ferraro S, Mozzi R, Panteghini M. Tumor Marker Ordering: Do Not Lose Control: A Prospective Clinical Trial. Am J Clin Pathol 2015; 144:649-58. [PMID: 26386087 DOI: 10.1309/ajcpnzapjrb3t6kk] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES In this study, we evaluated the extent of inappropriate tumor marker (TM) ordering in a secondary care setting, approximately 6 years after the introduction of local guidelines, and we identified the main factors potentially influencing clinicians when performing an inappropriate TM request. METHODS For this purpose, we regularly checked all requests containing more than two TMs. During the 21-month audit, the rate of rejected requests amounted to 3.6%. Several of those were performed for diagnostic purposes. The most frequent and inappropriately requested TMs were carcinoembryonic antigen and carbohydrate antigen 19.9. RESULTS The inappropriateness of requests appeared to be linked to the need for more education and knowledge on their clinical applicability and limitations. The clinical motivation was generally associated with patients displaying nonspecific signs/symptoms (ie, weight loss with worsening general conditions), having an incidentally positive result to some recently performed TM tests, or being tested by a TM to avoid more expensive diagnostic imaging procedures. CONCLUSIONS Our data show that real-time control and management of inappropriate requests by laboratory professionals may be relevant to increase the clinical efficacy of TM testing and useful in perspective to drive the introduction of new validated biomarkers.
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Affiliation(s)
- Simona Ferraro
- Clinical Pathology Unit, ‘Luigi Sacco’ University Hospital, and Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Roberta Mozzi
- Clinical Pathology Unit, ‘Luigi Sacco’ University Hospital, and Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Mauro Panteghini
- Clinical Pathology Unit, ‘Luigi Sacco’ University Hospital, and Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
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Ferraro S, Mozzi R, Panteghini M. Tracing a roadmap for vitamin B₁₂ testing using the health technology assessment approach. Clin Chem Lab Med 2014; 52:767-77. [PMID: 24304539 DOI: 10.1515/cclm-2013-0738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 10/29/2013] [Indexed: 11/15/2022]
Abstract
In our hospital, we are currently working to manage the appropriateness of vitamin B₁₂ (B12) testing. Unfortunately, the classic evidence-based approach is unhelpful in this process and meta-analyzing data on the accuracy of this marker for cobalamin deficiency detection is misleading due to the lack of reference diagnostic methods. The approach currently proposed by the Health Technology Assessment (HTA) enables us to tackle the issue of B₁₂ requests as a "healthcare" problem by considering the position of stakeholders involved in ordering, performing, interpreting the test, and receiving its results. Clinical expectations, methodological issues, and ethical aspects concerning the performance of the test can aid us in providing more guidance on the use of this marker. By building such structured information, hemodialysis patients and pregnant women have emerged as those groups preferentially requiring B₁₂ testing, as it may potentially improve the clinical outcome. To avoid misinterpretation of B₁₂ results more care should be taken in considering its biochemical and biological features, as well as the analytical issues. Spurious values obtained by current automated immunoassays may reflect suboptimal pre-analytical steps as well as known interfering conditions. Furthermore, the harmonization of results by available methods is still a far-reaching goal and the approach to interpret an individual's results should be improved. Tracing a roadmap for B₁₂ testing by exploiting the HTA model to balance the stakeholders' claims and maximizing the patient's outcome may help to manage the marker demand.
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22
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Smit I, Zemlin AE, Erasmus RT. Demand management: an audit of chemical pathology test rejections by an electronic gate-keeping system at an academic hospital in Cape Town. Ann Clin Biochem 2014; 52:481-7. [DOI: 10.1177/0004563214567688] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2014] [Indexed: 11/15/2022]
Abstract
Background Demand management is an area of laboratory activity, which is becoming increasingly important. Within the health-care system, demand management can be defined as the use of health resources to maximise its utility. Tygerberg Hospital has introduced an electronic gate-keeping system. Chemistry tests which generate the highest cost are subjected to this system and may be automatically rejected according to a set of rules. This study aimed: (1) to identify the number of chemistry tests rejected by the eGK; (2) to identify which of these rejected tests were subsequently restored and (3) to assess the impact of rejections on clinical outcome and cost-saving. Methods A retrospective audit was conducted to determine the number of chemistry tests rejected and subsequently restored over a 6-month period. The case-notes of patients for whom requested tests previously rejected had been restored were randomly selected and investigated to assess clinical impact. Any cost-saving was calculated. Results A total of 68,480 tests were subjected to gate-keeping, and 4605 tests (6.7%) were rejected while 679 (14.7%) of these were restored by the requestor phoning the laboratory after obtaining authorisation. After examining a subset of clinical notes it was found that in most cases (80%), patient care was unaffected. The total cost saved was £25,387. Conclusions The majority of the rejected tests were unnecessary and following rejection, real savings were made. Electronic gate-keeping is a simple, effective and sustainable method of demand management.
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Affiliation(s)
- Ida Smit
- Division of Chemical Pathology, Faculty of Health Sciences, National Health Laboratory Service (NHLS) and Stellenbosch University, Cape Town, South Africa
| | - Annalise E Zemlin
- Division of Chemical Pathology, Faculty of Health Sciences, National Health Laboratory Service (NHLS) and Stellenbosch University, Cape Town, South Africa
| | - Rajiv T Erasmus
- Division of Chemical Pathology, Faculty of Health Sciences, National Health Laboratory Service (NHLS) and Stellenbosch University, Cape Town, South Africa
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Abstract
Defensive medicine often involves the excessive ordering of diagnostic tests. Constantly aware of the risk of malpractice liability, physicians turn to diagnostic tests with the goal of reducing the likelihood of error. Findings reported in literature suggest that medical malpractice contributes significantly to the increased use of diagnostic testing and related costs. It has also been demonstrated that defensive testing not only increases costs but harms patients to a degree that depends on the risk incurred by the test itself, its false-positive and false-negative rates, the benefits and risks of available therapies, and the prior probability of disease. Several solutions have been proposed in the attempt to address this issue, but the physician's competence and training appear to be key factors, data from clinical trials showing that education and feedback for improving test-ordering tendencies have a prolonged effect. Particularly in the field of laboratory medicine, increasing attention is being paid to improving demand management in order to minimize inappropriate testing.
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Affiliation(s)
- Mario Plebani
- 1Department of Laboratory Medicine, University-Hospital, Padova, Azienda Ospedaliera di Padova Via Nicolo Giustiniani 2 Padova 35128, Italy
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24
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Stanfliet JC, Locketz M, Berman P, Pillay TS. Evaluation of the utility of serum prolidase as a marker for liver fibrosis. J Clin Lab Anal 2014; 29:208-13. [PMID: 24798655 DOI: 10.1002/jcla.21752] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 02/28/2014] [Accepted: 03/03/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Liver dysfunction is common and often unrecognized. Liver biopsy is the gold standard in the assessment of liver fibrosis, but has disadvantages. We assessed the diagnostic accuracy of serum prolidase enzyme activity (SPA) in predicting the presence and degree of liver fibrosis, as compared with liver biopsy. Further, we evaluated the effect of hemolysis on measured SPA levels. METHODS We undertook a prospective case control study. Thirty eight outpatients without apparent liver illness and 20 patients with liver pathology scheduled to undergo liver biopsy had their SPA levels measured. RESULTS Patients undergoing liver biopsy had higher SPA levels (361 (268) IU/l [median (interquartile range)]) compared with controls (169 (160) (P < 0.001)). A SPA cutoff value of 200 IU/l yielded a sensitivity of 89%, specificity of 59%, an odds ratio of 11.5, negative predictive value of 92%, and a positive predictive value of 50%. Hemolysis causes an apparent increase in SPA levels. CONCLUSION Higher SPA levels in patients undergoing liver biopsies compared with controls may reflect the presence of liver fibrosis. SPA levels could not be used to stage the degree of fibrosis. SPA measurement may be useful in the diagnostic workup of suspected liver disease.
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Affiliation(s)
- John C Stanfliet
- Division of Chemical Pathology, Department of Clinical Laboratory Sciences, University of Cape Town and National Health Laboratory Service, Cape Town, South Africa
| | - Michael Locketz
- Division of Anatomical Pathology, Department of Clinical Laboratory Sciences, University of Cape Town and National Health Laboratory Service, Cape Town, South Africa
| | - Peter Berman
- Division of Chemical Pathology, Department of Clinical Laboratory Sciences, University of Cape Town and National Health Laboratory Service, Cape Town, South Africa
| | - Tahir S Pillay
- Division of Chemical Pathology, Department of Clinical Laboratory Sciences, University of Cape Town and National Health Laboratory Service, Cape Town, South Africa.,Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria and National Health Laboratory Service, Tshwane Academic Division, Pretoria, South Africa
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25
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Plebani M, Panteghini M. Promoting clinical and laboratory interaction by harmonization. Clin Chim Acta 2014; 432:15-21. [DOI: 10.1016/j.cca.2013.09.051] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 09/16/2013] [Accepted: 09/23/2013] [Indexed: 01/23/2023]
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Plebani M, Zaninotto M, Faggian D. Utilization management: A European perspective. Clin Chim Acta 2014; 427:137-41. [DOI: 10.1016/j.cca.2013.03.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 02/28/2013] [Accepted: 03/02/2013] [Indexed: 11/24/2022]
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Seegmiller AC, Kim AS, Mosse CA, Levy MA, Thompson MA, Kressin MK, Jagasia MH, Strickland SA, Reddy NM, Marx ER, Sinkfield KJ, Pollard HN, Plummer WD, Dupont WD, Shultz EK, Dittus RS, Stead WW, Santoro SA, Zutter MM. Optimizing personalized bone marrow testing using an evidence-based, interdisciplinary team approach. Am J Clin Pathol 2013; 140:643-50. [PMID: 24124142 DOI: 10.1309/ajcp8cke9neinqfl] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES To address the overuse of testing that complicates patient care, diminishes quality, and increases costs by implementing the diagnostic management team, a multidisciplinary system for the development and deployment of diagnostic testing guidelines for hematologic malignancies. METHODS The team created evidence-based standard ordering protocols (SOPs) for cytogenetic and molecular testing that were applied by pathologists to bone marrow biopsy specimens on adult patients. Testing on 780 biopsy specimens performed during the six months before SOP implementation was compared with 1,806 biopsy specimens performed during the subsequent 12 months. RESULTS After implementation, there were significant decreases in tests discordant with SOPs, omitted tests, and the estimated cost of testing to payers. The fraction of positive tests increased. Clinicians reported acceptance of the new procedures and perceived time savings. CONCLUSIONS This process is a model for optimizing complex and personalized diagnostic testing.
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Affiliation(s)
- Adam C. Seegmiller
- Departments of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Annette S. Kim
- Departments of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Claudio A. Mosse
- Departments of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN
- Department of Pathology and Laboratory Medicine, VA Tennessee Valley Healthcare System, Nashville, TN
| | - Mia A. Levy
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Mary Ann Thompson
- Departments of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Megan K. Kressin
- Departments of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN
- Department of Pathology and Laboratory Medicine, VA Tennessee Valley Healthcare System, Nashville, TN
| | - Madan H. Jagasia
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | | | - Nishitha M. Reddy
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Edward R. Marx
- Office of the Vice Chancellor for Health Affairs, Vanderbilt University School of Medicine, Nashville, TN
| | - Kristy J. Sinkfield
- Office of Strategy and Transformation, Vanderbilt University School of Medicine, Nashville, TN
| | - Herschel N. Pollard
- Office of Strategy and Transformation, Vanderbilt University School of Medicine, Nashville, TN
| | - W. Dale Plummer
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - William D. Dupont
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Edward K. Shultz
- Departments of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN
| | - Robert S. Dittus
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
- Institute for Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN
- Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN
| | - William W. Stead
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN
- Office of Strategy and Transformation, Vanderbilt University School of Medicine, Nashville, TN
| | - Samuel A. Santoro
- Departments of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Mary M. Zutter
- Departments of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN
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Abstract
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.
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Affiliation(s)
- Anthony A Fryer
- Department of Clinical Biochemistry, Keele University School of Medicine, University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, Staffordshire, UK
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29
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Abstract
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.
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Affiliation(s)
- W S A Smellie
- Department of Chemical Pathology, Bishop Auckland General Hospital, Cockton Hill Road, Bishop Auckland, County Durham DL14 6AD, UK.
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30
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Driskell OJ, Holland D, Hanna FW, Jones PW, Pemberton RJ, Tran M, Fryer AA. Inappropriate Requesting of Glycated Hemoglobin (Hb A1c) Is Widespread: Assessment of Prevalence, Impact of National Guidance, and Practice-to-Practice Variability. Clin Chem 2012; 58:906-15. [DOI: 10.1373/clinchem.2011.176487] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Estimates suggest that approximately 25% of requests for pathology tests are unnecessary. Even in diabetes, for which international guidance provides recommended testing frequency, considerable variability in requesting practice exists. Using the diabetes marker, Hb A1c, we examined (a) the prevalence of under- and overrequesting, (b) the impact of international guidance on prevalence, and (c) practice-to-practice variability.
METHODS
We examined Hb A1c requests (519 664 requests from 115 730 patients, January 2001 to March 2011) processed by the Clinical Biochemistry Department, University Hospital of North Staffordshire, and prevalence of requesting outside guidance from intervals between requests was calculated. Requests were classified as “appropriate,” “too soon,” or “too late.” We also assessed the effect of demographic factors and publication of guidance, along with between-practice variability, on prevalence.
RESULTS
Only 49% of requests conformed to guidance; 21% were too soon and 30% were too late. Underrequesting was more common in primary care, in female patients, in younger patients, and in patients with generally poorer control (all P < 0.001); the reverse generally was true for overrequesting. Publication of guidance (e.g., American Diabetes Association, UK National Institute for Health and Clinical Excellence) had no significant impact on under- or overrequesting rates. Prevalence of inappropriate requests varied approximately 6-fold between general practices.
CONCLUSIONS
Although overrequesting was common, underrequesting was more prevalent, potentially affecting longer-term health outcomes. National guidance appears to be an ineffective approach to changing request behavior, supporting the need for a multisystem approach to reducing variability.
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Affiliation(s)
- Owen J Driskell
- Department of Clinical Biochemistry, Keele University School of Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - David Holland
- National Pathology Benchmarking Service, Department of Medicines Management, and
| | - Fahmy W Hanna
- Department of Diabetes and Endocrinology, Norton Unit, University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - Peter W Jones
- School of Computing and Mathematics, Keele University, Staffordshire, UK
| | - R John Pemberton
- Diabetes UK North Staffordshire Branch, Newcastle-under-Lyme, Staffordshire, UK
| | - Martin Tran
- Department of Clinical Biochemistry, Keele University School of Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - Anthony A Fryer
- Department of Clinical Biochemistry, Keele University School of Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, UK
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McHugh J, Afghan R, O'Brien E, Kennedy P, Leahy M, O'Keeffe D. Impact of the Introduction of Guidelines on Vitamin B12 Testing. Clin Chem 2012; 58:471-2. [DOI: 10.1373/clinchem.2011.172734] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Johnny McHugh
- Department of Haematology Mid Western Regional Hospital Limerick, Ireland
| | - Rabia Afghan
- Department of Haematology Mid Western Regional Hospital Limerick, Ireland
| | - Edel O'Brien
- Department of Haematology Mid Western Regional Hospital Limerick, Ireland
| | - Patricia Kennedy
- Department of Haematology Mid Western Regional Hospital Limerick, Ireland
| | - Maeve Leahy
- Department of Haematology Mid Western Regional Hospital Limerick, Ireland
| | - Denis O'Keeffe
- Department of Haematology Mid Western Regional Hospital Limerick, Ireland
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32
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Sturgeon C, Hill R, Hortin GL, Thompson D. Taking a new biomarker into routine use--a perspective from the routine clinical biochemistry laboratory. Proteomics Clin Appl 2010; 4:892-903. [PMID: 21137030 PMCID: PMC3060337 DOI: 10.1002/prca.201000073] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 08/23/2010] [Indexed: 12/30/2022]
Abstract
There is increasing pressure to provide cost-effective healthcare based on “best practice.” Consequently, new biomarkers are only likely to be introduced into routine clinical biochemistry departments if they are supported by a strong evidence base and if the results will improve patient management and outcome. This requires convincing evidence of the benefits of introducing the new test, ideally reflected in fewer hospital admissions, fewer additional investigations and/or fewer clinic visits. Carefully designed audit and cost-benefit studies in relevant patient groups must demonstrate that introducing the biomarker delivers an improved and more effective clinical pathway. From the laboratory perspective, pre-analytical requirements must be thoroughly investigated at an early stage. Good stability of the biomarker in relevant physiological matrices is essential to avoid the need for special processing. Absence of specific timing requirements for sampling and knowledge of the effect of medications that might be used to treat the patients in whom the biomarker will be measured is also highly desirable. Analytically, automation is essential in modern high-throughput clinical laboratories. Assays must therefore be robust, fulfilling standard requirements for linearity on dilution, precision and reproducibility, both within- and between-run. Provision of measurements by a limited number of specialized reference laboratories may be most appropriate, especially when a new biomarker is first introduced into routine practice.
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33
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Janssens PM. Managing the demand for laboratory testing: Options and opportunities. Clin Chim Acta 2010; 411:1596-602. [DOI: 10.1016/j.cca.2010.07.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 07/17/2010] [Accepted: 07/18/2010] [Indexed: 11/29/2022]
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34
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Fraser CG. Problems with the investigation of a problem with faecal occult blood tests. Ann Clin Biochem 2010; 47:391-2; author reply 392. [DOI: 10.1258/acb.2010.010061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Callum G Fraser
- Scottish Bowel Screening Centre Laboratory, Kings Cross, Dundee DD3 8EA, Scotland
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