Demand management and test request rationalization

Guidance-Based Appropriateness of Hemostasis Testing in the Acute Setting

In this review, we aim to highlight the extent of inappropriate hemostasis testing and provide practical guidance on how to prevent it. We will focus on the acute setting, including but not limited to the emergency department and intensive care unit. To this end, we will first discuss the significance of inappropriateness, in the general context of laboratory medicine. This includes acknowledging the importance of the phenomenon and attempting to define it. Next, we describe the harmful consequences of inappropriate testing. Finally, we focus on the inappropriate use of hemostasis testing in the acute setting. The second section describes how interventions-in particular, the implementation of guidance for testing-can efficiently reduce inappropriateness. In the third section, we summarize the available recommendations for rational use of hemostasis testing (platelet count, activated partial thromboplastin time, prothrombin time/international normalized ratio, fibrinogen, thrombin time, D-dimer, anti-Xa assay, antithrombin, ADAMTS13 activity, antiheparin-PF4 antibodies, viscoelastometric tests, coagulation factors, and platelet function testing), as supported by guidelines, recommendations, and/or expert opinions. Overall, this review is intended to be a toolkit in the effort to promote the appropriate use of hemostasis testing. Hopefully, the new In Vitro Diagnostic Medical Device Regulation (EU) 2017/746 (IVDR) should help in improving the availability of evidence regarding clinical performance of hemostasis assays.

Revisiting the Environmental Impact of Inappropriate Clinical Laboratory Testing: A Comprehensive Overview of Sustainability, Economic, and Quality of Care Outcomes

BACKGROUND

The use of laboratory resources has seen a substantial increase in recent years, driven by automation and emerging technologies. However, inappropriate use of laboratory testing, encompassing both overuse and underuse, poses significant challenges.

CONTENT

This review explores the complex interplay between patient safety, economic, and environmental factors-known as the "triple bottom line" or "3Ps" for people, profit, and planet-associated with inappropriate use of laboratory resources. The first part of the review outlines the impact of inappropriate laboratory testing on patient safety and economic outcomes. Then the review examines the available literature on the environmental impact of laboratory activities. Several practical solutions for mitigating the environmental impact of laboratories are discussed. Finally, this review emphasizes how decreasing unnecessary laboratory testing results in cost savings and environmental benefits, as evidenced by interventional studies, without compromising patient safety.

SUMMARY

The implementation of sustainable practices in laboratories can create a virtuous circle in which reduced testing enhances cost-efficiency, reduces the environmental footprint, and ensures patient safety, thereby benefiting the 3Ps. This review highlights the critical need for appropriate laboratory resource utilization in achieving sustainability in healthcare.

Laboratory reflex testing strategy for the early identification of primary care patients with multiple myeloma

OBJECTIVES

Our objective was to shorten the screen for multiple myeloma (MM), through reflex testing.

DESIGN AND METHODS

The clinical laboratory in the public University Hospital of San Juan (Alicante, Spain), serves 234,551 inhabitants. Through an intervention agreed with general practitioners, the Laboratory Information System (LIS) automatically registered serum immunoglobulins (Ig) when serum total proteins (STP) > 80 g/L for the first time in primary care patients. When concomitantly one Ig presented a value above and one below its reference interval, the LIS automatically registered a serum protein electrophoresis (SPEP). When a monoclonal peak in SPEP, immunofixation electrophoresis (IFE) for the typification of monoclonal bands (MB) was performed. If MB were present, a comment in the report explained the intervention. The number of additionally registered Ig, SPEP, IFE, and new diagnosis of MM were counted. The number of days elapsed from the report of elevated STP result to the final MM diagnosis was also counted as median and interquartile range (IQR), and compared to a pre intervention period.

RESULTS

2071 cases of hyperproteinemia were identified, and had 91 a monoclonal peak, confirmed by IFE. In 35 patients it was a new finding, and 9 were diagnosed with MM, 3 Waldestrom macroglobulinemia, 2 lymphoplasmacytic lymphoma and 21 monoclonal gammopathy of undetermined significance. The number of days elapsed from hyperproteinemia to diagnosis was lower in the intervention period (21.5 vs 119.4) (P < 0.01). As our results show, in addition to shortening the time to diagnosis, an increased rate of detection of plasma cell disorders was observed when using our algorithm.

CONCLUSIONS

The above laboratory interventions agreed with clinicians, making use of laboratory technology resulted in early identification of MM.

The Copenhagen Primary Care Laboratory (CopLab) Database

Background

The Copenhagen General Practice Laboratory (CGPL) was founded in 1922 to provide paraclinical analyses to the primary health-care sector in Copenhagen. At the end of 2015, CGPL was closed and the CopLab database was established to make CGPL data available for research.

Methods

We isolated tests performed at the CGPL with clinically relevant test results. The database was linked to national registers containing health, social, and demographic information. Results are presented with descriptive statistics showing counts, percentages, medians, and interquartile ranges (IQR).

Results

The CopLab database includes 1,373,643 unique individuals from primary care with test results from laboratory analyses of blood/urine/semen as well as cardiac and lung function tests collected by CGPL from greater Copenhagen from 2000 to 2015. The CopLab database holds nearly all test results requested by general practitioners throughout years 2000 to 2015 for residents in the greater Copenhagen area. The median age of the individuals was 51 years and 59.7% were females. Each individual has a median of 4 requisitions. More than 1 million participants are currently alive and living in Denmark and may be followed in national registries such as the Danish National Patient Registry, Laboratory Database, National Prescription Database etc.

Interventions to improve appropriateness of laboratory testing in the intensive care unit: a narrative review

Healthcare expenses are increasing, as is the utilization of laboratory resources. Despite this, between 20% and 40% of requested tests are deemed inappropriate. Improper use of laboratory resources leads to unwanted consequences such as hospital-acquired anemia, infections, increased costs, staff workload and patient stress and discomfort. The most unfavorable consequences result from unnecessary follow-up tests and treatments (overuse) and missed or delayed diagnoses (underuse). In this context, several interventions have been carried out to improve the appropriateness of laboratory testing. To date, there have been few published assessments of interventions specific to the intensive care unit. We reviewed the literature for interventions implemented in the ICU to improve the appropriateness of laboratory testing. We searched literature from 2008 to 2023 in PubMed, Embase, Scopus, and Google Scholar databases between April and June 2023. Five intervention categories were identified: education and guidance (E&G), audit and feedback, gatekeeping, computerized physician order entry (including reshaping of ordering panels), and multifaceted interventions (MFI). We included a sixth category exploring the potential role of artificial intelligence and machine learning (AI/ML)-based assisting tools in such interventions. E&G-based interventions and MFI are the most frequently used approaches. MFI is the most effective type of intervention, and shows the strongest persistence of effect over time. AI/ML-based tools may offer valuable assistance to the improvement of appropriate laboratory testing in the near future. Patient safety outcomes are not impaired by interventions to reduce inappropriate testing. The literature focuses mainly on reducing overuse of laboratory tests, with only one intervention mentioning underuse. We highlight an overall poor quality of methodological design and reporting and argue for standardization of intervention methods. Collaboration between clinicians and laboratory staff is key to improve appropriate laboratory utilization. This article offers practical guidance for optimizing the effectiveness of an intervention protocol designed to limit inappropriate use of laboratory resources.

Managing Resource Utilization Cost of Laboratory Tests for Patients on Chemotherapy in Johns Hopkins Aramco Healthcare

Introduction

Laboratory testing is a fundamental diagnostic and prognostic tool to ensure the quality of healthcare, treatment, and responses. This study aimed to evaluate the cost of laboratory tests performed for patients undergoing chemotherapy treatment in the oncology treatment center at Johns Hopkins Aramco Healthcare in Saudi Arabia. Additionally, we aimed to reduce the cost of unnecessary laboratory tests in a 1-year period.

Methods

This was a quality improvement study with a quasi-experimental design using DMAIC methodology. The intervention strategy involved educating staff about adhering to the British Columbia Cancer Agency (BCCA) guidelines when ordering laboratory tests for chemotherapy patients, then integrating those guidelines into the electronic health record system. Data were collected for 200 randomly selected cases with 10 different chemotherapy protocols before and after the intervention. A paired t test was used to analyze differences in mean cost for all laboratory tests and unnecessary testing before and after the intervention.

Results

A significant cost reduction was achieved for unnecessary laboratory tests (77%, p < 0.01) when following the BCCA guidelines. In addition, the mean cost of all laboratory tests (including necessary and unnecessary) was significantly reduced by 45.5% (p = 0.023).

Conclusion

Lean thinking in clinical practice, realized by integrating a standardized laboratory test guided by BCCA guidelines into the electronic health record, significantly reduced financial costs within 1 year, thereby enhancing efficient resource utilization in the organization. This quality improvement project may serve to increase awareness of further efforts to improve resource utilization for other oncology treatment protocols.

Specific test panels for patients with heart failure: implementation and use in the Spanish National Health System

Objectives

The use of specific test panels (STP) for heart failure (HF) could help improve the management of this condition. The purpose of this study is to gain an insight into the level of implementation of STPs in the management of HF in Spain and gather the opinions of experts, with a special focus on parameters related to iron metabolism.

Methods

The opinions of experts in HF were gathered in three stages STAGE 1 as follows: level of implementation of STPs (n=40). STAGE 2: advantages and disadvantages of STPs (n=12). STAGE 3: level of agreement with the composition of three specific STPs for HF: initial evaluation panel, monitoring panel, and de novo panel (n=16).

Results

In total, 62.5% of hospitals used STPs for the clinical management of HF, with no association found between the use of STPs and the level of health care (p=0.132) and location of the center (p=0.486) or the availability of a Heart Failure Unit in the center (p=0.737). According to experts, the use of STPs in clinical practice has more advantages than disadvantages (8 vs. 3), with a notable positive impact on diagnostics. Experts gave three motivations and found three limitations to the implementation of STPs. The composition of the three specific STPs for HF was viewed positively by experts.

Conclusions

Although the experts interviewed advocate the use of diagnostic and monitoring STPs for HF, efforts are still necessary to achieve the standardization and homogenization of test panels for HF in Spanish hospitals.

Efficiency over thoroughness in laboratory testing decision making in primary care: findings from a realist review

Background

Existing research demonstrates significant variation in test-ordering practice, and growth in the use of laboratory tests in primary care. Reviews of interventions designed to change test-ordering practice report heterogeneity in design and effectiveness. Improving understanding of clinicians’ decision making in relation to laboratory testing is an important means of understanding practice patterns and developing theory-informed interventions.

Aim

To develop explanations for the underlying causes of patterns of variation and increasing use of laboratory tests in primary care, and make recommendations for future research and intervention design.

Design & setting

Realist review of secondary data from primary care.

Method

Diverse evidence, including data from qualitative and quantitative studies, was gathered via systematic and iterative searching processes. Data were synthesised according to realist principles to develop explanations accounting for clinicians’ decision making in relation to laboratory tests.

Results

A total of 145 documents contributed data to the synthesis. Laboratory test ordering can fulfil many roles in primary care. Decisions about tests are incorporated into practice heuristics and tests are deployed as a tool to manage patient interactions. Ordering tests may be easier than not ordering tests in existing systems. Alongside high workloads and limited time to devote to decision making, there is a common perception that laboratory tests are relatively inconsequential interventions. Clinicians prioritise efficiency over thoroughness in decision making about laboratory tests.

Conclusion

Interventions to change test-ordering practice can be understood as aiming to preserve efficiency or encourage thoroughness in decision making. Intervention designs and evaluations should consider how testing decisions are made in real-world clinical practice.

Serum Tumor Markers in Paraneoplastic Neurologic Syndromes: A Systematic Review of Guidelines

Purpose: Algorithms for the detection of a malignancy in patients with unclear neurologic symptoms of suspicious paraneoplastic origins are not universally applied. Frequently, circulating tumor markers (TMs) are considered a valuable tool for cancer diagnosis in patients with paraneoplastic neurologic syndromes (PNS). Our aim was to extract the recommendations on the use of TMs and onconeural antibodies (Abs) for the diagnosis of malignancies in PNS from clinical practice guidelines and put them forward as evidence in a common framework to facilitate diffusion, dissemination, and implementation.

Methods: Systematic literature searches were performed for guidelines on both oncology and PNS published since 2007. Guidelines containing information and recommendations for clinical practice pertaining to the screening and diagnosis of PNS were selected. Information on circulating TMs and onconeural Abs was extracted and synthesized in consecutive steps of increasing simplification.

Results: We retrieved 799 eligible guidelines on oncology for the potential presence of information on PNS but only six covered treated diagnosis or the screening of cancer in PNS, which were then selected. Seventy-nine potentially relevant guidelines on PNS were identified as eligible and 15 were selected. Synoptic tables were prepared showing that classical TMs are not recommended for the screening or the diagnosis of a malignancy in patients with a suspected PNS. Neither should onconeural Abs be considered to screen for the presence of a malignancy, although they could be helpful to define the probability of the paraneoplastic origin of a neurologic disorder.

Conclusion: The present work of synthesis may be a useful tool in the diffusion, dissemination, and implementation of guideline recommendations, potentially facilitating the decrease of the inappropriate use of circulating biomarkers for cancer screening in the presence of PNS.

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.

Systematic review of clinical guidelines for lipid lowering in the secondary prevention of cardiovascular disease events

BACKGROUND

The WHO recommends that those with established cardiovascular disease should be treated with lipid-lowering therapy, but there is no specific guidance regarding lipid monitoring. Unnecessary general practitioner visits may be a burden for patients and increase healthcare costs. A systematic review of the current guidelines was performed to reveal gaps in the evidence base for optimal lipid monitoring approaches.

METHODS

For this systematic review, a search of Medline, Cumulative Index to Nursing and Allied Health Literature and Turning Research Into Practice databases was conducted for relevant guidelines published in the 10 years prior to 31 December 2019. Recommendations surrounding the frequency of testing, lipid-lowering therapies and target cholesterol values were compared qualitatively. Each guideline was assessed using the 2009 Appraisal of Guidelines for Research and Evaluation II tool.

RESULTS

Twenty-two guidelines were included. All recommended statins as the primary lipid-lowering therapy, with a high level of supporting evidence. Considerable variation was found in the recommendations for cholesterol targets. Seventeen guidelines provided at least one cholesterol target, which for low-density lipoprotein (LDL) cholesterol ranged between 1.0 and 2.6 mmol/L, although the most frequently recommended was <1.8 mmol/L (n=12). For long-term follow-up, many recommended reviewing patients annually (n=9), although there was some variation in recommendations for the interval of between 3 and 12 months. Supporting evidence for any approach was limited, often being derived from clinical opinion.

CONCLUSIONS

Further research is required to provide an evidence base for optimal lipid monitoring of the on-statin secondary prevention population.

Inappropriate practice in tumor marker requests at a university hospital in Western Saudi Arabia: A 3-year retrospective study

OBJECTIVES

This study assessed the level of appropriateness of tumor marker requests in a teaching hospital and estimated the financial cost associated with inappropriate use.

METHODS

A retrospective review of patients' electronic records was conducted over a 3-year period (2015-2017) for tumor marker requests, including carcinoembryonic antigen, alpha-fetoprotein, cancer antigen (CA)15-3, CA125, CA19-9, and total and free prostate-specific antigen (PSA and fPSA), along with the associated clinical data that motivated the requests. Inappropriate use was defined as tumor marker requests without any relevant clinical picture. Costs due to inappropriate tumor marker requests were estimated based on the unit costs applied in the institution.

RESULTS

A total of 7128 patients had at least one tumor marker request between 2015 and 2017. The clinical picture that motivated tumor marker requests was absent in 71.5%, while 12.9% of the requests were associated with a malignancy. The most frequent prescribing pattern was total prostate-specific antigen alone (2128; 29.9%), followed by alpha-fetoprotein alone (1185; 16.6%), and carcinoembryonic antigen alone (506; 7.1%). Year-over-year analysis revealed an increasing tendency in requesting carcinoembryonic antigen and CA15-3. The rate of inappropriate use varied by tumor marker and ranged between 56.4% for fPSA and 86.8% for total prostate-specific antigen. The overall costs due to inappropriate tumor marker requests were estimated at $2,785,493 over the 3 years, representing an average of $0.93 million per year.

CONCLUSION

Inappropriate use of tumor marker requests is a major issue regarding its high prevalence and the considerable associated costs. The role of laboratories in the management of tumor marker requests should be emphasized.

Evaluating the long-term effects of a data-driven approach to reduce variation in emergency department pathology investigations: study protocol for evaluation of the NSW Health Pathology Atlas of variation

INTRODUCTION

Variation in test ordering is a major issue in Australia and globally with significant financial and clinical impacts. There is currently a lack of research identifying and remediating variation in the use of pathology tests in emergency departments (EDs). In 2019, NSW Health Pathology introduced the Pathology Atlas of Variation that uses a data-driven tool (the Atlas Analytical Model) to investigate test order variation across New South Wales (NSW) and engage with local health districts (LHDs) to reduce variation. The objectives of this study are to evaluate whether this data-driven approach is associated with: (1) a reduction in test order variation; (2) improvements in patient outcomes and (3) cost benefits, for the five most frequent ED presentations.

METHODS AND ANALYSIS

This is a large multisite study including 45 major public hospitals across 15 LHDs in NSW, Australia. The Atlas Analytical Model is a data analytics and visualisation tool capable of providing analytical insights into variation in pathology investigations across NSW EDs, which will be used as feedback to inform LHDs efforts to reduce variation. Interrupted time series analyses using 2 years pre Atlas (2017-2018) and 2 years post Atlas (2021-2022) data will be conducted. Study data will be obtained by linking hospital and laboratory databases. Funnel plots will be used to identify EDs with outlying pathology test ordering practices. The outcome measures include changes in test ordering practices, ED length of stay, hospital admission and cost benefits (total pathology costs per ED encounter).

ETHICS AND DISSEMINATION

The study has received ethical approval from the NSW Population and Health Service Research Ethics Committee (reference, 2019/ETH00184). The findings of the study will be published in peer-reviewed journals and disseminated via presentations at conferences. We will also engage directly with key stakeholders to disseminate the findings and to inform policies related to pathology testing in the ED.

A compulsory pop-up form reduces the number of vitamin D requests from general practitioners by 25 percent

OBJECTIVE

Healthcare costs, including costs for laboratory tests, are increasing worldwide. One example is the measurement of vitamin D. General practitioners in the Capital Region of Denmark include a vitamin D status in approximately 20% of all laboratory requisitions. This study intended to examine the effect of a compulsory pop-up form in the electronic request system on the number of vitamin D tests and to monitor the indications.

DESIGN

From 1 January 2017, we introduced a compulsory pop-up form in which the general practitioners had to state the indication for measuring vitamin D, choosing from a predefined set of indications. Intervention practitioners were compared with control practitioners before and after the intervention.

SETTING

General practices in the Capital Region of Denmark.

SUBJECTS

In total, 572 general practitioners and 383,964 patients were included in the period from 1 January 2016 to 31 December 2018.

MAIN OUTCOME MEASURES

Number of vitamin D tests and distribution of indications.

RESULTS

We observed a drop in number of vitamin D requisitions to 70% (in 2017) and 75% (in 2018) relative to 2016. During the same period, the number of requisitions increased by 33% in a non-intervention group of practitioners. The indication 'Monitoring of treatment with vitamin D' was the most frequently used indication, recorded in 121,475 patients.

CONCLUSION

A compulsory pop-up form reduces the number of vitamin D requests from general practitioners by 25%. The implication is that pop-up forms can be used to decrease healthcare costs.

The clinically effective use of cardiac markers by restructuring laboratory profiles at Cardiology wards

Background

Laboratory overutilization is associated with diagnostic error and potential patient risk. We applied a demand management strategy in collaboration with the local Department of Cardiology to reduce the cardiac markers high-sensitive troponin T (hsTropT) and N-terminal pro brain natriuretic peptide (NTproBNP) in laboratory ordering profiles (LOPs). The present study aimed to retrospectively evaluate the implemented strategies.

Methods

Strategies included educational measures and evidence-guided, active test de-selection from all cardiology ward LOPs, and/or permanent removal from LOPs. Tests remained available at all times. We evaluated overutilization by reductions in monthly orders, and assessed differences in 30-day all-cause readmission rate and length of patients' hospital stay.

Results

Overall, we observed a mean reduction of 66.1% ± 7.6% (n = 277 ± 31) in hsTropT tests. Educational measures effectively reduced NTproBNP orders by 52.8% ± 17.7% (n = 60 ± 20). Permanent removal of tests from LOPs additionally decreased orders to a final extent of 75.8% ± 8.0% (n = 322 ± 31) in NTproBNP tests. The 30-day readmission rate and overall length of hospital stay did not increase.

Conclusions

Our results indicate that cardiac markers in routine care are subject to extensive overutilization when used within LOPs. Educational measures are an effective strategy to overcome the overutilization of cardiac markers but may be more effective when combined with the removal of cardiac markers from LOPs.

Blood sampling during nurse triage reduces patient length of stay in the emergency department: A propensity score-weighted, population-based study

BACKGROUND

Increases in patients' length of stay (LOS) in the emergency department (ED) have led to overcrowding.

OBJECTIVES

In this study, the implementation of blood sampling during triage in lower priority level patients was assessed as a possible means to reduce LOS.

METHODS

A retrospective study was performed from January 2018 to January 2019. Lower priority level patients who required blood sampling for further diagnosis were considered. Patients who underwent blood sampling during triage evaluation were compared with those who underwent blood sampling after a physician's initial evaluation.

RESULTS

During the study period, 15,596 patients were enrolled. LOS was shorter in patients who underwent triage blood sampling, presenting a median value of 154 min in comparison with the 172 min recorded in the control group (p < 0.001). Using a propensity score-matching to control the two groups' differences, LOS remained lower in the triage-sampling group (151 vs. 175 min; p < 0.001). In the adjusted multivariate model, triage blood sampling was found to be an independent factor for a decrease in the LOS, with standardized coefficient β = 0.857 (0.822-0.894; p < 0.001).

CONCLUSIONS

Performing blood sampling during nurse triage can decrease LOS in ED and also reduce ED permanence after a physician's initial evaluation.

Clinicians' and laboratory medicine specialists' views on laboratory demand management: a survey in nine European countries

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.

Effectiveness of minimum retesting intervals in managing repetitive laboratory testing: experience from a Croatian university hospital

Introduction

Inappropriate laboratory retesting can be addressed by implementing minimum retesting intervals (MRI). The aim of our study was to assess the effectiveness of the implemented MRI protocol for inpatients.

Materials and methods

Minimum retesting intervals were applied for 53 laboratory tests. The overall reduction of test requests, reduction in charges and reagent cost savings, frequency of MRI alert appearance as well as the rate of MRI acceptance and ignorance were calculated for a one-year period. Reasons for violating the MRI rule, hospital departments that contributed mostly to MRI rule violation, and the frequency of MRI violations between routine and emergency laboratory were evaluated.

Results

During the one-year period, 106,780 requests violated the MRI rule, which corresponds to 14.8% of all requests received. 13,843 requests were cancelled, yielding a 1.9% reduction of requested tests. High-volume tests, namely complete blood count, C-reactive protein, alanine aminotransferase, gamma-glutamyltransferase and total bilirubin, accounted for 65% of all generated alerts and had the highest alert ignorance (>85%). The highest cancellation rate was observed for tumor markers and autoimmunity tests, for most being at least 50%. Annual charge reduction was 62,641 EUR while reagent cost savings were 11,408 EUR. Tests performed in the emergency laboratory had a higher alert appearance than the same routine tests. The most common reason for MRI violation was clinical justification based on the patient's condition. Most frequently ignored MRI alerts were in the intensive care unit.

Conclusion

MRI implementation showed limited effectiveness in reducing testing repetition and achieving financial savings, yet provided the basis for future improvements.

Impact of blood cell counts and volumes on glucose concentration in uncentrifuged serum and lithium-heparin blood tubes

BACKGROUND

Although it is known that glucose concentration exhibits a time-dependent decay in uncentrifuged serum and lithium-heparin blood tubes, no evidence exists on how this variation may depend on blood cell counts (CBC) and volumes.

METHODS

Venous blood was drawn from 30 non fasting healthy volunteers into three serum and three lithium-heparin tubes. One serum and lithium-heparin tubes were centrifuged within 15 min after collection and glucose was measured with a hexokinase assay. The second and third serum and lithium-heparin tubes were maintained at room temperature for 1 and 2 h after the first tubes were centrifuged. These other tubes were then centrifuged and glucose was measured. CBC was performed in the first lithium-heparin tube, before centrifugation.

RESULTS

The mean decrease of glucose was higher in lithium-heparin plasma than in serum (0.33 vs. 0.24 mmol/L/h; p<0.001). Glucose concentration decreased by 7% and 5% per hour in lithium-heparin plasma and serum, respectively. In univariate analysis, the absolute decrease of glucose concentration was associated with sex (higher in men than in women), red blood cell (RBC) count, hematocrit, white blood cell (WBC) count, neutrophils and monocytes in both lithium-heparin plasma and serum. In multivariate analysis, the decrease of glucose concentration remained independently associated with RBC, WBC, neutrophils and monocytes in both sample matrices. No significant association was found with platelet number and erythrocyte or platelet volume.

CONCLUSIONS

Glucose concentration decrease in uncentrifuged lithium-heparin and serum tubes depends on the baseline number of RBC, WBC, neutrophils and monocytes within the tubes.

Interventions to prevent iatrogenic anemia: a Laboratory Medicine Best Practices systematic review

BACKGROUND

As many as 90% of patients develop anemia by their third day in an intensive care unit (ICU). We evaluated the efficacy of interventions to reduce phlebotomy-related blood loss on the volume of blood lost, hemoglobin levels, transfusions, and incidence of anemia.

METHODS

We conducted a systematic review and meta-analysis using the Laboratory Medicine Best Practices (LMBP) systematic review methods for rating study quality and assessing the body of evidence. Searches of PubMed, Embase, Cochrane, Web of Science, PsychINFO, and CINAHL identified 2564 published references. We included studies of the impact of interventions to reduce phlebotomy-related blood loss on blood loss, hemoglobin levels, transfusions, or anemia among hospital inpatients. We excluded studies not published in English and studies that did not have a comparison group, did not report an outcome of interest, or were rated as poor quality. Twenty-one studies met these criteria. We conducted a meta-analysis if > 2 homogenous studies reported sufficient information for analysis.

RESULTS

We found moderate, consistent evidence that devices that return blood from flushing venous or arterial lines to the patient reduced blood loss by approximately 25% in both neonatal ICU (NICU) and adult ICU patients [pooled estimate in adults, 24.7 (95% CI = 12.1-37.3)]. Bundled interventions that included blood conservation devices appeared to reduce blood loss by at least 25% (suggestive evidence). The evidence was insufficient to determine if these devices reduced hemoglobin decline or risk of anemia. The evidence suggested that small volume tubes reduced the risk of anemia, but was insufficient to determine if they affected the volume of blood loss or the rate of hemoglobin decline.

CONCLUSIONS

Moderate, consistent evidence indicated that devices that return blood from testing or flushing lines to the patient reduce the volume of blood loss by approximately 25% among ICU patients. The results of this systematic review support the use of blood conservation systems with arterial or venous catheters to eliminate blood waste when drawing blood for testing. The evidence was insufficient to conclude the devices impacted hemoglobin levels or transfusion rates. The use of small volume tubes may reduce the risk of anemia.

Primary care use of laboratory tests in Northern Ireland's Western Health and Social Care Trust: a cross-sectional study

OBJECTIVES

To describe the laboratory test ordering patterns by general practitioners (GPs) in Northern Ireland Western Health and Social Care Trust (WHSCT) and explore demographic and socioeconomic associations with test requesting.

DESIGN

Cross-sectional study.

SETTING

WHSCT, Northern Ireland. : Particip ANTS: 55 WHSCT primary care medical practices that remained open throughout the study period 1 April 2011-31 March 2016.

OUTCOMES

To identify the temporal patterns of laboratory test ordering behaviour for eight commonly requested clinical biochemistry tests/test groups in WHSCT. To analyse the extent of variations in laboratory test requests by GPs and to explore whether these variations can be accounted for by clinical outcomes or geographical, demographic and socioeconomic characteristics.

RESULTS

The median number of adjusted test request rates over 5 consecutive years of the study period decreased by 45.7% for urine albumin/creatinine ratio (p<0.000001) and 19.4% for lipid profiles (p<0.000001) while a 60.6%, 36.6% and 29.5% increase was observed for HbA_1c (p<0.000001), immunoglobulins (p=0.000007) and prostate-specific antigen (PSA) (p=0.0003), respectively. The between-practice variation in test ordering rates increased by 272% for immunoglobulins (p=0.008) and 500% for HbA_1c (p=0.0001). No statistically significant relationship between ordering activity and either demographic (age and gender) and socioeconomic factors (deprivation) or Quality and Outcome Framework scores was observed. We found the rural-urban differences in between-practice variability in ordering rates for lipid profiles, thyroid profiles, PSA and immunoglobulins to be statistically significant at the Bonferroni-adjusted significance level p<0.01.

CONCLUSIONS

We explored potential factors of the interpractice variability in the use of laboratory tests and found that differences in requesting activity appear unrelated to either demographic and socioeconomic characteristics of GP practices or clinical outcome indicators.

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.

Appropriateness of Using Tests for Blood Glucose and Diabetic Complications in Clinical Practice: Experiences in a Hospital in Thailand

BACKGROUND This study aimed to evaluate how the tests for blood glucose (BG) and diabetic complications have been utilized in a hospital in Thailand. MATERIAL AND METHODS Patient medical records having the results of BG, HbA1c, and/or urine microalbumin presented and the records of DM patients having the results of serum lipids, serum LDL-C, and/or serum creatinine presented were selected. The data of diagnosis, ordered tests, and testing results in these records were extracted for evaluation. RESULTS This study recruited 1066 patients diagnosed with DM and 3081 patients diagnosed with other diseases. Point-of-care testing (POCT) for BG was repeatedly used in 371 non-DM cases; most of its results were normal. The results of BG and HbA1c were often used together. There was a good relationship between them, and these test results indicated poor glycemic control in 58% of DM cases. In non-DM cases, the test results agreed, indicating normoglycemia in 17.32%, pre-diabetes in 20.47%, and diabetes in 21.78%. To prevent diabetic nephropathy, serum creatinine was frequently used, whereas urine microalbumin, the recommended test, was underutilized. The result of LDL-C from both direct measurement and calculation were used; however, based on the same guidelines, the results of measured LDL-C indicated risk of cardiovascular diseases in a higher percentage of DM cases than did the results of calculated LDL-C. CONCLUSIONS The use of POCT for BG in hospitalized patients may be inappropriate. The utilization of urine microalbumin should be promoted to effectively prevent diabetic nephropathy.

Clinical Management of Low Vitamin D: A Scoping Review of Physicians' Practices

The role of vitamin D in the prevention and treatment of non-skeletal health issues has received significant media and research attention in recent years. Costs associated with clinical management of low vitamin D (LVD) have increased exponentially. However, no clear evidence supports vitamin D screening to improve health outcomes. Authoritative bodies and professional societies do not recommend population-wide vitamin D screening in community-dwelling adults who are asymptomatic or at low risk of LVD. To assess patterns of physicians’ management of LVD in this conflicting environment, we conducted a scoping review of three electronic databases and the gray literature. Thirty-eight records met inclusion criteria and were summarized in an evidence table. Thirteen studies published between 2006 and 2015 across seven countries showed a consistent increase in vitamin D lab tests and related costs. Many vitamin D testing patterns reflected screening rather than targeted testing for individuals at high risk of vitamin D deficiency or insufficiency. Interventions aimed at managing inappropriate clinical practices related to LVD were effective in the short term. Variability and controversy were pervasive in many aspects of vitamin D management, shining a light on physicians’ practices in the face of uncertainty. Future research is needed to inform better clinical guidelines and to assess implementation practices that encourage evidence-based management of LVD in adult populations.

Errors in the Extra-Analytical Phases of Clinical Chemistry Laboratory Testing

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.

Extent and cost of inappropriate use of tumour markers in patients with pulmonary disease: a multicentre retrospective study in Shanghai, China

OBJECTIVES

The currently implemented healthcare reform in China requires substantial capital investment. Although overtreatment results in serious waste, inappropriate laboratory use is widespread, and overuse of tumour markers (TMs) has attracted increasing attention.

DESIGN

Retrospective study.

SETTING

The respiratory, thoracic surgery and oncology departments of three hospitals in Shanghai from 2014 to 2015.

PARTICIPANTS

Patients with chronic obstructive pulmonary disease (COPD) and primary bronchogenic lung cancer (PLC). Based on clinical guidelines and physician experience, the criteria of suitability of TM examinations were determined, and the number, cost and proportion of inappropriate TM requests were analysed.

RESULTS

The area under the receiver operating characteristic curve for carcinoembryonic antigen+cytokeratin fragment 21-1+squamous cell carcinoma antigen+neuron-specific enolase in patients with COPD and PLC was 0.813, in accordance with the cost-effectiveness principle, indicating good clinical and health economics values. In the 2706 patients, 12 496-16 956 (58.27%-79.06%) of TM requests were inappropriate. Furthermore, the involved expense was 650 200-1 014 156 yuan, accounting for 7.69%-12.00% of examination expenses and 1.35%-2.11% of hospitalisation costs.

CONCLUSIONS

We found that the inappropriate use of TMs was widespread for patients with pulmonary disease. Clinicians should use TMs strictly according to the guidelines to effectively manage laboratory resources and control costs.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Epidemiology-based assessment of tumor marker overordering in breast cancer: an algorithm to examine different disease conditions

Laboratory tests are frequently overused and have elevated inappropriateness rates. We previously developed a model to investigate the rate of utilization of tumor markers (TMs) in outpatients as an indirect indicator of inappropriateness. The model was based on the comparison between the number of actually ordered and expected tests, with the latter estimated on the basis of both epidemiological data and recommendations of available clinical practice guidelines.In this paper we propose an algorithm to distinguish prevalent cases without evidence of disease from those with metastatic spread, on the basis of both epidemiological and clinical information. The algorithm allows for a more precise prediction of the expected TM requests per year, to be compared with the actual number of requested TMs in order to assess possibly inappropriate overordering rates. Moreover, the implementation of the algorithm renders the epidemiologically based model more flexible to develop accurate indicators for appropriateness in the use of TMs in different stages of disease and for different clinical questions. A practical application with CA15.3 requests in breast cancer is presented.

Evaluating the appropriateness of hospital doctors' requests for pulmonary function tests beyond basic spirometry: results from a prospective observational study

OBJECTIVES

Hospitalists request 'complete' pulmonary function tests (PFTs), typically comprising of spirometry, diffusion capacity of the lung for carbon monoxide (DLCO) and absolute lung volumes (ALVs), the results of which assist in the management of patients with respiratory disorders. Recently, concerns have been raised about over-requesting of 'complete' PFTs, but there is a paucity of information on the proportion of requests that can be considered clinically inappropriate. This study prospectively evaluated the 'complete' PFTs requested in a hospital service and assessed the impact of medical review of the requests.

METHODS

A six-month prospective study on requests to two teaching hospital PFT laboratories from non-respiratory doctors was undertaken. Requests at one laboratory underwent review by a respiratory doctor ('intervention laboratory') while requests at the second laboratory were not reviewed ('control laboratory'). The appropriateness of requests was measured against pre-specified criteria.

RESULTS

PFT requests for 335 subjects were included in the study. In the intervention laboratory, 8 of 110 ALV and 122 of 134 DLCO requests fulfilled pre-specified criteria for appropriate test indications. Fewer ALV (7% vs. 100%, p < 0.001) and DLCO tests (91% vs. 100%, p = 0.031) could have been performed in the intervention laboratory compared to the control laboratory.

CONCLUSION

A considerable proportion of 'complete' PFT requests from non-respiratory hospital doctors may be unwarranted. Using a simple screening method, the number of unnecessary PFTs could be reduced, resulting in substantial time and cost savings for hospital PFT laboratories.

Appropriateness of tumor marker request: a case of study

Appropriateness is crucial to provide efficient and high-quality health services at affordable costs. Laboratory medicine is a sector of special interest for the investigation of inappropriateness, due to the high rate of technological innovation and its pivotal role in many diseases and clinical settings. Some subjective aspects related to either the patient or physician seem to have a major role on inappropriateness rates. Given the psychological impact of cancer on both patients and physicians, tumor markers represent a case of study for appropriateness. The assessment of inappropriateness of laboratory tests has been focused mainly on ordering patterns. Appropriateness can barely be appraised by matching the requested test with the clinical problem because clinical information on the test requisition form is usually inadequate. Monitoring inappropriateness through individual clinical information may be feasible in inpatient (clinical data are available), while an indirect approach should be used for outpatients. To estimate inappropriateness in outpatients our group developed innovative models based on comparison between the actually ordered and expected requests of tumor marker, calculated according to recommendations of clinical practice guidelines (CPGs) applied to figures of cancer prevalence. The implementation of the model at national scale in Italy led to recognize a very high rate of overordering of tumor markers. The model was further focused by a dedicated algorithm to be adapted to different clinical conditions or organizational settings by applying performance indicators to cohort-wide structured information in electronic health records (EHRs). With this novel approach, we showed that inappropriateness is multifaceted even within the specific category of tumour markers. The model was effective in identifying both over- and underordering. Implementation of evidence based information and monitoring their impact on the clinical practice are parts of the same, multistage, process aimed at the progressive improvement of health care.

Demand management by electronic gatekeeping of test requests does not influence requesting behaviour or save costs dramatically

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.

Failure to review STAT clinical laboratory requests and its economical impact

Background

Failure to follow-up laboratory test results has been described as one of the major processes contributing to unsafe patient care. Currently, most of the laboratories do not know with certainty not only their rate of missed (or unreviewed) requests but the economical cost and impact that this issue implies. The aim of our study was to measure that rate and calculate the resulting costs.

Material and methods

In January 2015, we checked in our Laboratory Information Management System (LIMS) for every emergency request from 1^st July 2011 to 30^th June 2014, if they had been reviewed by any allowed user or not. 319,064 requests were ordered during that period of time. Results were expressed as “ordered requests”, “missed requests” and its percentage. Additionally, total cost of missed requests was calculated in euros (€). “Non-productive days” were theorised (as the days producing requests that were not reviewed) based on these results.

Results

7924 requests (2.5%) were never reviewed by clinicians. This represented a total cost of 203,039 € and 27 “non-productive” days in three years. Significant differences between inpatients, outpatients and emergency department as well as different emergencies units were found after application of statistical analysis.

Conclusions

In terms of resources, never reviewed or missed requests appear to be a not negligible problem for the clinical laboratory management. Electronic result delivery, with electronic endorsement to indicate follow-up of requests along with better systems of electronic requesting should be investigated as a way of improving patient outcomes and save unnecessary expenses.

Computer-based-limited and personalised education management maximise appropriateness of vitamin D, vitamin B12 and folate retesting

Aim

To identify the best management strategy for improving the appropriateness of vitamin D, vitamin B12 and folate retesting.

Methods

The study was conducted between 3 November 2012 and 8 June 2015, with inpatients and outpatients being considered separately. After an observational reference period (3 November 2012 to 14 September 2013), an information technology (IT)-based permissive strategy (16 September 2013 to 27 July 2014) followed by a limiting strategy was used to manage the demand for inpatient retesting. For outpatients, an educational strategy period (28 July 2014 to 16 December 2014) with direct contact between medical personnel and general practitioners (GPs) was followed by a post-educational period without any restriction. Data from a total of 66 496 patients for vitamin D, 14 618 for vitamin B12 and 14 445 for folate were retrieved from the laboratory IT system. The main outcomes measures were inappropriate vitamin D, vitamin B12 and folate retesting. The minimal retesting intervals were 90 (vitamin D) or 180 days (vitamin B12 and folate).

Results

In the absence of a laboratory demand strategy, the frequency of inappropriate retesting for vitamin D, vitamin B12 and folate was 60%, 94% and 93%, respectively, for inpatients, and 27%, 87% and 87%, respectively, for outpatients. A limiting IT-based demand management strategy reduced inappropriate retesting for vitamin D (36%), but not for vitamin B12 and folate. The educational strategy was followed by a reduction in inappropriate retesting among outpatients (16% for vitamin D, 72% for vitamin B12 and folate).

Conclusions

Laboratory demand management based on an IT-limiting management strategy or on education of the referring physicians appears helpful in maximising appropriate retesting.

Tumor Marker Ordering: Do Not Lose Control: A Prospective Clinical Trial

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.

Request of laboratory liver tests in primary care in Spain: potential savings if appropriateness indicator targets were achieved

AIMS

Liver laboratory tests are used to screen for liver disease, suggest the underlying cause, estimate the severity, assess prognosis, and monitor the efficacy of therapy. The aim of this study was to compare the liver laboratory tests requesting patterns by GPs in Spain, according to geographic and hospital characteristics, to investigate the degree of requesting appropriateness.

MATERIALS AND METHODS

One hundred and forty-one clinical laboratories were invited to participate from diverse regions across Spain. They filed out the number of laboratory liver tests requested by GPs for the year 2012. Two types of appropriateness indicators were calculated: every test request per 1000 inhabitants or ratios of related tests requests. The indicator results obtained were compared between the different hospitals, according to their setting, location, and management. The savings generated, if each area would have achieved indicator targets, were calculated.

RESULTS

We recruited 76 laboratories covering a population of 17,679,195 inhabitants. GPs requested 20,916,780 laboratory liver tests in the year 2012. No differences were obtained according to their setting. Lactate dehydrogenase and direct bilirubin per 1000 inhabitants were significantly higher in institutions with private management. Largest differences were observed between communities. Nine, 31, 0, and 13 laboratories, respectively, achieved the aspartate aminotransferase, lactate dehydrogenase, γ-glutamyl transpeptidase, and total bilirubin-related alanine aminotransferase indicator targets. Reaching ratios would have resulted in savings of €1,028,468.

CONCLUSION

There was a high variability in the request of liver tests. This emphasizes the need to implement interventions to improve appropriate use of liver tests.

Demand management: an audit of chemical pathology test rejections by an electronic gate-keeping system at an academic hospital in Cape Town

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.

Value-based flow testing of chronic lymphoproliferative disorders: a quality improvement project to develop an algorithm to streamline testing and reduce costs

OBJECTIVES

Flow cytometry is essential for the evaluation of lymphoproliferative disorders (LPDs) and their classification. Flow panels routinely incorporate a large array of antibodies, making testing complex and expensive; such panels are likely unnecessary in benign cases or those with straightforward diagnoses. Our aim was to develop a more cost-effective testing strategy based on a retrospective analysis of flow studies for possible LPDs in blood.

METHODS

We identified LPD frequencies and types, as well as associated results with patient age and absolute lymphocyte count.

RESULTS

We found that the likelihood of LPDs increased with patient age and absolute lymphocyte count and that CD5-positive LPD was the most common LPD diagnosed in our institution (71% of LPDs). Using these data, we devised flow-testing algorithms with a screening test for patients at low risk of disease and a focus on CD5-positive LPD detection, with reflexing as needed.

CONCLUSIONS

We project this approach will result in a 40% decrease in antibody utilization.

The laboratory test utilization management toolbox

Efficiently managing laboratory test utilization requires both ensuring adequate utilization of needed tests in some patients and discouraging superfluous tests in other patients. After the difficult clinical decision is made to define the patients that do and do not need a test, a wealth of interventions are available to the clinician and laboratorian to help guide appropriate utilization. These interventions are collectively referred to here as the utilization management toolbox. Experience has shown that some tools in the toolbox are weak and other are strong, and that tools are most effective when many are used simultaneously. While the outcomes of utilization management studies are not always as concrete as may be desired, what data is available in the literature indicate that strong utilization management interventions are safe and effective measures to improve patient health and reduce waste in an era of increasing financial pressure.

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.

Variation in diagnostic testing in ICUs: a comparison of teaching and nonteaching hospitals in a regional system

OBJECTIVES

To explore variation in the use of diagnostic testing in ICUs, with emphasis on differences between teaching and nonteaching ICUs.

DESIGN

Retrospective review of a prospective clinical ICU database.

SETTING

Five teaching and four nonteaching ICUs in Winnipeg, Canada, during 2006-2010.

PATIENTS

All adults admitted to the nine ICUs during the study period were eligible. After excluding subgroups restricted to teaching ICUs, inter-ICU transfers, prior ICU admission within 90 days, ICU length of stay less than 12 hours, and missing death dates, 10,262 patients were evaluated.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Our primary outcome variable (TotalTesting) was the cumulative number of nine common laboratory tests, three radiologic tests, and electrocardiograms performed in each ICU. We used multivariable median regression to identify factors associated with TotalTesting, including length of stay, demographics, admission details, type and severity of acute illness, and specific medical interventions. We estimated the predictive power of variables as the decline in pseudo-R2 (a goodness-of-fit measure for median regression) when omitting those variables from the model. Median (interquartile range) TotalTesting was 27 (18-49) in teaching ICUs and 20 (13-36) in nonteaching units. With multivariable adjustment, median TotalTesting was 7.1 higher (95% CI, 6.6-7.7) in teaching ICUs. The most influential variable was length of stay, accounting for almost half of the variation. ICU teaching status was the second most important factor, greater than the degree of physiologic derangement and details of medical management.

CONCLUSIONS

After adjustment for confounding variables, patients in teaching ICUs had slightly but significantly more diagnostic tests done than those in nonteaching ICUs. In addition to increasing costs, prior studies have shown that excessive testing can cause harm in various ways and does not improve outcomes. Interventions to reduce testing should be directed to all caregivers with responsibility for ordering diagnostic tests, in both teaching and nonteaching institutions.

Harmonization of pre-analytical quality indicators

Quality indicators (QIs) measure the extent to which set targets are attained and provide a quantitative basis for achieving improvement in care and, in particular, laboratory services. A body of evidence collected in recent years has demonstrated that most errors fall outside the analytical phase, while the pre- and post-analytical steps have been found to be more vulnerable to the risk of error. However, the current lack of attention to extra-laboratory factors and related QIs prevent clinical laboratories from effectively improving total quality and reducing errors. Errors in the pre-analytical phase, which account for 50% to 75% of all laboratory errors, have long been included in the ‘identification and sample problems’ category. However, according to the International Standard for medical laboratory accreditation and a patient-centered view, some additional QIs are needed. In particular, there is a need to measure the appropriateness of all test request and request forms, as well as the quality of sample transportation. The QIs model developed by a working group of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) is a valuable starting point for promoting the harmonization of available QIs, but further efforts should be made to achieve a consensus on the road map for harmonization.

Establishing benchmarks and metrics for disruptive technologies, inappropriate and obsolete tests in the clinical laboratory

Benchmarks and metrics related to laboratory test utilization are based on evidence-based medical literature that may suffer from a positive publication bias. Guidelines are only as good as the data reviewed to create them. Disruptive technologies require time for appropriate use to be established before utilization review will be meaningful. Metrics include monitoring the use of obsolete tests and the inappropriate use of lab tests. Test utilization by clients in a hospital outreach program can be used to monitor the impact of new clients on lab workload. A multi-disciplinary laboratory utilization committee is the most effective tool for modifying bad habits, and reviewing and approving new tests for the lab formulary or by sending them out to a reference lab.