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Caruso S, Szoke D, Panteghini M. 'Penelope test': a practical instrument for checking appropriateness of laboratory tests. Clin Chem Lab Med 2022; 60:1342-1349. [PMID: 35785546 DOI: 10.1515/cclm-2022-0368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/22/2022] [Indexed: 11/15/2022]
Abstract
In medical laboratories, the appropriateness challenge directly revolves around the laboratory test and its proper selection, data analysis, and result reporting. However, laboratories have also a role in the appropriate management of those phases of total testing process (TTP) that traditionally are not under their direct control. So that, the laboratory obligation to act along the entire TTP is now widely accepted in order to achieve better care management. Because of the large number of variables involved in the overall TTP structure, it is difficult to monitor appropriateness in real time. However, it is possible to retrospectively reconstruct the body of the clinical process involved in the management of a specific laboratory test to track key passages that may be defective or incomplete in terms of appropriateness. Here we proposed an appropriateness check-list scheme along the TTP chain to be potentially applied to any laboratory test. This scheme consists of a series of questions that healthcare professionals should answer to achieve laboratory test appropriateness. In the system, even a single lacking answer may compromise the integrity of all appropriateness evaluation process as the inability to answer may involve a significant deviation from the optimal trajectory, which compromise the test appropriateness and the quality of subsequent steps. Using two examples of the check-list application, we showed that the proposed instrument may offer an objective help to avoid inappropriate use of laboratory tests in an integrated way involving both laboratory professionals and user clinicians.
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Affiliation(s)
- Simone Caruso
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Dominika Szoke
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Mauro Panteghini
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
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Kawata E, Hedley BD, Chin-Yee B, Xenocostas A, Lazo-Langner A, Hsia CC, Howson-Jan K, Yang P, Levy MA, Santos S, Bhai P, Howlett C, Lin H, Kadour M, Sadikovic B, Chin-Yee I. Reducing cytogenetic testing in the era of next generation sequencing: Are we choosing wisely? Int J Lab Hematol 2021; 44:333-341. [PMID: 34713980 DOI: 10.1111/ijlh.13747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/22/2021] [Accepted: 10/13/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION In most laboratories, next generation sequencing (NGS) has been added without consideration for redundancy compared to conventional cytogenetics (CG). We tested a streamlined approach to genomic testing in patients with suspected myeloid and plasma cell neoplasms using next generation sequencing ("NGS first") as the primary testing modality and limiting cytogenetics (CG) to samples with morphologic abnormalities in the marrow aspirate. METHODS Based on morphologic interpretation of bone marrow aspirate and flow cytometry, samples were triaged into four groups: (a) Samples with dysplasia or excess blasts had both NGS and karyotyping; (b) Samples without excess blasts or dysplasia had NGS only; (c) Repeat samples with previous NGS and/or CG studies were not retested; (d) Samples for suspected myeloma with less than 5% plasma cell had CG testing cancelled. RESULTS Seven hundred eleven adult bone marrow (BM) samples met the study criteria. The NGS first algorithm eliminated CG testing in 229/303 (75.6%) of patients, primarily by reducing repeat testing. Potential cost avoided was approximately $124 000 per annum. Hematologists overruled the triage comment in only 11/303 (3.6%) cases requesting CG testing for a specific indication. CONCLUSIONS Utilizing NGS as the primary genomic testing modality NGS was feasible and well accepted, reducing over three quarters of all CG requests and improving the financial case for adoption of NGS. Key factors for the success of this study were collaboration of clinical and genomic diagnostic teams in developing the algorithm, rapid turnaround time for BM interpretation for triage, and communication between laboratories.
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Affiliation(s)
- Eri Kawata
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Department of Hematology, Panasonic Health Insurance Organization Matsushita Memorial Hospital, Moriguchi, Japan.,Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Benjamin D Hedley
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Benjamin Chin-Yee
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Anargyros Xenocostas
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Alejandro Lazo-Langner
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Cyrus C Hsia
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry Western University, London, Ontario, Canada
| | - Kang Howson-Jan
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ping Yang
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry Western University, London, Ontario, Canada.,Cytogenetics Laboratory, London Health Sciences Centre, London, Ontario, Canada
| | - Michael A Levy
- Molecular Diagnostic Division, London Health Sciences Centre, London, Ontario, Canada.,Verspeeten Clinical Genome Centre, London Health Sciences Centre, London, Ontario, Canada
| | - Stephanie Santos
- Molecular Diagnostic Division, London Health Sciences Centre, London, Ontario, Canada
| | - Pratibha Bhai
- Molecular Diagnostic Division, London Health Sciences Centre, London, Ontario, Canada
| | - Christopher Howlett
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry Western University, London, Ontario, Canada.,Molecular Diagnostic Division, London Health Sciences Centre, London, Ontario, Canada
| | - Hanxin Lin
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry Western University, London, Ontario, Canada.,Molecular Diagnostic Division, London Health Sciences Centre, London, Ontario, Canada
| | - Mike Kadour
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, London, Ontario, Canada.,Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry Western University, London, Ontario, Canada.,Verspeeten Clinical Genome Centre, London Health Sciences Centre, London, Ontario, Canada
| | - Bekim Sadikovic
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry Western University, London, Ontario, Canada.,Molecular Diagnostic Division, London Health Sciences Centre, London, Ontario, Canada.,Verspeeten Clinical Genome Centre, London Health Sciences Centre, London, Ontario, Canada
| | - Ian Chin-Yee
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada.,Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry Western University, London, Ontario, Canada
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Bindraban RS, Ten Berg MJ, Naaktgeboren CA, Kramer MHH, Van Solinge WW, Nanayakkara PWB. Reducing Test Utilization in Hospital Settings: A Narrative Review. Ann Lab Med 2018; 38:402-412. [PMID: 29797809 PMCID: PMC5973913 DOI: 10.3343/alm.2018.38.5.402] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/23/2018] [Accepted: 05/06/2018] [Indexed: 11/19/2022] Open
Abstract
Background Studies addressing the appropriateness of laboratory testing have revealed approximately 20% overutilization. We conducted a narrative review to (1) describe current interventions aimed at reducing unnecessary laboratory testing, specifically in hospital settings, and (2) provide estimates of their efficacy in reducing test order volume and improving patient-related clinical outcomes. Methods The PubMed, Embase, Scopus, Web of Science, and Canadian Agency for Drugs and Technologies in Health-Health Technology Assessment databases were searched for studies describing the effects of interventions aimed at reducing unnecessary laboratory tests. Data on test order volume and clinical outcomes were extracted by one reviewer, while uncertainties were discussed with two other reviewers. Because of the heterogeneity of interventions and outcomes, no meta-analysis was performed. Results Eighty-four studies were included. Interventions were categorized into educational, (computerized) provider order entry [(C)POE], audit and feedback, or other interventions. Nearly all studies reported a reduction in test order volume. Only 15 assessed sustainability up to two years. Patient-related clinical outcomes were reported in 45 studies, two of which found negative effects. Conclusions Interventions from all categories have the potential to reduce unnecessary laboratory testing, although long-term sustainability is questionable. Owing to the heterogeneity of the interventions studied, it is difficult to conclude which approach was most successful, and for which tests. Most studies had methodological limitations, such as the absence of a control arm. Therefore, well-designed, controlled trials using clearly described interventions and relevant clinical outcomes are needed.
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Affiliation(s)
- Renuka S Bindraban
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands.,Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Maarten J Ten Berg
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christiana A Naaktgeboren
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark H H Kramer
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Wouter W Van Solinge
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Prabath W B Nanayakkara
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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Rubinstein M, Hirsch R, Bandyopadhyay K, Madison B, Taylor T, Ranne A, Linville M, Donaldson K, Lacbawan F, Cornish N. Effectiveness of Practices to Support Appropriate Laboratory Test Utilization: A Laboratory Medicine Best Practices Systematic Review and Meta-Analysis. Am J Clin Pathol 2018; 149:197-221. [PMID: 29471324 PMCID: PMC6016712 DOI: 10.1093/ajcp/aqx147] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Thomas Taylor
- Centers for Disease Control and Prevention, Atlanta, GA
| | - Anne Ranne
- Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | - Nancy Cornish
- Centers for Disease Control and Prevention, Atlanta, GA
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Nydegger U, Lung T, Risch L, Risch M, Medina Escobar P, Bodmer T. Inflammation Thread Runs across Medical Laboratory Specialities. Mediators Inflamm 2016; 2016:4121837. [PMID: 27493451 PMCID: PMC4963559 DOI: 10.1155/2016/4121837] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/31/2016] [Indexed: 12/16/2022] Open
Abstract
We work on the assumption that four major specialities or sectors of medical laboratory assays, comprising clinical chemistry, haematology, immunology, and microbiology, embraced by genome sequencing techniques, are routinely in use. Medical laboratory markers for inflammation serve as model: they are allotted to most fields of medical lab assays including genomics. Incessant coding of assays aligns each of them in the long lists of big data. As exemplified with the complement gene family, containing C2, C3, C8A, C8B, CFH, CFI, and ITGB2, heritability patterns/risk factors associated with diseases with genetic glitch of complement components are unfolding. The C4 component serum levels depend on sufficient vitamin D whilst low vitamin D is inversely related to IgG1, IgA, and C3 linking vitamin sufficiency to innate immunity. Whole genome sequencing of microbial organisms may distinguish virulent from nonvirulent and antibiotic resistant from nonresistant varieties of the same species and thus can be listed in personal big data banks including microbiological pathology; the big data warehouse continues to grow.
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Affiliation(s)
- Urs Nydegger
- Labormedizinisches Zentrum Dr. Risch and Kantonsspital Graubünden, 7000 Chur, Switzerland
| | - Thomas Lung
- Labormedizinisches Zentrum Dr. Risch and Kantonsspital Graubünden, 7000 Chur, Switzerland
| | - Lorenz Risch
- Labormedizinisches Zentrum Dr. Risch and Kantonsspital Graubünden, 7000 Chur, Switzerland
| | - Martin Risch
- Labormedizinisches Zentrum Dr. Risch and Kantonsspital Graubünden, 7000 Chur, Switzerland
| | - Pedro Medina Escobar
- Labormedizinisches Zentrum Dr. Risch and Kantonsspital Graubünden, 7000 Chur, Switzerland
| | - Thomas Bodmer
- Labormedizinisches Zentrum Dr. Risch and Kantonsspital Graubünden, 7000 Chur, Switzerland
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