Towards laboratory knowledge, not data, in 70% of clinical decision-making. What "knowledge management" can add to clinical practice?

La gestión de la demanda de las pruebas: un reto en el nuevo modelo de medicina de laboratorio

Introducción

En las últimas décadas está evolucionando el posicionamiento de la Medicina de Laboratorio en el proceso médico asistencial de atención al paciente y también el modelo de laboratorio; de un modelo tradicional, con solo intervención, a un modelo líder, que además de intervenir condiciona la decisión clínica. La mejora en tecnología y automatización ha permitido también al profesional de laboratorio centrarse en la primera y última fase del ciclo de laboratorio, la solicitud de pruebas, y la acción tras su resultado, las etapas con más errores, y donde principalmente se debe actuar para conseguir una mejora en la calidad asistencial del paciente.

Contenido

Se muestra el diseño y la implantación de intervenciones de gestión de la demanda de pruebas de laboratorio, logrando el diagnóstico de la enfermedad oculta, y mejorando la adherencia a las guías clínicas y la seguridad del paciente.

Resumen

Se expondrán los puntos clave en el proceso de gestión de la demanda, tanto de exceso como de defecto.

Perspectivas

El objetivo de la revisión es lograr que el profesional del laboratorio se involucre en el diseño e implantación de intervenciones de gestión de la demanda y en la creación de ese nuevo modelo de Laboratorio Líder.

Impact of laboratory involvement in the characterization of B12 hypervitaminosis in clinical practice

Objectives

Unexplained B12 hypervitaminosis (HB12) in asymptomatic patients leads to a cascade of medical consultations and diagnostic tests aimed at determining its etiology. The objective of this study was to assess the efficacy of the laboratory getting involved in the detection and elimination of immune complexes with vitamin B12 in clinical practice and its economic impact.

Methods

A retrospective longitudinal study was undertaken to assess the laboratory strategy of detecting B12 macrovitamin (macro-B12) in patients with HB12 >1,000 pg/mL. The clinical characteristics of patients with HB12 referred to Internal Medicine (IM) in the pre- and post-implantation period of the new strategy were compared. Additionally, the healthcare costs of one-year follow-up were estimated.

Results

The prevalences of HB12 in the pre- and post-implantation period were 3.9 % and 3 %, respectively. Macro-B12 explained 25 % of the HB12 cases initially detected. A 41 % reduction was observed in the number of patients with HB12 after the implantation of the new strategy, thereby resulting in a cost reduction of 5,000 €.

Conclusions

The laboratory intervention for the detection of macro-B12 provides clear economic and clinical benefits in clinical practice.

Managing laboratory test ordering: a challenge in the new laboratory medicine model

Introduction

The role of Laboratory Medicine in patient care has evolved in the last decades. The same has occurred to the laboratory model, which has evolved from a traditional model where the laboratory is merely involved in clinical decision-making to a leading model where the laboratory is not only involved but also determines decision-making. The advent of new technologies and automation of processes have enabled laboratory professionals to focus on the first and last phase of the analytical process namely, test ordering and decision-making based on laboratory results. These phases are more error-prone than the analytical phase, and where action must be taken to improve the quality of patient care.

Content

We share our experience in the design and establishment of laboratory test demand management interventions that facilitated diagnosis of occult disease, improved adherence to clinical guidelines, and optimized patient safety.

Summary

A description is provided of key points in the management of laboratory test over/underutilization.

Outlook

The objective of this review is to promote the involvement of laboratory professionals in the design and implementation of demand management interventions and in the development of the new Leader Laboratory model.

Impacto de la intervención del laboratorio en la caracterización de la hipervitaminosis B12 en la práctica asistencial

Objectivos

El hallazgo de hipervitaminosis B12 (HB12) no justificado en pacientes asintomáticos desencadena consultas médicas y pruebas diagnósticas, a fin de determinar la etiología. Nuestro objetivo fue probar la eficacia de la intervención del laboratorio en la detección y eliminación de inmunocomplejos con vitamina B12 en la práctica clínica, así como su impacto económico.

Métodos

Es un estudio retrospectivo y longitudinal diseñado para evaluar la estrategia del laboratorio para detectar macrovitamina B12 (macro-B12) en aquellos pacientes con HB12 mayor a 1.000 pg/mL. Se compararon las características clínicas de los pacientes con HB12 derivados a las consultas de Medicina Interna (MI) en el año anterior y posterior a la implantación de la estrategia y se calcularon los costes asistenciales generados en el año de seguimiento de los pacientes.

Resultados

La prevalencia de HB12 en el periodo previo y posterior a la implantación fue del 3,9 % y 3 %, respectivamente. La macro-B12 fue responsable del 25 % de la HB12 iniciales detectadas. El número de pacientes con HB12 derivados a las consultas de MI se redujo en el 41 % tras la implantación, traduciéndose en un ahorro de más de 5.000€.

Conclusiones

La intervención del laboratorio de detección de macro-B12 tiene un claro beneficio asistencial y económico en la práctica clínica.

Towards a Comprehensive Knowledge Management Improvement Model for Medical Laboratories

Medical laboratories are complex facilities in which managing knowledge could impact patients’ lives. This paper presents a comprehensive and phased framework for knowledge management (KM) developed and applied within the Research and Medical Analysis Laboratory of the Gendarmerie Royale in Morocco. The model is built according to the PDCA wheel, and the four pillars of methodology are: leadership, knowledge core process, performance evaluation, and finally elements for its continuous improvement. This KM framework will help identify the knowledge needs and expectations of the medical laboratory’s relevant interested parties, support medical laboratory professionals with the decision-making process, and therefore enhance the quality of the services they provide.

Indications for laboratory tests in primary care: assessment of the most frequent indications and requests with blank clinical information

Introduction

The aim of this work is twofold. Firstly, to study the temporal evolution in the number of laboratory requests from primary care without clinical indication, and to analyse the number of such requests before and after the implementation of an automated requesting procedure. Secondly, to investigate what are the most frequent clinical indications that prompted laboratory testing.

Materials and methods

This is a retrospective observational study conducted from January 2009 to December 2015. We counted the requests without clinical question, calculated the number of such requests per total number of requests and listed the most frequent indications.

Results

The number of tests requests with a blank clinical indication was significantly higher in 2009 when compared to 2015 (80% vs. 20%; P < 0.001). For every year in this 7-year period, dyslipidemia, essential hypertension and diabetes were the most prevalent diagnoses that prompted a laboratory test in primary care, accounting for more than 20% of all indications.

Conclusions

The number of primary care requests without patient clinical question has decreased after the implementation of an automated requesting procedure. Disorders of lipid metabolism, essential hypertension and diabetes mellitus were the most prevalent diagnoses that prompted a laboratory test in primary care.

Alert value reporting: a new strategy for patient safety

OBJECTIVES

The objectives of this study are to introduce the "alert value reporting" concept in primary care setting, to propose a list of chemistry and hematology alert limit tests that can be chosen for that strategy, to show how this notification procedure can be designed and established, and finally to evaluate the effectiveness and physicians' satisfaction regarding the proposed approach. In contrast to critical value reporting, alert value reporting would not allude to a result that may imply a life-threatening situation, but would indicate that an early diagnostic/therapeutic action would improve the patient's management and quality of life.

DESIGN AND METHODS

A list of chemistry and hematology alert limit tests to be used for the strategy was agreed upon between laboratory professionals and general practitioners. Next, a retrospective 12-month study involving more than 1 million laboratory tests was made to check how many of these alert values would have been communicated if these theoretical alert values had been applied. A prospective analysis of every reported alert value during 6 months was carried out to assess the intervention effectiveness and the requesting physician's satisfaction with the new strategy.

RESULTS

The alert value reporting was successfully executed. 20% of the reported alert values motivated the decision to reschedule the next patient's appointment. 90% of physicians considered alert value reporting as an interesting strategy to be continued.

CONCLUSIONS

Alert value reporting strategy motivated changes in patient's management. Further studies are needed to test if this approach can contribute to enhance patient safety and decision-making.

Regional variations in test requiring patterns of general practitioners in Spain

OBJECTIVE

To analyze the requesting patterns for a range of laboratory tests ordered in 2009 from eight laboratories providing services to eight health areas, using appropriate indicators.

DESIGN

Indicators measured every test request per 1,000 inhabitants, and indicators that measured the number of tests per related test requested by general practitioners were calculated. The savings generated, if each Health Care Department achieved the appropriate indicator standard, were also calculated. Laboratory Information System registers were collected, and indicators were calculated automatically in each laboratory using a data warehouse application.

RESULTS

There was a large difference in demand for tests by health areas. The ratio of related tests also showed a great variability. The savings generated if each Health Care Department had achieved the appropriate indicator standard were €172,116 for free thyroxine, €18,289 for aspartate aminotransferase, and €62,678 for urea.

CONCLUSIONS

Considerable variability exists in general practitioners' demand for laboratory tests.