Cost-Effectiveness of School Urinary Screening for Early Detection of IgA Nephropathy in Japan

Importance

The evidence for and against screening for chronic kidney disease in youths who are asymptomatic is inconsistent worldwide. Japan has been conducting urinary screening in students for 50 years, allowing for a full economic evaluation that includes the clinical benefits of early detection and intervention for chronic kidney disease.

Objectives

To evaluate the clinical effectiveness and cost-effectiveness of school urinary screening in Japan, with a focus on the benefits of the early detection and intervention for IgA nephropathy, and to explore key points in the model that are associated with the cost-effectiveness of the school urinary screening program.

Design, Setting, and Participants

This economic evaluation with a cost-effectiveness analysis used a computer-simulated Markov model from the health care payer's perspective among a hypothetical cohort of 1 000 000 youths aged 6 years in first grade in Japanese elementary schools, followed up through junior and high school. The time horizon was lifetime. Costs and clinical outcomes were discounted at a rate of 2% per year. Costs were calculated in Japanese yen and 2020 US dollars (¥107 = US $1).

Interventions

School urinary screening for IgA nephropathy was compared with no screening.

Main Outcomes and Measures

Outcomes were costs and quality-adjusted life-years (QALYs). Cost-effectiveness was determined by evaluating whether the incremental cost-effectiveness ratio (ICER) per QALY gained remained less than ¥7 500 000 (US $70 093).

Results

In the base case analysis, the ICER was ¥4 186 642 (US $39 127)/QALY, which was less than the threshold. There were 60.3 patients/1 000 000 patients in the no-screening strategy and 31.7 patients/1 000 000 patients in the screening strategy with an end-stage kidney disease. Cost-effectiveness improved as the number of screenings decreased (screening frequency <3 times: incremental cost, -¥75 [US $0.7]; incremental QALY, 0.00025; ICER, dominant), but the number of patients with end-stage kidney disease due to IgA nephropathy increased (40.9 patients/1 000 000 patients). Assuming the disutility due to false positives had a significant impact on the analysis; assuming a disutility of 0.01 or more, the population with no IgA nephropathy had an ICER greater than the threshold (¥8 304 093 [US $77 608]/QALY).

Conclusions and Relevance

This study found that Japanese school urinary screening was cost-effective, suggesting that it may be worthy of resource allocation. Key factors associated with cost-effectiveness were screening cost, the probability of incident detection outside of screening, and IgA nephropathy incidence, which may provide clues to decision-makers in other countries when evaluating the program in their own context.

Can a semi-quantitative method replace the current quantitative method for the annual screening of microalbuminuria in patients with diabetes? Diagnostic accuracy and cost-saving analysis considering the potential health burden

OBJECTIVES

Diabetes is a global epidemic, and the high cost of annually and quantitatively measuring urine albumin excretion using the turbidimetric immunoassay is challenging. We aimed to determine whether a semi-quantitative urinary albumin-creatinine ratio test could be used as a screening tool for microalbuminuria in diabetic patients.

METHODS

We assessed the diagnostic accuracy of the semi-quantitative method. The costs of false results in the semi-quantitative method were calculated based on the annual probability of disease progression analyzed through a systematic literature review and meta-analysis. The pooled long-term cost-saving effect of the semi-quantitative method compared with the quantitative test was assessed using a Markov model simulating a long-term clinical setting. Diagnostic accuracy and the cost-saving effect were also validated in an independent external cohort.

RESULTS

Compared with the quantitative test, the semi-quantitative method had sensitivities of 93.5% and 81.3% and specificities of 61.4% and 63.1% in the overall sample of diabetic patients (n = 1,881) and in diabetic patients with eGFR ≥60 ml/min/1.73 m2 and a negative dipstick test (n = 1,110), respectively. After adjusting for direct and indirect medical costs, including the risk of disease progression, which was adjusted by the meta-analyzed hazard ratio for clinical outcomes, it was determined that using the semi-quantitative method could save 439.4 USD per person for 10 years. Even after adjusting the result to the external validation cohort, 339.6 USD could be saved for one diabetic patient for 10 years.

CONCLUSIONS

The semi-quantitative method could be an appropriate screening tool for albuminuria in diabetic patients. Moreover, it can minimize the testing time and inconvenience and significantly reduce national health costs.

Economic and clinical benefits of early identification of acute kidney injury using a urinary biomarker

Purpose: To evaluate the budget impact of adding a diagnostic test of tissue inhibitor of metalloproteinase 2 and insulin-like growth factor binding protein 7 ([TIMP-2]·[IGFBP7]), which identifies patients at risk of moderate-to-severe acute kidney injury (AKI), to the current standard of care (SOC) in a hospital setting.Materials and methods: A budget impact model (2017 USD) was developed from the perspective of a hypothetical US hospital system serving 10,000 inpatients annually. The model estimated the impact of assessing the risk of AKI using SOC vs a combination of SOC and the US Food and Drug Administration-approved assay [TIMP-2]·[IGFBP7] over a 1-year period. Potential cost implications were assessed using estimates for payer mix among patients, diagnostic efficacy, and patient healthcare resource utilization. The model also considered provider adoption rates and the estimated costs of [TIMP-2]·[IGFBP7].Results: Compared to SOC alone, adding [TIMP-2]·[IGFBP7] to SOC was associated with a $1,855 reduction in uncompensated care per patient tested, which, after accounting for the additional costs of the test ($277), resulted in net savings of $1,578 per patient tested. The findings were robust to input parameter variations, as demonstrated by deterministic and probabilistic sensitivity analyses. In the probabilistic sensitivity analyses, net cost savings to the hospital ranged from $50,308-$3,971,514, or $101-$7,943 per tested patient (mean = $1,710; 95% confidence interval = $1,691-$1,729).Conclusions: The introduction of [TIMP-2]·[IGFBP7] as a novel tool in the identification of AKI risk may result in considerable cost savings from a hospital perspective under this model's base-case assumptions. Further prospective studies are needed to confirm these findings in a real-world setting.Key points for decision makersAn economic model was constructed to determine the budget impact of adding a diagnostic test ([TIMP-2]·[IGFBP7]), which identifies patients at risk of moderate-to-severe acute kidney injury, to the current standard of care (SOC) in a hospital setting.According to the present model, the use of [TIMP-2]·[IGFBP7] to identify acute kidney injury risk may reduce costs for hospitals by ∼$1,578 per patient tested.

Diagnostic value of the urine lipoarabinomannan assay in HIV-positive, ambulatory patients with CD4 below 200 cells/μl in 2 low-resource settings: A prospective observational study

BACKGROUND

Current guidelines recommend the use of the lateral flow urine lipoarabinomannan assay (LAM) in HIV-positive, ambulatory patients with signs and symptoms of tuberculosis (TB) only if they are seriously ill or have CD4 count ≤ 100 cells/μl. We assessed the diagnostic yield of including LAM in TB diagnostic algorithms in HIV-positive, ambulatory patients with CD4 < 200 cells/μl, as well as the risk of mortality in LAM-positive patients who were not diagnosed using other diagnostic tools and not treated for TB.

METHODS AND FINDINGS

We conducted a prospective observational study including HIV-positive adult patients with signs and symptoms of TB and CD4 < 200 cells/μl attending 6 health facilities in Malawi and Mozambique. Patients were included consecutively from 18 September 2015 to 27 October 2016 in Malawi and from 3 December 2014 to 22 August 2016 in Mozambique. All patients had a clinical exam and LAM, chest X-ray, sputum microscopy, and Xpert MTB/RIF assay (Xpert) requested. Culture in sputum was done for a subset of patients. The diagnostic yield was defined as the proportion of patients with a positive assay result among those with laboratory-confirmed TB. For the 456 patients included in the study, the median age was 36 years (IQR 31-43) and the median CD4 count was 50 cells/μl (IQR 21-108). Forty-five percent (205/456) of the patients had laboratory-confirmed TB. The diagnostic yields of LAM, microscopy, and Xpert were 82.4% (169/205), 33.7% (69/205), and 40.0% (84/205), respectively. In total, 50.2% (103/205) of the patients with laboratory-confirmed TB were diagnosed only through LAM. Overall, the use of LAM in diagnostic algorithms increased the yield of algorithms with microscopy and with Xpert by 38.0% (78/205) and 34.6% (71/205), respectively, and, specifically among patients with CD4 100-199 cells/μl, by 27.5% (14/51) and 29.4% (15/51), respectively. LAM-positive patients not diagnosed through other tools and not treated for TB had a significantly higher risk of mortality than LAM-positive patients who received treatment (adjusted risk ratio 2.57, 95% CI 1.27-5.19, p = 0.009). Although the TB diagnostic conditions in the study sites were similar to those in other resource-limited settings, the added value of LAM may depend on the availability of microscopy or Xpert results.

CONCLUSIONS

LAM has diagnostic value for identifying TB in HIV-positive patients with signs and symptoms of TB and advanced immunodeficiency, including those with a CD4 count of 100-199 cells/μl. In this study, the use of LAM enabled the diagnosis of TB in half of the patients with confirmed TB disease; without LAM, these patients would have been missed. The rapid identification and treatment of TB enabled by LAM may decrease overall mortality risk for these patients.

Reducing inappropriate urine testing at Hutt Valley District Health Board using Choosing Wisely principles

AIM

Unnecessary treatment of asymptomatic bacteriuria is a concern. Hutt Valley District Health Board sought to reduce clinically inappropriate urine culture requests through removal of urine dipsticks from wards and education of staff using Choosing Wisely principles. The purpose of this research is to quantitatively evaluate the success of these initiatives.

METHODS

The numbers and results of urine cultures performed for Hutt Valley DHB were analysed, for the period from January 2015 to October 2017. Urinalyses were compared between those designated as 'inpatient' and those as 'outpatient', with the latter being the control of this study. The numbers of primary and secondary coded discharge diagnoses of UTIs were used as a measure of the negative impact of the interventions.

RESULTS

There was a 28% reduction in monthly urine culture requests for inpatients, after staff education and removal of urine dipsticks, with no change in those for outpatients (the negative control). After the intervention, a higher proportion of urine cultures were positive for urinary pathogens (25.2% compared to 23.0%) and the average number of diagnoses of UTI in hospital discharges decreased 17% (from 161 to 134).

CONCLUSION

The removal of urine dipsticks from wards and the education of staff significantly reduced the number of urine culture requests and is a useful strategy to reduce the overuse of antibiotics for asymptomatic bacteriuria without an increase in the number of UTIs. These simple interventions could be used at other hospitals as part of measures to reduce unnecessary care and overdiagnosis.

Clinical Benefits of Direct-to-Definitive Testing for Monitoring Compliance in Pain Management

BACKGROUND

The technical advantages of direct-to-definitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) urine testing for monitoring patient compliance in pain management are well known. However, the design and implementation of LC-MS/MS methods are more controversial, including factors such as determining appropriate cutoffs, specimen processing (e.g., specimen hydrolysis), reporting of qualitative and/or quantitative results, and test menu.

OBJECTIVES

The objective of the research was to compare the clinical performance of our previous urine pain toxicology panel, a combination of immunoassay (IA) screens and LC-MS/MS, to our current pain toxicology panel, which features direct-to-definitive LC-MS/MS for 34 drugs and metabolites.

STUDY DESIGN

Six months of results from our previous pain toxicology panel were compared to 5.5 months of results from our current pain toxicology panel, enabling us to make conclusions regarding clinical performance.

SETTING

The research took place at Brigham and Women's Hospital in Boston, MA.

METHODS

The percentage of false positive IA results was evaluated for our previous pain toxicology panel. The positivity rates for each drug and/or metabolite were calculated for both the previous and current panels, including rates of detection of both prescribed and illicit drugs. The turnaround time (TAT), direct and send-out costs associated with each approach, as well as projected cost savings were also determined.

RESULTS

False positive rates with IA ranged from 0% to 29%; the highest false positive rate was seen for 6-acetylmorphine (6-AM). The elimination of IA, addition of metabolites, and/or lowering of cutoffs increased the detection rate of 6-AM, benzoylecgonine (cocaine metabolite), fentanyl, morphine, and oxycodone. The ability to differentiate compliance from simulated compliance improved after eliminating specimen hydrolysis. The TAT improved significantly and projected yearly cost savings with the current panel was $95,003 (USD). In our opinion, qualitative results appeared sufficient to assess compliance in the majority of cases.

LIMITATIONS

Our study was performed in a single academic center in a specific geographic region; therefore, our results may not be generalizable to other types of centers or regions.

CONCLUSION

Direct-to-definitive LC-MS/MS testing has several clinical benefits, including reduction of false positive results, improved assessment of patient compliance, decreased TAT, and increased detection of drug use and abuse. Cost savings were also realized using this approach.

KEY WORDS

Direct-to-definitive, LC-MS/MS, immunoassay, sensitivity, cost, pain management, turnaround time, patient compliance.

Can a non-invasive urine-based test become the next-generation diagnostic tool for malaria?

This mini review summarises the non-invasive urine-based diagnostic approaches that have been used to diagnose malaria. Amongst all urine-based diagnosis methods, commercially available Rapid Diagnostic kit/strip is most likely to be suitable for malaria detection in a cost-effective, time-consuming and user-friendly manner. With further improvement in sensitivity, specificity and accuracy, this technique may become a useful next-generation gold standard malaria diagnostic tool in resource-limited regions and in areas where invasive blood tests are restricted.

Low-power, low-cost urinalysis system with integrated dipstick evaluation and microscopic analysis

We introduce a coupled dipstick and microscopy device for analyzing urine samples. The device is capable of accurately assessing urine dipstick results while simultaneously imaging the microscopic contents within the sample. We introduce a long working distance, cellphone-based microscope in combination with an oblique illumination scheme to accurately visualize and quantify particles within the urine sample. To facilitate accurate quantification, we couple the imaging set-up with a power-free filtration system. The proposed device is reusable, low-cost, and requires very little power. We show that results obtained with the proposed device and custom-built app are consistent with those obtained with the standard clinical protocol, suggesting the potential clinical utility of the device.

The Diagnosis of Urinary Tract Infection in Young Children (DUTY) Study Clinical Rule: Economic Evaluation

OBJECTIVE

To estimate the cost-effectiveness of a two-step clinical rule using symptoms, signs and dipstick testing to guide the diagnosis and antibiotic treatment of urinary tract infection (UTI) in acutely unwell young children presenting to primary care.

METHODS

Decision analytic model synthesising data from a multicentre, prospective cohort study (DUTY) and the wider literature to estimate the short-term and lifetime costs and healthcare outcomes (symptomatic days, recurrent UTI, quality adjusted life years) of eight diagnostic strategies. We compared GP clinical judgement with three strategies based on a 'coefficient score' combining seven symptoms and signs independently associated with UTI and four strategies based on weighted scores according to the presence/absence of five symptoms and signs. We compared dipstick testing versus laboratory culture in children at intermediate risk of UTI.

RESULTS

Sampling, culture and antibiotic costs were lowest in high-specificity DUTY strategies (£1.22 and £1.08) compared to clinical judgement (£1.99). These strategies also approximately halved urine sampling (4.8% versus 9.1% in clinical judgement) without reducing sensitivity (58.2% versus 56.4%). Outcomes were very similar across all diagnostic strategies. High-specificity DUTY strategies were more cost-effective than clinical judgement in the short- (iNMB = £0.78 and £0.84) and long-term (iNMB =£2.31 and £2.50). Dipstick tests had poorer cost-effectiveness than laboratory culture in children at intermediate risk of UTI (iNMB = £-1.41).

CONCLUSIONS

Compared to GPs' clinical judgement, high specificity clinical rules from the DUTY study could substantially reduce urine sampling, achieving lower costs and equivalent patient outcomes. Dipstick testing children for UTI is not cost-effective.

Utility of routine urinalysis and urine culture testing in an ambulatory urology clinic: a quality improvement initiative in a Veterans healthcare facility

INTRODUCTION

Urinalysis (UA) and urine culture (UCx) are commonly performed tests in the urology clinic. Many of these urine studies are performed prior to the patient visit may not always be indicated, thus contributing to unintended consequences such as antibiotic use and costs without enhancing patient care. Our objective was to perform a quality improvement initiative aimed to assess the utility of routine UA/UCx.

MATERIALS AND METHODS

The practice pattern at our site's Veteran Affairs (VA) urology clinic prior to 2014 was to obtain routine UA/UCx on most clinic visits prior to patient evaluation. Starting in 2014, we designed an intervention whereby our nurse practitioner triaged all new patient referrals and selectively ordered UA/UCx. We performed multivariable logistic regression to assess for predictors of obtaining UA or UCx.

RESULTS

A total of 1308 patients were seen in January-March 2013 and 1456 in June-August 2014 and were included in this analysis. Fewer patients in 2014 received UA (59.8% versus 70.0%, p < 0.001) and UCx (49.6% versus 64.2%, p < 0.001). There was a decreased odds of obtaining UA in 2014 (OR 0.52, p < 0.001) as well as a decreased odds of obtaining UCx in 2014 (OR0.38, p < 0.001) on multivariable logistic regression. The results of UA/UCx only rarely resulted in change of management in either cohort (3%). Selective ordering resulted in an estimated cost savings of $4915.08/month in UCx costs alone.

CONCLUSIONS

Our quality improvement initiatives reduced rates of UA/UCx testing when providers assess patients prior to ordering these tests. The implication of this initiative is significant cost savings for the healthcare system.

Robust dipstick urinalysis using a low-cost, micro-volume slipping manifold and mobile phone platform

We introduce a novel manifold and companion software for dipstick urinalysis that eliminate many of the aspects that are traditionally plagued by user error: precise sample delivery, accurate readout timing, and controlled lighting conditions. The proposed all-acrylic slipping manifold is reusable, reliable, and low in cost. A simple timing mechanism ensures results are read out at the appropriate time. Results are obtained by capturing videos using a mobile phone and by analyzing them using custom-designed software. We show that the results obtained with the proposed device are as accurate and consistent as a properly executed dip-and-wipe method, the industry gold-standard, suggesting the potential for this strategy to enable confident urinalysis testing in home environments.

[CALCIUM LEVELS IN URINE SAMPLE IN PREGNANT WOMEN WITH PREECLAPMSIA]

Hypertensive disorders during pregnancy are still leading cause for maternal and perinatal death. Calcium metabolism is impaired significantly in women with preeclampsia. Measurement of calcium levels in 24 hours urine sample is easy, modern, fast and not expensive predictive test to reveal women in high risk of developing preeclampsia in late pregnancy. The severity of condition strongly correlates with decrease level of calcium excretion in urine.

Comprehensive Urine Drug Screen by Gas Chromatography/Mass Spectrometry (GC/MS)

Drug screening is an essential component of clinical toxicology laboratory service. Some laboratories use only automated chemistry analyzers for limited screening of drugs of abuse and few other drugs. Other laboratories use a combination of various techniques such as immunoassays, colorimetric tests, and mass spectrometry to provide more detailed comprehensive drug screening. Mass spectrometry, gas or liquid, can screen for hundreds of drugs and is often considered the gold standard for comprehensive drug screening. We describe an efficient and rapid gas chromatography/mass spectrometry (GC/MS) method for comprehensive drug screening in urine which utilizes a liquid-liquid extraction, sample concentration, and analysis by GC/MS.

Accuracy of δ(18)O isotope ratio measurements on the same sample by continuous-flow isotope-ratio mass spectrometry

RATIONALE

The doubly labeled water method is considered the reference method to measure energy expenditure. Conventional mass spectrometry requires a separate aliquot of the same sample to be prepared and analyzed separately. With continuous-flow isotope-ratio mass spectrometry, the same sample could be analyzed sequentially for both (2)H and (18)O content and thus minimize sample requirement, reduce analytical cost, and avoid memory effect.

METHODS

The (2)H contents of 197 urine samples collected from 22 doubly labeled water studies were determined using a Thermo Delta V Advantage continuous-flow isotope-ratio mass spectrometer. The (18)O content of these samples was measured either using a separate aliquot of the same sample using a VG Isogas gas-isotope-ratio mass spectrometer or using the same sample following the (2)H measurements on a Thermo Delta V continuous-flow isotope-ratio instrument.

RESULTS

The δ(18)O values using the same aliquot of samples were accurate to 0.18 ± 2.61‰ (mean difference ± standard deviation (SD); 95% CI, -0.18 to 0.55‰; P = 0.33) compared with the values based on the standard conventional method. Bland and Altman pair-wise comparison also yielded a bias of 0.18‰ with a 95% limit of agreement between -4.94 and 5.30‰.

CONCLUSIONS

The study demonstrated that continuous-flow isotope-ratio mass spectrometry is capable of producing accurate (18)O measurements on the same sample after (2)H measurements. The method greatly reduces the analytical cost and sample size requirement and could easily be adopted by any laboratories equipped with a continuous-flow isotope-ratio mass spectrometer.

Automated urine screening devices make urine sediment microscopy in diagnostic laboratories economically viable

Automated urinalysis devices are reproducible, accurate and faster than the standard manual microscopy. Economic analysis has shown that decreases in turn-around-time and labour cost savings offered by these devices make them more economic than manual microscopy.

Salt intake assessed by 24 h urinary sodium excretion in a random and opportunistic sample in Australia

OBJECTIVE

The gold standard method for measuring population sodium intake is based on a 24 h urine collection carried out in a random population sample. However, because participant burden is high, response rates are typically low with less than one in four agreeing to provide specimens. At this low level of response it is possible that simply asking for volunteers would produce the same results.

SETTING

Lithgow, New South Wales, Australia.

PARTICIPANTS

We randomly selected 2152 adults and obtained usable 24 h urine samples from 306 (response rate 16%). Specimens were also collected from a further 113 volunteers. Estimated salt consumption and the costs for each strategy were compared.

RESULTS

The characteristics of the 'random' and 'volunteer' samples were moderately different in mean age 58 (SD 14.6 vs 49(17.7) years, respectively; p<0.001) as well as self-reported alcohol use, tobacco use, history of hypertension and prescription drug use (all p<0.04). Overall crude mean 24 h urinary salt excretion was 8.9(3.6) g/day in the random sample vs 8.5(3.3) g/day for the volunteers (p=0.42). Corresponding age-adjusted and sex-adjusted estimates were 9.2(3.3) and 8.8(3.4) g/day (p=0.29). Estimates for men 10.3(3.8) vs 9.6(3.3) g/day; (p=0.26) and women 7.6(3) vs 7.9(3.2) g/day; (p=0.43) were also similar for the two samples, as was salt excretion across age groups (p=0.72). The cost of obtaining each 24 h urine sample was two times greater for the random compared to volunteer samples ($A62 vs $A31).

CONCLUSIONS

The estimated salt consumption derived from the two samples was comparable and was not substantively different to estimates obtained from other surveys. In countries where salt is pervasive and cannot easily be avoided, estimates of consumption obtained from volunteer samples may be valid and less costly.

Cost benefit analysis of same day pregnancy tests in elective orthopaedic surgery

We reviewed the results of 4,723 day of surgery pregnancy tests performed at two of our institution's locations, our ambulatory surgery center and our acute orthopaedics hospital over a 23 month time period. All patients were scheduled for elective orthopaedic surgery. There were seven positive results (0.15%) and one false negative result (0.02%). The cost per positive result for both hospital locations was $1,005.32.

INTRODUCTION

Performing elective surgery on pregnant women can harm the mother and fetus. In order to minimize the likelihood of this happening, we administer a urine pregnancy test to each woman of childbearing age on the date of surgery. From November 2009 to September 2011, we performed 4,723 urine human chorionic gonadotropin (hCG) pregnancy tests on the day of surgery. We reviewed the results and cost of each pregnancy test. We then used these results to calculate the percentage of positive tests and the cost of diagnosing each pregnant female on the date of their surgery.

METHODS

We obtained the records of all urine hCG pregnancy tests performed from November 2009 to September 2011. Each test was reviewed to determine if the result was positive or negative. Costs were calculated using the charges incurred for a qualitative hCG pregnancy test. We then contacted each patient with a positive result to determine if the urine hCG test results were accurate.

RESULTS

4,723 pregnancy tests were reviewed over a 23 month period with 7 (0.15%) having a positive result. Over the 23 month time period, we were notified of one false negative result (0.02%). The Positive Predictive Value (PPV) was 100% and the Negative Predictive Value (NPV) was 99.9%. The cost of a single urine hCG test was $1.49, the total cost for all 4,723 tests was $7,037.27. The cost of diagnosing 7 positive tests was $1,005.32.

CONCLUSION

Routinely performing urine hCG pregnancy tests on the day of surgery is a cost effective method of preventing elective orthopaedic surgery on pregnant women. Of 4,723 women tested 7 had a positive result and 1 had a false negative result. The cost of $1,005.32 for each positive test must be compared with the benefit of not performing elective surgery on a pregnant female.

An automated RP-SCX solid-phase extraction procedure for urinary peptidomics biomarker discovery studies

Urine represents the most easily obtainable body fluid and consequently one of the most common samples in clinical chemistry. The majority of pathological changes in human organs may well be reflected in urine. In this way, urine analysis can aid in disease diagnosis, treatment monitoring, and prognosis. Currently, the most commonly used method for identification of new urine biomarkers involves centrifugation of the urine sample to collect either the soluble urine proteins or the urinary exosomes followed by 1 or 2 protein purification and separation steps before visualization and finally identification of potential biomarkers, usually by mass spectrometry. Here we present a generally applicable, rapid, and robust method for screening large number of urine samples, resulting in a broad spectrum of native peptides, as a tool to be used for biomarker discovery. The method combines online sample pretreatment with a well-established mass spectrometric technique. Native peptides are extracted from urine samples on a miniaturized reverse-phase-strong cation exchange cartridge system. As the proper identification of native peptides often requires combination of data acquired on different mass analyzers, we have aimed at a procedure providing us with sufficient material to identify and characterize the differentially expressed markers.

Does self monitoring of blood glucose as opposed to urinalysis provide additional benefit in patients newly diagnosed with type 2 diabetes receiving structured education? The DESMOND SMBG randomised controlled trial protocol

BACKGROUND

The benefit of self-monitoring of blood glucose (SMBG) in people with type 2 diabetes on diet or oral agents other than sulphonylureas remains uncertain. Trials of interventions incorporating education about self-monitoring of blood glucose have reported mixed results. A recent systematic review concluded that SMBG was not cost-effective. However, what was unclear was whether a cheaper method of self-monitoring (such as urine glucose monitoring) could produce comparable benefit and patient acceptability for less cost.

METHODS/DESIGN

The DESMOND SMBG trial is comparing two monitoring strategies (blood glucose monitoring and urine testing) over 18 months when incorporated into a comprehensive self-management structured education programme. It is a multi-site cluster randomised controlled trial, conducted across 8 sites (7 primary care trusts) in England, UK involving individuals with newly diagnosed Type 2 diabetes.The trial has 80% power to demonstrate equivalence in mean HbA1c (the primary end-point) at 18 months of within ± 0.5% assuming 20% drop out and 20% non-consent. Secondary end-points include blood pressure, lipids, body weight and psychosocial measures as well as a qualitative sub-study.Practices were randomised to one of two arms: participants attend a DESMOND programme incorporating a module on self-monitoring of either urine or blood glucose. The programme is delivered by accredited educators who received specific training about equipoise. Biomedical data are collected and psychosocial scales completed at baseline, and 6, 12, and 18 months post programme. Qualitative research with participants and educators will explore views and experiences of the trial and preferences for methods of monitoring.

DISCUSSION

The DESMOND SMBG trial is designed to provide evidence to inform the debate about the value of self-monitoring of blood glucose in people with newly diagnosed type 2 diabetes. Strengths include a setting in primary care, a cluster design, a health economic analysis, a comparison of different methods of monitoring while controlling for other components of training within the context of a quality assured structured education programme and a qualitative sub-study.

TRIAL REGISTRATION

ISRCTN: ISRCTN95696668.

A simple and smart telemedicine device for developing regions: a pocket-sized colorimetric reader

We have proposed a novel mobile healthcare platform, combining a pocket-sized colorimetric reader (13.5 × 6.5 × 2.5 cm(3)) and commercially available 10-parameter urinalysis paper strips (glucose, protein, glucose, bilirubin, urobilinogen, ketones, nitrite, pH, specific gravity, erythrocytes, and leukocytes), capable of sending data with a smart phone. The reader includes a novel colorimetric multi-detection module, which consists of three-chromatic light-emitting diodes, silicon photodiodes and a novel poly(methylmethacrylate) (PMMA) optical splitter. We employed data reading methods using conversions of the signal data (red, blue, and green) to the hue (H) color map or the Y model data, and used a curve-fitting method for the quantification. The reader is battery-powered, inexpensive, light-weight, and very speedy in analysis. And, it was applied to detection of a thousand of human urine samples and demonstrated reliable quantification of urinary glucose and protein. The features can be used by unskilled people on-site to transfer the analyzed data to experts off-site.

Using a spreadsheet/table template for economic value added analysis

Translating clinical research into practical applications that are cost effective has received significant attention as staff nurses attempt to expand new knowledge into an already complex daily workflow. spreadsheet/table template created in a word processing format can assist with setting up and carrying out the analysis of costs for comparing different approaches to routine activities. By encouraging nurses to take the initiative to examine parts of everyday nursing practice with an eye to cost analysis, significant contributions can be made to maximizing the bottom line.

Pooling of urine specimens allows accurate and cost-effective genetic detection of Chlamydia trachomatis in Lithuania and other low-resource countries

The aims of this study were to compare performance characteristics and cost-effectiveness of pooling urine samples for screening and diagnosis of Chlamydia trachomatis using Digene Hybrid Capture II CT/NG Test (HCII), and to examine the prevalence of C. trachomatis in male military recruits in Lithuania. A total of 410 urine samples were individually tested and pooled by 5 and 10 samples, respectively. The sensitivity and specificity of diagnosis were not affected by either pooling strategy. The estimated population prevalence of C. trachomatis infection was nearly identical, i.e. 4.4%, 4.4% and 4.1% based on individually tested samples, and samples pooled by 5 and 10, respectively. For this estimation of the population prevalence, pooling 5 samples reduced the costs by 80% and pooling 10 samples reduced the costs by 90%. For diagnosis of each individual sample, the pooling strategies resulted in cost savings of 60% (5 samples per pool) and 56% (10 samples per pool). The present pooling strategies were sensitive, specific and cost-efficient for screening and diagnosis of C. trachomatis infection in male military recruits in Lithuania. The strategies would be most useful for reasonably inexpensive large-scale screening, prevalence studies and even diagnostics in Lithuania and many other low-resource countries.

Mistiming of intercourse as a primary cause of failure to conceive: results of a survey on use of a home-use fertility monitor

OBJECTIVE

To assess demographics, fecundity characteristics and fertility history of couples who successfully conceived using a home-use Fertility Monitor.

STUDY DESIGN

This was a retrospective US observational study of couples who successfully conceived using a Fertility Monitor. Data were self-reported by volunteers using a questionnaire supplied and collected by mail. Of 276 surveys distributed, 196 (71.0%) were returned and evaluated.

RESULTS

Length of time trying to conceive was < 12 months for 70% of women; proportions were similar across age groupings. After switching to the Fertility Monitor, 49.5% and 91.9% of women had conceived within first and third cycles, respectively. Prior to Fertility Monitor use, conception aids were used by 84.2% and 64.3% had consulted a physician to seek help in attempting to conceive. Average costs of prior treatment were (in US dollars) 6637 dollars; median costs for infertility evaluation were 1075 dollars per cycle. Fertility Monitor costs ranged from 250 dollars for one cycle to 550 dollars after 10 cycles.

CONCLUSIONS

A probable cause for failure to conceive appeared to be mistiming of intercourse. The issue of early intervention with tests and medications were highlighted, resulting in escalating costs and strain on the couple. The use of a home Fertility Monitor that identifies all fertile days of the cycle and allows couples to target intercourse accordingly, should be considered as an alternative choice for couples seeking to conceive during the first year, before other attempts at infertility diagnosis are made, unless there are conflicting clinical reasons.

Clinical effectiveness and cost-effectiveness of tests for the diagnosis and investigation of urinary tract infection in children: a systematic review and economic model

OBJECTIVES

To determine the diagnostic accuracy of tests for detecting urinary tract infection (UTI) in children under 5 years of age and to evaluate the effectiveness of tests used to investigate further children with confirmed UTI. Also, to evaluate the effectiveness of following up children with UTI and the cost-effectiveness of diagnostic and imaging tests for the diagnosis and follow-up of UTI in children under 5. An additional objective was to develop a preliminary diagnostic algorithm for healthcare professionals.

DATA SOURCES

Electronic databases were searched up to the end of 2002/early 2003. Consultation with experts in the field.

REVIEW METHODS

A systematic review was undertaken using published guidelines and results were analysed according to test grouping: diagnosis of UTI and further investigation of UTI. The cost-effectiveness results from existing evaluations were synthesised. A separate cost-effectiveness model was developed using the best available evidence, in part derived from the results of the systematic review, to illustrate the potential cost-effectiveness of some alternative management strategies in a UK setting. The results of the systematic review were used to propose diagnostic algorithms for the diagnosis and further investigation of UTI in children. Economic analyses did not contribute directly to the development of these algorithms.

RESULTS

The studies included in the review provided very little data on the accuracy of clinical investigations for the diagnosis of UTI, and criteria for clinical suspicion of UTI were not further defined. The majority of studies included in the review found that clean voided midstream urine (CVU) samples had similar accuracy to suprapubic aspiration (SPA) samples when cultured with the advantage of being a non-invasive collection method that can be used in the GP's surgery. Pad, nappy or bag specimens may be appropriate methods for obtaining a urine sample in non-toilet-trained children, although only limited data were available. Although the glucose test was reported to have the highest accuracy in terms of both ruling in and ruling out disease, only a limited number of studies of this test were included and these were conducted over 30 years ago. Dipstick tests are easy to perform in the GP's surgery, give an immediate result and are relatively cheap. The results of the systematic review showed that a dipstick for leucocyte esterase (LE) and nitrite, where both test results are interpreted in combination, was a good test both for ruling in (both positive) and ruling out (both negative) a UTI. A dipstick positive for either LE or nitrite and negative for the other provides inconclusive diagnostic information and further testing is therefore required in these patients. Microscopy is more time consuming and expensive to perform than a dipstick test, but potentially quicker and cheaper than culture. As with dipstick tests, a combination of microscopy for pyuria and bacteriuria can be used accurately to rule in and rule out a UTI. An indeterminate test result is again obtained if microscopy is positive for either pyuria or bacteriuria, and negative for the other. Confirmatory culture is required in these patients. In patients considered to have a UTI, further culture to determine antibiotic sensitivities may be an option to inform treatment decisions. Only one study satisfied the inclusion criteria of the economic review and the review highlighted a number of potential limitations of this study for NHS decision-making. A separate decision-analytic model was therefore developed to provide a more reliable estimate of the optimal strategy regarding the diagnosis and further investigation of children under 5 with suspected UTI from the perspective of the NHS. The economic model found that the optimal diagnostic strategy for children presenting with symptoms suggestive of UTI depends on a number of key factors. These included the relevant subgroup of children concerned, in terms of gender and age, and the health service's maximum willingness to pay for an additional quality-adjusted life-year.

CONCLUSIONS

The results of the systematic review were used to derive an algorithm for the diagnosis of UTI in children under 5. This algorithm represents the conclusions of the review in terms of effective practice. There were insufficient data to propose an algorithm for the further investigation of UTI in children under 5. The quality assessment highlighted several areas that could be improved upon in future diagnostic accuracy studies.

Cost/benefit of laboratory tests

BACKGROUND

Insurers choose laboratory test requirements to maximize the relationship between cost and benefit. Traditional means of analysis, such as experience studies, take years or decades to perform. Cost/benefit models provide a more timely option by projecting possible experience according to different scenarios.

METHODS

The article describes how to create a cost/benefit model.

RESULTS

Hemoglobin A1c and hepatitis C virus antibody tests--and more generally tests reflexed after a prior abnormal test--often have the highest cost/benefit ratio. Mortality savings is higher for tests done on older aged applicants (except for impairments that are more common in young people) and on tobacco users. Indirect costs, such as time, overhead, delays, and false positives, decrease the cost/benefit of testing. Entire markets may follow inefficient testing strategies because insurers do not deviate from the practices of market leaders.

CONCLUSION

Cost/benefit analysis helps insurers set underwriting requirements by age, gender, tobacco/nontobacco status, and policy amount.

Obtaining urine for culture from non-potty-trained children

The accurate diagnosis of urinary tract infection (UTI) in young children is important for initial management and the prevention of long-term damage to the developing kidney. Various methods are used for urine collection from the non-potty-trained age group, including catheterisation, suprapubic aspiration, clean-catch sampling, adhesive bag sampling and urine collection pads. Research literature was examined to identify which method is most effective. The themes that evolved from the review were parents' and nurses' views on ease of use, reliability of sample obtained and cost-effectiveness. Although not the most convenient method, clean-catch gives more reliable results making it also the most cost effective approach. Change management strategies are required to overcome barriers to research implementation and to ensure best practice.

Evaluation of tests for microalbuminuria screening in patients with diabetes

BACKGROUND

The first step in the diagnosis of diabetic nephropathy is to measure albumin in a spot urine sample. The aim of this study was to assess the accuracy of urinary albumin concentration (UAC), urinary albumin-to-creatinine ratio (UACR), and the Micral-Test II in a random urine specimen (RUS) for microalbuminuria screening in diabetes mellitus.

METHODS

Two hundred and seventy-eight patients collected 24 h timed urine specimens followed by RUS. Albumin (immunoturbidimetry) and creatinine were measured in protein-negative (Combur-Test) urine samples. Samples were classified as normoalbuminuric [24 h urinary albumin excretion rate (UAER) <20 microg/min; n = 189] and microalbuminuric (UAER =20-199 microg/min; n = 89). Micral-Test II readings were performed in 130 RUS. Receiver operating characteristics (ROC) curves were constructed using UAER as the reference standard.

RESULTS

The areas under the ROC curves were similar for UAC (0.934+/-0.032) and UACR (0.920+/-0.035; P = 0.626), but the Micral-Test II had lower accuracy to diagnose microalbuminuria (area = 0.846+/-0.047) than UAC (P = 0.014). The first cutoff point with 100% sensitivity for UAC was 14.4 mg/l (specificity =77.2%), and 15.7 mg/g for UACR (specificity =73.0%). Concerning the Micral-Test II, sensitivity and specificity for the 20 mg/l cutoff point were 90.0 and 46.0%, respectively. The agreement between UAER and the Micral-Test II for microalbuminuria diagnosis was 55.8% (kappa = 0.22; P < 0.001). The cost of diagnosing microalbuminuria was 1.74 dollars(UAC), 2.00 dollars (UACR) and 4.09 dollars (Micral-Test II) per patient.

CONCLUSIONS

Measurement of UAC in a RUS was the best choice for the diagnosis screening of microalbuminuria in diabetic patients, considering cost and accuracy.

Frequency and treatment of urinary tract infection in children subjected to urine culture, in Sana'a, Yemen

BACKGROUND

This study was carried out to estimate the frequency of urinary tract infection among children subjected to urine culture presenting to Sam Hospital, Sana'a city, Yemen and to determine the susceptibility of the isolated bacteria to the antibiotics.

METHODS

Record-based study was done in Sam hospital in Sana'a city Yemen during three years 1/1/1999-31/12/2001. Out of 70,500 patients seen for different causes through that period 820 (1.16%) having urinary symptoms (fever, rigor, vomiting, frequency or screams during the act of urination) were subjected to urine culture. Data about age and sex were also collected.

RESULTS

Frequency of urinary tract infections among children examined by urine culture was 36.8% (n=302), with mean age of 7.6 years. 272 (90.1%) of them were females, and 30 (9.9%) were males. More than half 154 (51%) of infected patients were less than three years old. The isolated bacteria was Escherichia coli 201 (66.3%) followed by Staphylococcus suprofyticus 45 (14.9%), Proteus spp 15 (4.9%), Klebsiella 12 (3.9%) then Enterococcus spp 12 (3.9%). Sensitivity of E. coli to Nalidexic acid was 70%, to Amoxicillin/Clavulanic acid was 29.9%, to Co-trimoxasole was 16.4%, and to Nitrofurantoin was 15.9%.

CONCLUSION

The majority of the infected patients were females and the highest frequency of the disease was in the first three years of age. The most common isolated microorganism was E. coli followed by Staphylococcus suprofyticus, Proteus spp, then Enterococcus spp. The highly active antibiotic for most organisms isolated was Nalidexic acid, then amoxicillin/clavulanic acid. Nalidexic acid can be used as a first line empiric treatment and/or prophylaxis of UTI in children.

A Swedish cost-effectiveness analysis of community-based Chlamydia trachomatis PCR testing of postal urine specimens obtained at home

AIMS

A study was undertaken to assess the cost-effectiveness of identifying and treating asymptomatic carriers of Chlamydia trachomatis when using community-based testing of urine specimens obtained at home and mailed to a central laboratory.

METHODS

A total of 100 males and 100 females aged 20-24 living in Umeå were randomly sampled from the population registry. A societal cost-effective analysis was carried out, based on screening and medical care costs in Sweden.

RESULTS

With a participation rate of 55% (45% males and 65% females), the female screening became cost-saving as the C. trachomatis prevalence exceeded 5.1%, and the male screening became cost-saving with over 12.3% prevalence.

CONCLUSION

Postal screening for C. trachomatis in an asymptomatic young population can be cost-effective only at prevalences higher than at present.

Economical choices in setting up a diagnostic myeloma laboratory

In setting up a diagnostic myeloma laboratory the popular, highly automated and otherwise excellent choices of equipment and laboratory practices, so exorbitantly raise costs that the sustainability, even in large government hospitals in third world countries may become difficult. Based on our experience in a regional cancer center in India, we offer here, guidelines for carrying out high resolution electrophoresis, densitometry, immunofixation and urine concentration. We show that by simply employing well established techniques and doing them properly, one can get results of excellent quality at minimum cost and minimum dependence on costly imports.

Significance of bacteriuria in neurogenic bladder

OBJECTIVE

To investigate the usefulness of performing routine urine cultures in veterans with spinal cord injury (SCI) who come for annual evaluation. RESEARCH DESIGN/PARTICIPANTS: This retrospective study was performed on asymptomatic patients who came for outpatient annual evaluation. The records of 89 healthy male veterans with SCI between the ages of 22 and 82 years (mean age = 50.6) were reviewed from March through October 2000.

METHODS

The following information was collected: patient's name, social security numbers, age, year of injury, level of injury, American Spinal Injury Association (ASIA) classification, urinalysis including white blood cell (WBC) count and presence or absence of nitrite, urine culture results (> or <100,000 colony-forming units of uropathogens per milliliter), blood WBC count, and mode of bladder management. The data were analyzed statistically to look at the effects of age at injury, level of injury, injury category (ASIA classification), pyuria, urinary nitrite, serum WBC count, and mode of bladder control on the presence of bacteriuria.

RESULTS

Results revealed that regardless of the level of injury, individuals with ASIA A injuries were at high risk of having bacteriuria with positive culture results. Patients who were nitrite positive and/or had > or =6 WBCs per high-powered field (HPF) in the urine were also at high risk for significant bacteriuria.

CONCLUSION

Urinary tract infections (UTIs) in the SCI population frequently are asymptomatic, polymicrobial, caused by antibiotic-resistant bacteria, and very likely to recur or relapse. However, there are no data to support or justify treatment of asymptomatic bacteriuria. The present study suggests that healthy asymptomatic patients with SCI who come for annual evaluations should not have routine urine cultures if they are at low risk for UTIs; that is, <6 WBC/HPF in the urine and/or nitrite negative.

All dysuria is local. A cost-effectiveness model for designing site-specific management algorithms

OBJECTIVE

To determine the cost-effectiveness of management strategies for dysuria in different office settings.

DESIGN

Decision and cost-effectiveness analyses, assuming the payer's perspective. Data on disease prevalence, test characteristics, treatment efficacy, and adverse effects were drawn from the English language literature using medline searches and bibliographies.

SETTING

Hypothetical primary care practice.

PATIENTS

Otherwise healthy, nonpregnant women with symptoms of dysuria, urgency, and frequency.

INTERVENTIONS

All reasonable combinations of urinalysis, urine culture, pelvic examination, chlamydia and gonorrhea cultures, and empiric treatment with trimethoprim-sulfamethoxazole.

RESULTS

The cost-effectiveness of strategies varied substantially among different patient settings. In all settings, empiric trimethoprim-sulfamethoxazole for all patients was least expensive and least effective. Most testing increased both cost and effectiveness. Compared to empiric antibiotics, performing pelvic examination and urine culture for women with normal urinalyses had a marginal cost-effectiveness ratio of $4 to $32 per symptom-day avoided (SDA). Adding urine culture for patients with pyuria had a marginal cost of $34 to $107 per SDA, which fell to $40/SDA when the prevalence of resistance to trimethoprim-sulfamethoxazole exceeded 40%. Pelvic examination and urine culture for all patients regardless of urinalysis results achieved the greatest benefit but at the highest cost (>$300 per SDA).

CONCLUSIONS

In otherwise healthy women with symptoms of dysuria and no vaginal complaints, performing pelvic exam and urine culture based on urinalysis offers a reasonable alternative to empiric therapy. Other testing may be warranted, depending on antibiotic resistance and the value of avoiding a day of dysuria.

Cost-Effectiveness Analysis of Screening Adolescent Males for Chlamydia On Admission to Detention

BACKGROUND

Chlamydia trachomatis infections can lead to serious and costly sequelae. Because chlamydia is most often asymptomatic, many infected youth do not seek testing. Entry to a detention system provides an opportunity to screen and treat many at-risk youth. GOAL The goal of this study was to determine the cost-effectiveness of screening male youth for chlamydia on entry to detention.

STUDY DESIGN

Incremental cost-effectiveness of 3 chlamydia screening strategies was compared for a hypothetical cohort of 4000 male youth per year: 1) universal chlamydia screening using a urine-based nucleic acid amplification test (NAAT), 2) selective NAAT screening of urine leukocyte esterase (LE)-positive urines, and 3) no screening. The model incorporated programmatic costs of screening and treatment and medical cost savings from sequelae prevented in infected males and female partners. The analysis was conducted from the healthcare system perspective.

RESULTS

Chlamydia prevalence in the sampled population of 594 was 4.8%, and the average number of female sexual partners/infected male was 1.6. Universal NAAT screening was the most cost-effective strategy, preventing 37 more cases of pelvic inflammatory disease (PID) and 3 more cases of epididymitis than selective screening and saving an additional 24,000 dollars. The analysis was sensitive to NAAT cost, LE sensitivity, rate of PID development, PID sequelae cost, and number of female partners. Universal screening remained the most cost saving for prevalence as low as 2.8% or higher.

CONCLUSIONS

Universal chlamydia screening of adolescent males on entry to detention was the most cost-effective strategy. Savings are primarily the result of the prevention of PID in recent and future partners of index males. Screening detained male youth using a urine-based NAAT provides a public health opportunity to significantly reduce chlamydia infections in youth at risk for sexually transmitted diseases.

The urinalysis--inexpensive and informative

The urinalysis dates back 6000 years. Information has evolved from tasting it for sugar to computer assisted assessment for the presence of cells and casts. The urine gives valuable information about kidney function in general and the glomeruli in particular. Findings can lead to a diagnosis of various medical conditions, most notable being diabetes mellitus. Proteinuria has many implications, including the presence of systemic disease and the progression of an underlying renal condition.

Screening for proteinuria in US adults: a cost-effectiveness analysis

CONTEXT

Chronic kidney disease is a growing public health problem. Screening for early identification could improve health but could also lead to unnecessary harms and excess costs.

OBJECTIVE

To assess the value of periodic, population-based dipstick screening for early detection of urine protein in adults with neither hypertension nor diabetes and in adults with hypertension.

DESIGN, SETTING, AND POPULATION

Cost-effectiveness analysis using a Markov decision analytic model to compare a strategy of annual screening with no screening (usual care) for proteinuria at age 50 years followed by treatment with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II-receptor blocker (ARB).

MAIN OUTCOME MEASURE

Cost per quality-adjusted life-year (QALY).

RESULTS

For persons with neither hypertension nor diabetes, the cost-effectiveness ratio for screening vs no screening (usual care) was unfavorable (282 818 dollars per QALY; incremental cost of 616 dollars and a gain of 0.0022 QALYs per person). However, screening such persons beginning at age 60 years yielded a more favorable ratio (53 372 dollars per QALY). For persons with hypertension, the ratio was highly favorable (18 621 dollars per QALY; incremental cost of 476 dollars and a gain of 0.03 QALYs per person). Cost-effectiveness was mediated by both chronic kidney disease progression and death prevention benefits of ACE inhibitor and ARB therapy. Influential parameters that might make screening for the general population more cost-effective include a greater incidence of proteinuria, age at screening (53 372 dollars per QALY for persons beginning screening at age 60 years), or lower frequency of screening (every 10 years: 80 700 dollars per QALY at age 50 years; 6195 dollars per QALY at age 60 years; and 5486 dollars per QALY at age 70 years).

CONCLUSIONS

Early detection of urine protein to slow progression of chronic kidney disease and decrease mortality is not cost-effective unless selectively directed toward high-risk groups (older persons and persons with hypertension) or conducted at an infrequent interval of 10 years.

A cheap and convenient modification of arsine generator used for arsenic estimation

In a study observing the effect of spirulina in the treatment of chronic arsenic poisoning quantitative estimation of arsenic in the urine of the patients was necessary. It was decided to try a modification of the arsine generator in the process. An alternative apparatus was designed following the structure of arsine generator by White (1976) using a 50-ml conical flask with rubber cork, 4-ml injection vial, two 3" long glass tubes and a glass test tube. An experiment was carried out with solutions containing known amounts of arsenic. The alternative arsine generator was tried in the estimation of arsenic content in those solutions. The results revealed that the apparatus permitted correct measurement of arsenic concentration. The alternative arsine generator was cheap easy to use and provided authentic results in estimation of arsenic concentration in the urine of patients with chronic arsenic poisoning.

Biochemical and microscopic urinalysis: time and cost in a nephrology laboratory

BACKGROUND

Urinalysis is a fundamental test in internal medicine and nephrology. Figures for costs are available in the general laboratory, where biochemical and microscopic urinalysis are commonly performed as semiautomated screening tests. Information on costs is lacking in the nephrology laboratory, where a time-consuming morphological analysis is usually preferred. This study analyses the costs of urinalysis in a nephrology laboratory.

METHODS

In the nephrology laboratory at the University of Turin - Italy, biochemical urinalysis consists of multi-property strip and proteinuria/creatininuria, done by laboratory technicians. Phase-contrast microscopy is done by a nephrologist or biologist. Time dedicated to the tests was recorded by the same operator over 20 working days, during which 350 urine samples were processed (median 19/day, range 842). The production costs were calculated with the logic bottom-up technique.

RESULTS

Overall time needed was 11.9 minutes/sample. Biochemical urinalysis required 6.6 minutes/sample; time required and samples processed were inversely related (< or =19 samples: 7.95 minutes/sample; >19 samples: 5.6 minutes/sample, p=0.01). Microscopic urinalysis took 5.3 minutes/slide; the best time-to-samples ratio was at 18-22 samples per day (with peak efficiency at 21 samples: 4.6 minutes). Cost of reagents and disposables was Euro1.06/sample. Time accounted for euro 5.32/sample (technicians, nephrologist-biologist), with total direct cost of euro 6.38/sample.

CONCLUSION

In a nephrology laboratory, microscopic urinalysis is a time-consuming, expensive test. Analysis of cost and modalities may be useful, in a time of budget constrains, to maintain a role for this precious semeiotic art.

The optimal use of diagnostic testing in women with acute uncomplicated cystitis

Acute uncomplicated cystitis is a common and costly disorder in women, and there is considerable variation in the diagnostic strategies currently used in clinical practice. Because the diagnosis of cystitis can be established in most patients using the history alone, the clinician's responsibility is to determine which patients require additional diagnostic testing. Patients with typical symptoms (i.e., dysuria, frequency, urgency, hematuria), without risk factors for complicated infection or pyelonephritis, and without a history of vaginal discharge, have a very high probability of cystitis and are appropriate candidates for empiric treatment. It is more difficult, however, to rule out infection in patients with suspected cystitis. Because the prevalence of culture-proven infection is very high in women who present with >/=1 symptom, and because the treatment threshold for this condition is low, a urine culture is generally required to rule out infection in patients with atypical symptoms, even in the presence of a negative dipstick test. In population-based, before-and-after studies, use of diagnostic algorithms has been shown to significantly decrease the use of urinalysis, urine culture, and office visits while increasing the percentage of patients who receive recommended antibiotics. These strategies have substantially reduced the cost of managing cystitis without an increase in adverse events or a decrease in patient satisfaction. Randomized controlled trials are needed to more closely examine the outcomes, costs of care, and patient satisfaction from different diagnostic and management strategies.

Urine drug screening in the medical setting

BACKGROUND

The term drug screen is a misnomer since it implies screening for all drugs, which is not possible. Current practice is to limit the testing to the examination of serum for several drugs such as ethanol, acetaminophen, salicylate, and of urine for several specific drugs or classes of drugs. In the emergency setting the screen should be performed in less than one hour. Controversies continue to exist regarding the value of urine drug testing in the medical setting. The reasons for these include the drugs involved, the sample, the methods utilized to perform the tests, and the level of understanding of the physician using the data, all of which are closely related to the other.

METHODS

Current automated methods provide rapid results demanded in emergency situations, but are often designed for, or adapted from, workplace testing and are not necessarily optimized for clinical applications. Furthermore, the use of these methods without consideration of the frequency in which the drugs are found in a given area is not cost-effective. The laboratory must understand the limitations of the assays used and provide this information to the physician. Additionally, the laboratory and the physicians using the data must cooperate to determine which drugs are appropriate and necessary to measure for their institution and clinical setting. In doing so it should be remembered that for many drugs, the sample, urine, contains the end product(s) of drug metabolism, not the parent drug. Furthermore, it is necessary to understand the pharmacokinetic parameters of the drug of interest when interpreting data. Finally, while testing for some drugs may not appear cost-effective, the prevention or reduction of morbidity and mortality may offset any laboratory costs.

CONCLUSIONS

While the literature is replete with studies concerning new methods and a few regarding physician understanding, there are none that we could find that thoroughly, objectively, and fully addressed the issues of utility and cost-effectiveness.