Assessing the research landscape and clinical utility of large language models: a scoping review

IMPORTANCE

Large language models (LLMs) like OpenAI's ChatGPT are powerful generative systems that rapidly synthesize natural language responses. Research on LLMs has revealed their potential and pitfalls, especially in clinical settings. However, the evolving landscape of LLM research in medicine has left several gaps regarding their evaluation, application, and evidence base.

OBJECTIVE

This scoping review aims to (1) summarize current research evidence on the accuracy and efficacy of LLMs in medical applications, (2) discuss the ethical, legal, logistical, and socioeconomic implications of LLM use in clinical settings, (3) explore barriers and facilitators to LLM implementation in healthcare, (4) propose a standardized evaluation framework for assessing LLMs' clinical utility, and (5) identify evidence gaps and propose future research directions for LLMs in clinical applications.

EVIDENCE REVIEW

We screened 4,036 records from MEDLINE, EMBASE, CINAHL, medRxiv, bioRxiv, and arXiv from January 2023 (inception of the search) to June 26, 2023 for English-language papers and analyzed findings from 55 worldwide studies. Quality of evidence was reported based on the Oxford Centre for Evidence-based Medicine recommendations.

FINDINGS

Our results demonstrate that LLMs show promise in compiling patient notes, assisting patients in navigating the healthcare system, and to some extent, supporting clinical decision-making when combined with human oversight. However, their utilization is limited by biases in training data that may harm patients, the generation of inaccurate but convincing information, and ethical, legal, socioeconomic, and privacy concerns. We also identified a lack of standardized methods for evaluating LLMs' effectiveness and feasibility.

CONCLUSIONS AND RELEVANCE

This review thus highlights potential future directions and questions to address these limitations and to further explore LLMs' potential in enhancing healthcare delivery.

Evaluating the coding accuracy of type 2 diabetes mellitus among patients with non-alcoholic fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) describes a spectrum of chronic fattening of liver that can lead to fibrosis and cirrhosis. Diabetes has been identified as a major comorbidity that contributes to NAFLD progression. Health systems around the world make use of administrative data to conduct population-based prevalence studies. To that end, we sought to assess the accuracy of diabetes International Classification of Diseases (ICD) coding in administrative databases among a cohort of confirmed NAFLD patients in Calgary, Alberta, Canada.

METHODS

The Calgary NAFLD Pathway Database was linked to the following databases: Physician Claims, Discharge Abstract Database, National Ambulatory Care Reporting System, Pharmaceutical Information Network database, Laboratory, and Electronic Medical Records. Hemoglobin A1c and diabetes medication details were used to classify diabetes groups into absent, prediabetes, meeting glycemic targets, and not meeting glycemic targets. The performance of ICD codes among these groups was compared to this standard. Within each group, the total numbers of true positives, false positives, false negatives, and true negatives were calculated. Descriptive statistics and bivariate analysis were conducted on identified covariates, including demographics and types of interacted physicians.

RESULTS

A total of 12,012 NAFLD patients were registered through the Calgary NAFLD Pathway Database and 100% were successfully linked to the administrative databases. Overall, diabetes coding showed a sensitivity of 0.81 and a positive predictive value of 0.87. False negative rates in the absent and not meeting glycemic control groups were 4.5% and 6.4%, respectively, whereas the meeting glycemic control group had a 42.2% coding error. Visits to primary and outpatient services were associated with most encounters.

CONCLUSION

Diabetes ICD coding in administrative databases can accurately detect true diabetic cases. However, patients with diabetes who meets glycemic control targets are less likely to be coded in administrative databases. A detailed understanding of the clinical context will require additional data linkage from primary care settings.

Automated Paper Screening for Clinical Reviews Using Large Language Models: Data Analysis Study

BACKGROUND

The systematic review of clinical research papers is a labor-intensive and time-consuming process that often involves the screening of thousands of titles and abstracts. The accuracy and efficiency of this process are critical for the quality of the review and subsequent health care decisions. Traditional methods rely heavily on human reviewers, often requiring a significant investment of time and resources.

OBJECTIVE

This study aims to assess the performance of the OpenAI generative pretrained transformer (GPT) and GPT-4 application programming interfaces (APIs) in accurately and efficiently identifying relevant titles and abstracts from real-world clinical review data sets and comparing their performance against ground truth labeling by 2 independent human reviewers.

METHODS

We introduce a novel workflow using the Chat GPT and GPT-4 APIs for screening titles and abstracts in clinical reviews. A Python script was created to make calls to the API with the screening criteria in natural language and a corpus of title and abstract data sets filtered by a minimum of 2 human reviewers. We compared the performance of our model against human-reviewed papers across 6 review papers, screening over 24,000 titles and abstracts.

RESULTS

Our results show an accuracy of 0.91, a macro F1-score of 0.60, a sensitivity of excluded papers of 0.91, and a sensitivity of included papers of 0.76. The interrater variability between 2 independent human screeners was κ=0.46, and the prevalence and bias-adjusted κ between our proposed methods and the consensus-based human decisions was κ=0.96. On a randomly selected subset of papers, the GPT models demonstrated the ability to provide reasoning for their decisions and corrected their initial decisions upon being asked to explain their reasoning for incorrect classifications.

CONCLUSIONS

Large language models have the potential to streamline the clinical review process, save valuable time and effort for researchers, and contribute to the overall quality of clinical reviews. By prioritizing the workflow and acting as an aid rather than a replacement for researchers and reviewers, models such as GPT-4 can enhance efficiency and lead to more accurate and reliable conclusions in medical research.

Distribution of videos demonstrating best practices in preventing hemolysis is associated with reduced hemolysis among nurse-collected specimens in hospitals

BACKGROUND

Minimizing hemolysis during phlebotomy ensures accurate chemistry results and reduces test cancellations and specimen recollections. We developed videos demonstrating best practices to reduce hemolysis and tested whether distribution to clinical nurse educators (CNEs) for provision to nursing staff affected the degree of specimen hemolysis in hospital inpatient units and outpatient clinics.

METHODS

Videos of common blood collections demonstrating best practices to reduce hemolysis were filmed and then distributed via email link to all hospital-based CNEs in Calgary, Alberta, Canada. (https://vimeo.com/user18866730/review/159869683/a0cec9827f). Roche Cobas hemolysis index (H-index) results from specimens collected +/- 12 months from the date of video distribution were extracted from Roche Cobas IT middleware (cITM) and linked to collection location. An interrupted time series (ITS) analysis with collection location as the unit of anlaysis was used to quantify impact of video distribution on the trajectory of weekly mean log-H-index weighted by inverse variance.

RESULTS

In +/- 3 months of data flanking video distribution (n = 137 241 collections), where overall impact was strongest, H-index trajectory (change in units per week) decreased immediately following video distribution (-5.7% / week, p < 0.01). This was accompanied by a 22% drop in overall H-index from the week before to the week after video distribution (y-intercept change, or gap). There was also a small but significant overall decrease in the proportion of hemolyzed specimens (-0.3%, p < 0.01). These changes were not observed at all collection locations, and in fact increases occured at some locations.

CONCLUSIONS

We developed a novel and convenient educational aid that, when distributed, was associated with beneficial changes in specimen hemolysis at hospital inpatient units and outpatient clinics. Including it in ongoing nursing education will fill a knowledge gap that may help to reduce specimen hemolysis.

How much is enough? Proposing achievement thresholds for core EPAs of graduating medical students in Canada

PURPOSE

The transition towards Competency-Based Medical Education at the Cumming School of Medicine was accelerated by the reduced clinical time caused by the COVID-19 pandemic. The purpose of this study was to define a standard protocol for setting Entrustable Professional Activity (EPA) achievement thresholds and examine their feasibility within the clinical clerkship.

METHODS

Achievement thresholds for each of the 12 AFMC EPAs for graduating Canadian medical students were set by using sequential rounds of revision by three consecutive groups of stakeholders and evaluation experts. Structured communication was guided by a modified Delphi technique. The feasibility/consequence models of these EPAs were then assessed by tracking their completion by the graduating class of 2021.

RESULTS

The threshold-setting process resulted in set EPA achievement levels ranging from 1 to 8 across the 12 AFMC EPAs. Estimates were stable after the first round for 9 of 12 EPAs. 96.27% of EPAs were successfully completed by clerkship students despite the shortened clinical period. Feasibility was predicted by the slowing rate of EPA accumulation overtime during the clerkship.

CONCLUSION

The process described led to consensus on EPA achievement thresholds. Successful completion of the assigned thresholds was feasible within the shortened clerkship.[Box: see text].

Risk Factors and Outcomes of Bloodstream Infections Among People With Human Immunodeficiency Virus: A Longitudinal Cohort Study From 2000 to 2017

Background

Bloodstream infections (BSIs) among people with human immunodeficiency virus (PWH) remain a poorly studied source of morbidity and mortality. We characterize the epidemiology, microbiology, and clinical outcomes including reinfection, hospitalization, and mortality rates of both community-acquired and hospital-acquired BSI in PWH.

Methods

We identified all BSI, between January 1, 2000 and December 31, 2017 in PWH in care at Southern Alberta Clinic, by linking data from laboratory and clinical databases. Crude incidence rates per 1000 person-years for BSI and death were calculated. Cox proportional hazards models estimated crude and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) to conduct a risk factor analysis of BSI in PWH. Logistic regression models with generalized estimating equations estimated crude and adjusted odds ratios (aORs) to identify characteristics associated with 1-year mortality after BSI.

Results

Among 2895 PWH, 396 BSI episodes occurred in 228 (8%) PWH. There were 278 (72%) Gram-positive and 109 (28%) Gram-negative BSI. People with human immunodeficiency virus with lower CD4 nadirs, higher Charlson comorbidity indices, and hepatitis C virus were at highest risk for BSI. Long-term all-cause mortality was greater in those experiencing BSI (HR, 5.25; 95% CI, 4.21-6.55). CD4 count <200 cells/mm³ measured closest to the time of BSI was associated with 1-year mortality after BSI (aOR, 3.88; 95% CI, 1.78-8.46). Repeat episodes (42%) and polymicrobial BSI (19%) were common.

Conclusions

Bloodstream infections continue to occur at an elevated rate among PWH with high reoccurrence rates and associated morbidity and mortality. To risk stratify and develop targeted interventions, we identified PWH at greatest risk for BSI. People with human immunodeficiency virus with low immunity at the time of BSI are at highest risk of poor outcomes.

Variation in Patient-Described Barriers to and Facilitators of Diabetes Management by Individual-Level Characteristics: A Cross-Sectional, Open-Ended Survey

This study analyzed patient-described barriers and facilitators related to diabetes management, focusing on how these differ by glycemia and across individual characteristics. A cross-sectional telephone survey was conducted with adult patients with diabetes in Alberta, Canada, asking two open-ended questions to describe the most helpful and difficult components of their diabetes management. Responses were analyzed using directed content analysis using the Theoretical Domains Framework as a template. The most frequently cited facilitator was care context and information, and the most frequently cited barriers were cognitive challenges and structural barriers, with patient-perceived barriers and facilitators varying by individual-level factors.

The mean abnormal result rates of laboratory tests ordered in the emergency department: shooting percentage insights from a multi-centre study

OBJECTIVE

While there is concern about excessive laboratory test ordering in the ED, it is difficult to quantify the problem. One solution involves the Mean Abnormal Result Rate (MARR), which is the proportion of tests ordered that return abnormal results. The primary objective of this study was to calculate MARR scores, and factors associated with MARR scores, for tests ordered between April 2014 and March 2019 at adult EDs in Calgary.

METHODS

Administrative data were obtained for 40 laboratory tests that met selection criteria. One possible MARR correlate, physician experience, was quantified for 209 ED physicians as number of years since licensure. Analyses were descriptive where appropriate for whole-population data.

RESULTS

The condensed dataset comprised 3,395,312 test results on 415,653 unique patients. The aggregate 5-year MARR score was 40.1%. The highest per-test score was for BNP (80.5%), while the lowest was for glucose (7.9%). MARR scores were higher for nurse-initiated orders than for physician-initiated orders (44.7% vs. 38.1%). The MARR score correlated inversely with number of tests per order (r = - 0.90; 95% confidence interval [CI] - 0.65 to - 0.94; p < 0.001) and directly with physician experience (r = 0.28, 95% CI 0.20 to 0.27; p < 0.001).

CONCLUSION

This is the first study to measure MARR scores in an ED setting. While lower scores (close to 5%) are less optimal in principle, ideal scores will depend on the clinical context in which tests are used. However, once departmental benchmarks are established, MARR score-monitoring allows efficient tracking of ordering practices across millions of tests.

A longitudinal population-based study of predictors of mortality from bloodstream infections in Calgary, Alberta, Canada

Aim: To study the predictors of mortality from nine major pathogens causing approximately 70% of cases over a 7-year period. Materials & methods: A population-based surveillance cohort of all adult and pediatric patients in the Calgary Zone with an initial episode of bloodstream infections (BSI). Results: The 1-year mortality was 29.2% among 9524 patients (5164 males [54%]). Incidence rates for BSI increased annually to 119.7/100,000 persons by 2016. Distinct survival curves were found for each specific pathogen. Age, comorbidity burden and infecting organism were significantly associated with increased hazard of death. No relationship occurred between the time to positivity for blood cultures and overall mortality. Conclusion: BSI has a high mortality, but overall survival depends on underlying host health and the type of pathogen acquired.

The life of a laboratory requisition form: Patient compliance with clinical laboratory testing in a Canadian primary care health region

OBJECTIVE

To examine patient laboratory testing compliance by tracking time to submission of laboratory requisitions in Southern Alberta, Canada as part of a quality improvement initiative.

METHODS

Data was collected retrospectively from patients from the Chinook Primary Care Network in Alberta, Canada, who received a laboratory requisition consisting of a complete blood count (CBC) test order between September 1, 2016 and August 31, 2017. To allow for all laboratory requisitions created to be submitted within one year, the study collection period was from September 1, 2016 to August 31, 2018. Patient age, sex, and dates of laboratory requisition creation and submission were collected. The days-to-test-submission served as a marker of compliance. Association of age, sex, and clinic location with time to laboratory requisition completion was determined using Cox regression analysis.

RESULTS

During the study period, 70.4% (n = 1607) of laboratory requisitions created were completed within one year, and over half (50.5%) of the laboratory requisitions ordered were completed within two weeks. There were no significant associations between time to laboratory requisition submission and sex or clinic locations (P > 0.05), but there were significant associations between patients who were 20-49 or 70-79 and increased laboratory requisition compliance (P < 0.05). However, 26.0% of the laboratory requisitions created were not submitted at all.

CONCLUSIONS

This was the first study that quantified the proportion and timing of laboratory requisitions that were submitted by patients in a primary care setting. Community patients should be engaged and educated regarding the importance of complying with their physician-ordered laboratory requests in a timely manner.

Age and sex-specific incidence rates of group A streptococcal pharyngitis between 2010 and 2018: a population-based study

Aim: Group A streptococcus (GAS) pharyngitis is a common clinical infection with significant morbidity but remains understudied. Materials & methods: We sought to assess the rates of testing and incidence of GAS pharyngitis in Calgary, Alberta based on age and sex. Results: A total of 1,074,154 tests were analyzed (58.8% female, mean age 24.8 years) of which 16.6% were positive. Age-standardized testing and positivity was greatest in the 5-14 years age group and lowest in persons over 75 years. Females had greater rates of testing and positivity throughout. Testing rates (incidence rate ratios: 1.40, 95% CI: 1.39-1.41) and case rates (incidence rate ratios: 1.36, 95% CI: 1.33-1.39) increased over time. Conclusion: Future studies should focus on evaluating disparities in testing and treatment outcomes to optimize the approach to this infection.

A multicenter study investigating SARS-CoV-2 in tertiary-care hospital wastewater. viral burden correlates with increasing hospitalized cases as well as hospital-associated transmissions and outbreaks

SARS-CoV-2 has been detected in wastewater and its abundance correlated with community COVID-19 cases, hospitalizations and deaths. We sought to use wastewater-based detection of SARS-CoV-2 to assess the epidemiology of SARS-CoV-2 in hospitals. Between August and December 2020, twice-weekly wastewater samples from three tertiary-care hospitals (totaling > 2100 dedicated inpatient beds) were collected. Hospital-1 and Hospital-2 could be captured with a single sampling point whereas Hospital-3 required three separate monitoring sites. Wastewater samples were concentrated and cleaned using the 4S-silica column method and assessed for SARS-CoV-2 gene-targets (N1, N2 and E) and controls using RT-qPCR. Wastewater SARS-CoV-2 as measured by quantification cycle (Cq), genome copies and genomes normalized to the fecal biomarker PMMoV were compared to the total daily number of patients hospitalized with active COVID-19, confirmed cases of hospital-acquired infection, and the occurrence of unit-specific outbreaks. Of 165 wastewater samples collected, 159 (96%) were assayable. The N1-gene from SARS-CoV-2 was detected in 64.1% of samples, N2 in 49.7% and E in 10%. N1 and N2 in wastewater increased over time both in terms of the amount of detectable virus and the proportion of samples that were positive, consistent with increasing hospitalizations at those sites with single monitoring points (Pearson's r = 0.679, P < 0.0001, Pearson's r = 0.799, P < 0.0001, respectively). Despite increasing hospitalizations through the study period, nosocomial-acquired cases of COVID-19 (Pearson's r = 0.389, P < 0.001) and unit-specific outbreaks were discernable with significant increases in detectable SARS-CoV-2 N1-RNA (median 112 copies/ml) versus outbreak-free periods (0 copies/ml; P < 0.0001). Wastewater-based monitoring of SARS-CoV-2 represents a promising tool for SARS-CoV-2 passive surveillance and case identification, containment, and mitigation in acute- care medical facilities.

Laboratory reporting of framingham risk score increases statin prescriptions in at-risk patients

BACKGROUND

The under-utilization of cardiovascular preventative therapy with statins warrants novel interventions to optimize prescriptions in at-risk patients. We investigated the role of a laboratory generated Framingham Risk Score (FRS) provided to primary care clinicians in changing statin use in a primary care setting.

METHODS

Data was acquired from the electronic medical records of 1573 anonymized patients undergoing routine lipid testing. Follow-up statin use and low-density lipoprotein cholesterol levels were obtained for 2 years post intervention. FRS parameters were entered into a laboratory information system, and provided to ordering physicians along with the cholesterol profile and the appropriate current Canadian Dyslipidemia treatment recommendation in a single report. Statin prescription rates following the intervention were compared with historical use 6 months prior to the study.

RESULTS

A total of 1283 participants (mean age of 60 ± 11 years) had an FRS report and were considered for analysis. Two hundred individuals filled a statin prescription in the 6 months prior to their index lipid test, and an additional 84 filled a statin prescription following the intervention (42% increase). The relative and absolute increase in statin prescription was 47.3% and 13.6% in the high-risk group p < 0.001, 53.3% and 8.1% in the intermediate-risk group p < 0.001, and 17.0% and 1.42% in the low-risk group p = 0.008, respectively.

CONCLUSION

The use of the laboratory reported FRS was associated with a significant increase in the rate of statin prescription across all risk groups. The expansion of FRS reporting across other health regions would improve cardiovascular risk prevention.

Factors Associated with Hyponatremia in Patients Newly Prescribed Citalopram: A Retrospective Observational Study

Background

Hyponatremia is a common and under-recognized adverse drug reaction of selective serotonin re-uptake inhibitor (SSRI) antidepressants. Despite its clinical importance, there are few large-scale studies on the factors associated with hyponatremia.

Objective

The aim of this study was to determine the incidence of hyponatremia and to identify patient factors associated with hyponatremia in a large, population-based cohort initiating new prescriptions for citalopram.

Methods

We included all patients with a new prescription for citalopram during 2010–2017, inclusive, with baseline and post-initiation serum sodium values available. Data were obtained from an Alberta Health Pharmacy database to identify new citalopram prescriptions. Laboratory values for patients with new prescriptions were obtained from linked Calgary Laboratory Services data. Incident hyponatremia was defined as serum sodium level < 135 mmol/L, following prescription initiation. Associations were determined by performing Cox regression with time-varying covariate analysis, with the development of hyponatremia as the dependent variable.

Results

A total of 19,679 patients with new prescriptions were identified; 12,842 females and 6837 males. The mean age was 55.48 years (SD 21.35). Of these patients, 3250 (16.5%) developed hyponatremia, 1996 (15.5% of) females and 1254 (18.3% of) males (p = 0.002). Cox regression showed significant associations of hyponatremia with lower baseline sodium (HR 0.788), older age (HR 1.029), thiazide diuretic use (HR 1.141), and male sex (HR 1.168). Pharmaceutical manufacturer or strength of citalopram did not have significant effects on the development of hyponatremia.

Conclusion

This study provides additional data on the predictors of hyponatremia among patients initiating citalopram therapy. We report a 16.5% incidence of hyponatremia after starting citalopram treatment, and significant new findings include a higher incidence in males. This is the first published incidence of hyponatremia following the initiation of citalopram treatment across all ages in Canada.

Electronic Medical Record-Based Case Phenotyping for the Charlson Conditions: Scoping Review

Background

Electronic medical records (EMRs) contain large amounts of rich clinical information. Developing EMR-based case definitions, also known as EMR phenotyping, is an active area of research that has implications for epidemiology, clinical care, and health services research.

Objective

This review aims to describe and assess the present landscape of EMR-based case phenotyping for the Charlson conditions.

Methods

A scoping review of EMR-based algorithms for defining the Charlson comorbidity index conditions was completed. This study covered articles published between January 2000 and April 2020, both inclusive. Embase (Excerpta Medica database) and MEDLINE (Medical Literature Analysis and Retrieval System Online) were searched using keywords developed in the following 3 domains: terms related to EMR, terms related to case finding, and disease-specific terms. The manuscript follows the Preferred Reporting Items for Systematic reviews and Meta-analyses extension for Scoping Reviews (PRISMA) guidelines.

Results

A total of 274 articles representing 299 algorithms were assessed and summarized. Most studies were undertaken in the United States (181/299, 60.5%), followed by the United Kingdom (42/299, 14.0%) and Canada (15/299, 5.0%). These algorithms were mostly developed either in primary care (103/299, 34.4%) or inpatient (168/299, 56.2%) settings. Diabetes, congestive heart failure, myocardial infarction, and rheumatology had the highest number of developed algorithms. Data-driven and clinical rule–based approaches have been identified. EMR-based phenotype and algorithm development reflect the data access allowed by respective health systems, and algorithms vary in their performance.

Conclusions

Recognizing similarities and differences in health systems, data collection strategies, extraction, data release protocols, and existing clinical pathways is critical to algorithm development strategies. Several strategies to assist with phenotype-based case definitions have been proposed.

Levothyroxine prescribing and laboratory test use after a minor change in reference range for thyroid-stimulating hormone

BACKGROUND

Prescribing of levothyroxine and rates of thyroid function testing may be sensitive to minor changes in the upper limit of the reference range for thyroid-stimulating hormone (TSH) that increase the proportion of abnormal results. We evaluated the population-level change in levothyroxine prescribing and TSH testing after a minor planned decrease in the upper limit of the reference range for TSH in a large urban centre with a single medical laboratory.

METHODS

Using provincial administrative data, we compared predicted volumes of TSH tests with actual TSH test volumes before and after a planned change in the TSH reference range. We also determined the number of new levothyroxine prescriptions for previously untreated patients and the rate of changes to the prescribed dose for those on previously stable, long-term levothyroxine therapy before and after the change in the TSH reference range.

RESULTS

Before the change in the TSH reference range, actual and predicted monthly volumes of TSH testing followed an identical course. After the change, actual test volumes exceeded predicted test volumes by 7.3% (95% confidence interval [CI] 5.3%-9.3%) or about 3000 to 5000 extra tests per month. The proportion of patients with newly "abnormal" TSH results almost tripled, from 3.3% (95% CI 3.2%-3.4%) to 9.1% (95% CI 9.0%-9.2%). The rate of new levothyroxine prescriptions increased from 3.24 (95% CI 3.15-3.33) per 1000 population in 2013 to 4.06 (95% CI 3.96-4.15) per 1000 population in 2014. Among patients with preexisting stable levothyroxine therapy, there was a significant increase in the number of dose escalations (p < 0.001) and a total increase of 500 new prescriptions per month.

INTERPRETATION

Our findings suggest that clinicians may have responded to mildly elevated TSH results with new or increased levothyroxine prescriptions and more TSH testing. Knowledge translation efforts may be useful to accompany minor changes in reference ranges.

Cervical Screening Practices and Outcomes for Young Women in Response to Changed Guidelines in Calgary, Canada, 2007-2016

OBJECTIVE

The aim of the study was to describe temporal trends in screening and outcomes for women, after changes in guidelines in Alberta, Canada, that raised starting age to 21 years, then to 25 years of age, and reduced frequency to 3 yearly.

MATERIALS AND METHODS

Calgary Laboratory Information System data were used to examine screening rates, follow-up procedures, and cancer among women 10-29 years from 2007 to 2016 in the whole population of Calgary. Interrupted time-series analyses were used to assess changes in screening and subsequent diagnostic procedures over the 10-year period.

RESULTS

Annual screening rates dropped by approximately 10% at all ages older than 15 years after the 2009 Alberta cervical cancer screening guidelines, followed by a steady decrease. Further change continued subsequent to minimal apparent effect of the 2013 Canadian Task Force on Preventive Health Care guidelines. The rates of abnormal test results decreased in concert with decreased screening. No increases in cervical intraepithelial neoplasia 1, cervical intraepithelial neoplasia 2/3, or invasive cervical cancer rates were observed after reduced testing.

CONCLUSIONS

The largest decrease in screening and follow-up procedures occurred in the period immediately after implementation of 2009 Alberta screening guidelines. The number of consequent procedures also decreased in proportion to decreased screening, but there was no increase in cancer rates. Starting screening at the age of 25 years and reducing intervals seem to be safe.

Effectiveness of Alberta Family Integrated Care on infant length of stay in level II neonatal intensive care units: a cluster randomized controlled trial

Background

Parents of infants in neonatal intensive care units (NICUs) are often unintentionally marginalized in pursuit of optimal clinical care. Family Integrated Care (FICare) was developed to support families as part of their infants’ care team in level III NICUs. We adapted the model for level II NICUs in Alberta, Canada, and evaluated whether the new Alberta FICare™ model decreased hospital length of stay (LOS) in preterm infants without concomitant increases in readmissions and emergency department visits.

Methods

In this pragmatic cluster randomized controlled trial conducted between December 15, 2015 and July 28, 2018, 10 level II NICUs were randomized to provide Alberta FICare™ (n = 5) or standard care (n = 5). Alberta FICare™ is a psychoeducational intervention with 3 components: Relational Communication, Parent Education, and Parent Support. We enrolled mothers and their singleton or twin infants born between 32 ^0/7 and 34 ^6/7 weeks gestation. The primary outcome was infant hospital LOS. We used a linear regression model to conduct weighted site-level analysis comparing adjusted mean LOS between groups, accounting for site geographic area (urban/regional) and infant risk factors. Secondary outcomes included proportions of infants with readmissions and emergency department visits to 2 months corrected age, type of feeding at discharge, and maternal psychosocial distress and parenting self-efficacy at discharge.

Results

We enrolled 654 mothers and 765 infants (543 singletons/111 twin cases). Intention to treat analysis included 353 infants/308 mothers in the Alberta FICare™ group and 365 infants/306 mothers in the standard care group. The unadjusted difference between groups in infant hospital LOS (1.96 days) was not statistically significant. Accounting for site geographic area and infant risk factors, infant hospital LOS was 2.55 days shorter (95% CI, − 4.44 to − 0.66) in the Alberta FICare™ group than standard care group, P = .02. Secondary outcomes were not significantly different between groups.

Conclusions

Alberta FICare™ is effective in reducing preterm infant LOS in level II NICUs, without concomitant increases in readmissions or emergency department visits. A small number of sites in a single jurisdiction and select group infants limit generalizability of findings.

Trial registration

ClinicalTrials.gov Identifier NCT02879799, retrospectively registered August 26, 2016.

Strategies for enhancing the initiation of cholesterol lowering medication among patients at high cardiovascular disease risk: a qualitative descriptive exploration of patient and general practitioners' perspectives on a facilitated relay intervention in Alberta, Canada

OBJECTIVE

The objective of our study was to explore the perspectives of patients and general practitioners (GPs) regarding interventions to increase initiation of cholesterol lowering medication (or statins), including a proposed laboratory-based facilitated relay intervention.

DESIGN

Qualitative descriptive study using interviews and focus groups for data collection, and thematic analysis for data analysis.

SETTING

Primary care providers and patients in Calgary, Alberta, Canada.

PARTICIPANTS

17 GPs with primarily community-based, non-academic practices with at least 1 year of practice experience participated in semistructured interviews. 14 patients at high risk of cardiovascular disease participated in focus groups.

MAIN OUTCOME MEASURES

Exploration of strategies that might be used to enhance the prescription of, and adherence to statin therapy for patients with statin-indicated conditions.

RESULTS

GPs proposed a variety of interventions to improve statin prescription, including electronic record audit solutions, GP directed education, and patient-oriented campaigns. Patients expressed that they may benefit from being provided access to their laboratory test results, as well as targeted education. Both parties provided positive feedback on the proposed laboratory-based facilitated relay intervention, while pointing out areas for improvement. Notably, GPs were concerned that the patient-directed component of the intervention might jeopardise therapeutic relationships, and patients were concerned about accidental disclosure of personal health information. Important considerations for the design of facilitated relay messaging should include brevity, simplicity and the provision of contact information for inquiries.

CONCLUSIONS

GPs and patients described several suggestions for increasing statin initiation and welcomed the proposal of a laboratory-based facilitated relay strategy. These findings support further testing of this intervention which may enhance GPs' ability to successfully engage patients in cardiovascular risk reduction through statin therapy.

Barriers and Facilitators to Using Statins: A Qualitative Study With Patients and Family Physicians

Background

Despite their proven efficacy to reduce cardiovascular disease, statin medication use remains low in individuals at high risk of cardiovascular disease considering their widespread availability and safety. Our objective was to explore the perspectives of patients and family physicians with regard to the barriers and facilitators of statin use in primary care.

Methods

In this qualitative descriptive study, we conducted 2 focus groups with patients (number, n = 8/6) and individual semistructured interviews with family physicians (n = 17) from community settings. Interviewers asked participants about barriers to and facilitators of statin use. Focus groups and interviews were digitally recorded, transcribed, and analyzed in duplicate using conventional content analysis.

Results

Patients were averse to taking statins for a variety of reasons: medication avoidance and burden; inadequate buy-in for statin therapy; and difficulty remembering to take statins regularly. Family physicians perceived similar barriers and reported other barriers: lack of resources such as inadequate tracking systems; specialist-primary care provider guideline discordance; and lack of continuity and relationship. Patients expressed that key facilitators were patient education and support; splitting tablets to increase cost-effectiveness; and changing to a different statin or lower dose in those with side effects. Family physicians described several similar strategies to facilitate therapy as well as shared decision making and clinical decision support tools as enablers for improvement.

Conclusions

We identified several important barriers to and facilitators of statin use at the patient and prescriber level. This information offers insight into strategies to improve statin use and the development of innovative programs and interventions.

Is the Utilization of Helicobacter pylori Stool Antigen Tests Appropriate in an Urban Canadian Population?

OBJECTIVES

Helicobacter pylori stool antigen test (HpSAT) appropriateness was investigated by assessing its testing and positivity rates in Calgary, Canada.

METHODS

The laboratory information system was accessed for all patients who received an HpSAT in 2018. Testing volume, test results, age, and sex of patients were collected. Sociodemographic risk factors and geospatial analysis were performed by matching laboratory data to the 2016 census data. Testing appropriateness was defined as a concordance between testing and positivity rates for each sociodemographic variable.

RESULTS

In 2018, 25,518 H pylori stool antigen tests were performed in Calgary, with an overall positivity rate of 14.7%. Geospatial mapping demonstrated significant distribution variations of testing and positivity rates of HpSAT in the city. Certain sociodemographic groups studied (eg, recent immigrants) appeared to be appropriately tested (testing rate relative risk [RR] = 2.26, positivity rate RR = 4.32; P < .0001), while other groups (eg, male) may have been undertested (testing rate RR = 0.85, positivity rate RR = 1.14; P < .0001).

CONCLUSIONS

Determining concordance of testing and positivity rate of a laboratory test can be used for assessing testing appropriateness for other diseases in other jurisdictions. This study demonstrated some at-risk patients may be missed for H pylori testing.

Ethnic disparity and exposure to supplements rather than adverse childhood experiences linked to preterm birth in Pakistani women

BACKGROUND

Adverse childhood experiences (ACEs) are associated with prenatal mental health and negative pregnancy outcomes in high income countries, but whether the same association exists in Pakistan, a low- to middle-income (LMI) country, remains unclear.

METHODS

Secondary data analyses of a prospective longitudinal cohort study examining biopsychosocial measures of 300 pregnant women at four sites in Karachi, Pakistan. A predictive multiple logistic regression model for preterm birth (PTB; i.e., <37 weeks' gestation) was developed from variables significantly (P < 0.05) or marginally (P < 0.10) associated with PTB in the bivariate analyses.

RESULTS

Of the 300 women, 263 (88%) returned for delivery and were included in the current analyses. The PTB rate was 11.1%. We found no association between ACE and PTB. Mother's education (P = 0.011), mother's ethnicity (P = 0.010), medications during pregnancy (P = 0.006), age at birth of first child or current age if primiparous (P = 0.049) and age at marriage (P = 0.091) emerged as significant in bivariate analyses. Mother's ethnicity and taking medications remained predictive of PTB in the multivariate model.

LIMITATIONS

Findings are limited by the relatively small sample size which precludes direct testing for possible interactive effects.

CONCLUSIONS

In sum, pathways to PTB for women in LMI countries may differ from those observed in high-income countries and may need to be modelled differently to include behavioural response to emotional distress and socio-cultural contexts.

Essential role of laboratory physicians in transformation of laboratory practice and management to a value-based patient-centric model

The laboratory is a vital part of the continuum of patient care. In fact, there are few programs in the healthcare system that do not rely on ready access and availability of complex diagnostic laboratory services. The existing transactional model of laboratory "medical practice" will not be able to meet the needs of the healthcare system as it rapidly shifts toward value-based care and precision medicine, which demands that practice be based on total system indicators, clinical effectiveness, and patient outcomes. Laboratory "value" will no longer be focused primarily on internal testing quality and efficiencies but rather on the relative cost of diagnostic testing compared to direct improvement in clinical and system outcomes. The medical laboratory as a "business" focused on operational efficiency and cost-controls must transform to become an essential clinical service that is a tightly integrated equal partner in direct patient care. We would argue that this paradigm shift would not be necessary if laboratory services had remained a "patient-centric" medical practice throughout the last few decades. This review is focused on the essential role of laboratory physicians in transforming laboratory practice and management to a value-based patient-centric model. Value-based practice is necessary not only to meet the challenges of the new precision medicine world order but also to bring about sustainable healthcare service delivery.

Dataset of test volume and tests repeated for complete blood count and electrolyte panels from hospitals in a Canadian province in 2018

All laboratory tests performed within the province of Alberta in Canada are captured by three Laboratory Information Systems (LIS; Millennium, Sunquest and Meditech), which comprise the provincial Consolidated Laboratory Data Repository (CLDR). The following secondary laboratory data for electrolyte panel (EP) and complete blood count (CBC) test panels performed in emergency room (ER) and inpatient settings were collected from January 1 – December 31, 2018: total test panel volume, total number of test panels repeated, number of test panels repeated within the 24 hour period, test result, date of testing, time of test, and patient Provincial Health Number (PHN). Patient PHN were used as a linking variable to match subsequent tests performed on the same patient. The first time a test was recorded per patient was defined as the “index test”. If the same test panel was performed within a 24-h period following the index test for the patient, data for the repeated test panel was also collected. The index test was defined as “normal” or “abnormal” according to established laboratory normal values and laboratory test reference ranges. For CBCs, we considered the panel to be abnormal if any of the hematocrit (Hct), hemoglobin (Hgb), mean corpuscular hemoglobin concentration (MCHC), mean corpuscular volume (MCV), platelet (PLT), red blood cell (RBC), red cell distribution width (RDW) or white blood cell (WBC) values were outside the normal laboratory reference range. For electrolyte panels, we considered the panel to be abnormal if any of the chloride (Cl), potassium (K), and sodium (Na) were outside of the normal laboratory reference range. All EP results were from clinical chemistry analyzers only. The reuse potential of this dataset can allow other jurisdictions in Canada to compare their redundant repeat testing in their hospital settings with this dataset as a benchmark. This article was submitted via another Elsevier journal as a co-submission (“Inappropriate repeat testing of complete blood count (CBC) and electrolytes in inpatients from Alberta, Canada” [1]), and readers should refer to the co-submission article for interpretation of the results.

Inappropriate repeat testing of complete blood count (CBC) and electrolyte panels in inpatients from Alberta, Canada

INTRODUCTION

The avoidance of repeat chemistry testing such as Complete Blood Count (CBC) and Electrolyte Panel (EP) on clinically stable patients was identified as important utilization goals by Choosing Wisely Canada. The purpose of this study was to assess the volume of overutilization of CBC and EP in an inpatient setting in Alberta, Canada, and provide an estimated cost assessment of unnecessary testing.

METHODS

The total laboratory testing volumes of two common test panels were collected retrospectively for one-year from January to December 2018. Data was collected on test panels performed in an emergency room (ER) and inpatient setting from three separate Laboratory Information Systems covering the provincial population in Alberta, Canada. Total initial test panel instances, total repeated panels, repeated panels that were previously normal or abnormal, and estimated costs were examined. Cost assessment was completed based on Reference Median Cost (RMC) analysis for each of these two common test panels.

RESULTS

During the study period, 2,020,467 (CBC) and 1,455,983 (EP) initial test panel instances were recorded, of which 67.7% and 73.5% were repeated for the CBC and EP, respectively. There was a higher proportion of EP repeated inappropriately (previously normal; 35.6%) compared to CBCs (5.4%). The cost to the province for inappropriately repeating CBC and EP were estimated to be RMC $0.52 million and RMC $1.90 million CAD, respectively.

CONCLUSION

Results from this study can assist policy makers in implementing utilization management initiatives and update clinical practice guidelines to reduce costs to healthcare without compromising patient care.

Vitamin B12 test volume data before and after the implementation of an educational province-wide intervention to reduce redundant testing in Alberta

The data presented in this article is the provincial vitamin B12 test volume data for Alberta, Canada per month between April 1, 2015 and April 30, 2018. This data set was collected from the three different Alberta Public Laboratories Laboratory Information Systems: Cerner Millennium for Calgary, Sunquest for Edmonton, and MediTech for the remaining rural zones of Alberta (Bonnyville, Grand Prairie, Camrose, Red Deer, and Medicine Hat). An educational province-wide intervention aimed at reducing redundant testing was implemented on April 11, 2017 in Calgary, Alberta and Edmonton, Alberta and on May 2, 2017 in rural Alberta sites. All vitamin B12 test results in Alberta were appended with the educational comment “A normal test result indicates adequate stores and should not be repeated. However, if specific clinical situations require re-testing, the interval should not be sooner than 1 year.” Provincial monthly test volumes prior to this intervention ranged from 54,182 to 73,522 tests per month and after this intervention ranged from 59,116 to 74,006 tests per month. The total number of vitamin B12 tests ordered over the 37 months in Alberta was 2,444,724; 690,448 tests were ordered in Calgary, 1,029,315 tests were ordered in Edmonton, and 724,961 tests were ordered in rural sites. This data article was submitted as a companion paper to the related research article, “Implementation of an educational province-wide intervention to reduce redundant vitamin B12 testing: a cross-sectional study”[1].

Implementation of an educational province-wide intervention to reduce redundant vitamin B12 testing: A cross-sectional study

INTRODUCTION

We describe the implementation of an Alberta-wide intervention aimed at educating clinicians about redundant vitamin B₁₂ testing. We hypothesized that the introduction of an educational comment outlining recommended vitamin B₁₂ test intervals would reduce the annual number of vitamin B₁₂ tests performed.

MATERIALS AND METHODS

We performed a cross-sectional observational study that included all vitamin B₁₂ tests ordered in Alberta between May 1, 2017 and April 30, 2018. An educational comment was appended to all vitamin B₁₂ test results in Alberta beginning May 2, 2017. Using a simple seasonal model, we compared predicted versus observed vitamin B₁₂ test volumes for the 12-month period following the introduction of the educational comment. The sole outcome measured was the monthly change in volume of vitamin B₁₂ testing. A cost-analysis of the effects of the intervention on test volumes was also performed.

RESULTS

Over the sum of the first 12 months of the intervention, 18,000 more vitamin B₁₂ tests were ordered compared to the predicted value in Alberta. With an estimated cost of $7 per test, this resulted in a $126,000 increase in costs for vitamin B₁₂ testing provincially.

CONCLUSIONS

An educational intervention aimed at limiting inappropriate vitamin B₁₂ testing in Alberta did not alter testing as desired. Multiple utilization management strategies and a longer observation period may be needed to reduce redundant vitamin B₁₂ testing.

Dataset of clinical laboratory tests according to ordering variance among family physicians in Calgary, Alberta, Canada

This data incorporates 2016 testing volumes ordered by family physicians and performed at Calgary Laboratory Services (CLS), the sole supplier of clinical laboratory services for the catchment area of the City of Calgary, Alberta, Canada. For each test, the mean number of tests ordered per patient was calculated over ordering Calgary physicians, along with arithmetic coefficients of variation (CV's). The latter parameter is reflective of variance in ordering practice among family physicians practicing in Calgary and is proposed as a benchmark measure for laboratory utilization in our accompanying research article [1]. The data table encompasses 358 tests ordered by at least 3 family physicians at a minimum total frequency of 100 within the 2016 study period and is presented in ascending order of rank in CV.

Sociodemographic and geospatial associations with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections in a large Canadian city: an 11 year retrospective study

Background

The first Canadian outbreak of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) was identified in 2004 in Calgary, Alberta. Using a novel model of MRSA population-based surveillance, sociodemographic risk associations, yearly geospatial dissemination and prevalence of CA-MRSA infections over an 11 year period was identified in an urban healthcare jurisdiction of Calgary.

Methods

Positive MRSA case records, patient demographics and laboratory data were obtained from a centralized Laboratory Information System of Calgary Laboratory Services in Calgary, Alberta, Canada between 2004 and 2014. Public census data was obtained from Statistics Canada, which was used to match with laboratory data and mapped using Geographic Information Systems.

Results

During the study period, 52.5% of positive MRSA infections in Calgary were CA-MRSA cases. The majority were CMRSA10 (USA300) clones (94.1%; n = 4255), while the remaining case (n = 266) were CMRSA7 (USA400) clones. Period prevalence of CMRSA10 increased from 3.6 cases/100000 population in 2004, to 41.3 cases/100000 population in 2014. Geospatial analysis demonstrated wide dissemination of CMRSA10 annually in the city. Those who are English speaking (RR = 0.05, p <  0.0001), identify as visible minority Chinese (RR = 0.09, p = 0.0023) or visible minority South Asian (RR = 0.25, p = 0.015), and have a high median household income (RR = 0.27, p <  0.0001) have a significantly decreased relative risk of CMRSA10 infections.

Conclusions

CMRSA10 prevalence increased between 2004 and 2007, followed by a stabilization of cases by 2014. Certain sociodemographic factors were protective from CMRSA10 infections. The model of MRSA population-surveillance and geomap outbreak events can be used to track the epidemiology of MRSA in any jurisdiction.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7169-3) contains supplementary material, which is available to authorized users.

Benefits and risks of standardization, harmonization and conformity to opinion in clinical laboratories

Large laboratory systems that include facilities with a range of capabilities and capacity are being created within consolidated healthcare systems. This paradigm shift is being driven by administrators and payers seeking to achieve resource efficiencies and to conform practice to the requirements of computerization as well as the adoption of electronic medical records. Although standardization and harmonization of practice improves patient care outcomes and operational efficiencies, administratively driven practice conformity (conformity to opinion) also has serious drawbacks and may lead to significant system failure. Juxtaposition of the distinct philosophical approaches of physicians and scientists (i.e. "professionalism") versus administrators and managers (i.e. "managerialism") towards bringing about conformity of the laboratory system inherently creates conflict. Despite an administrative edict to "perform all tests using the same methods" regardless of available "best practice" evidence to do so, medical/scientific input on these decisions is critical to ensure quality and safety of patient care. Innovation within the laboratory system, including the adoption of advanced technologies, practices, and personalized medicine initiatives, will be enabled by balancing the relentless drive by non-medical administration to meet "business" requirements, the medical responsibility to provide the best care possible, and customizing practice to meet individual patient care needs.

Evaluating practice variance among family physicians to identify targets for laboratory utilization management

BACKGROUND

There is widespread variation in testing practice among practitioners, however there has been no objective way to pinpoint target tests for utilization management. We propose to take advantage of inter-physician variance in clinical practice as a quantitative measure to generate lists of potentially misutilized tests.

METHODS

Testing frequencies from a database of clinical testing volumes for outpatients in Calgary, Canada, were obtained for the study period of 2016. For each chemistry, microbiology or hematology test, an arithmetic coefficient of variation (CV) was calculated from family physicians' ordering frequencies.

RESULTS

The mean CV for all 358 tests considered was 219% (95% CI 206-231%) with a range of 52-729%. The highest variance was observed for human T-lymphotropic virus antibody testing and several tests for heavy metal levels (mercury, copper, zinc and chromium). Among the 100 most commonly run tests, high variance was found for several endocrinology tests including cortisol.

CONCLUSIONS

The utility of ranking clinical tests by ordering variance presents a practical approach to evaluate relative variation in physician practice strategy and to identify potential areas of misutilization.

Incidence of myeloproliferative neoplasms in Calgary, Alberta, Canada

Objective

The incidence of the combined myeloproliferative neoplasms (MPNs) was determined for a major Canadian city. Retrospective cases of MPN diagnoses (essential thrombocythemia, polycythemia vera, and primary myelofibrosis) between 2011 to 2015 were retrieved from the Southern Alberta Cancer Cytogenetics Laboratory’s database at Alberta Public Laboratories.

Results

An incidence rate of 2.05 cases per 100,000 person-years (95% CI 1.73–2.41) was determined, giving an age-standardized Canadian incidence of 2.71 cases per 100,000 person years (95% CI 2.63–2.78). MPN diagnoses occurred at a wide age range of 8–93 (median 66) and an age-dependent increase in incidence. Incidence rates for the MPNs are first reported here for a Canadian population.

The Impact of Malaria on Liver Enzymes: A Retrospective Cohort Study (2010-2017)

Background

It is unclear if malaria causes deranged liver enzymes. This has implications both in clinical practice and in research, particularly for antimalarial drug development.

Method

We performed a retrospective cohort study of returning travelers (n = 4548) who underwent a malaria test and had enzymes measured within 31 days in Calgary, Canada, from 2010 to 2017. Odds ratios of having an abnormal alkaline phosphatase (ALP), alanine aminotransferases (ALT), aspartate aminotransferases (AST), and total bilirubin (TB) were calculated using multivariable longitudinal analysis with binomial response.

Results

After adjusting for gender, age, and use of hepatotoxic medications, returning travelers testing positive for malaria had higher odds of having an abnormal TB (odds ratio [OR], 12.64; 95% confidence interval [CI], 6.32–25.29; P < .001) but not ALP (OR, 0.32; 95% CI, 0.09–1.10; P = .072), ALT (OR, 1.01; 95% CI, 0.54–1.89; P = .978) or AST (OR, 1.26; 95% CI, 0.22–7.37; P = .794), compared with those who tested negative. TB was most likely to be abnormal in the “early” period (day 0–day 3) but then normalized in subsequent intervals. Returning travelers with severe malaria (OR, 2.56; 95% CI, 0.99–6.62; P = .052) had borderline increased odds of having an abnormal TB, but malaria species (OR, 0.70; 95% CI, 0.24–2.05; P = .511) did not.

Conclusions

In malaria-exposed returning travelers, the TB is abnormal, especially in the early period, but no abnormalities are seen for ALT, AST, or ALP.

Automation and artificial intelligence in the clinical laboratory

The daily operation of clinical laboratories will be drastically impacted by two disruptive technologies: automation and artificial intelligence (the development and use of computer systems able to perform tasks that normally require human intelligence). These technologies will also expand the scope of laboratory medicine. Automation will result in increased efficiency but will require changes to laboratory infrastructure and a shift in workforce training requirements. The application of artificial intelligence to large clinical datasets generated through increased automation will lead to the development of new diagnostic and prognostic models. Together, automation and artificial intelligence will support the move to personalized medicine. Changes in pathology and clinical doctoral scientist training will be necessary to fully participate in these changes. KEYWORDS: Automation; artificial intelligence; deep learning; laboratory medicine.

Utility of Multistep Protocols in the Analysis of Sentinel Lymph Nodes in Cutaneous Melanoma: An Assessment of 194 Cases

Context.—

Currently, no universal protocol exists for the assessment of sentinel lymph nodes (SLNs) in cutaneous melanoma. Many institutions use a multistep approach with multiple hematoxylin-eosin (H&E) and immunohistochemical stains. However, this can be a costly and time- and resource-consuming task.

Objective.—

To assess the utility for multistep protocols in the analysis of melanoma SLNs by specifically evaluating the Calgary Laboratory Services (CLS) protocol (which consists of 3 H&E slides and 1 S100 protein, 1 HMB-45, and 1 Melan-A slide per melanoma SLN block) and to develop a more streamlined protocol.

Design.—

Histologic slides from SLN resections from 194 patients with diagnosed cutaneous melanoma were submitted to the CLS dermatopathology group. Tissue blocks were processed according to the CLS SLN protocol. The slides were re-reviewed to determine whether or not metastatic melanoma was identified microscopically at each step of the protocol. Using SPSS software, a decision tree was then created to determine which step most accurately reflected the true diagnosis.

Results.—

We found with Melan-A immunostain that 337 of 337 negative SLNs (100%) were correctly diagnosed as negative and 55 of 56 positive nodes (98.2%) were correctly diagnosed as positive. With the addition of an H&E level, 393 of 393 SLNs (100%) were accurately diagnosed.

Conclusions.—

We recommend routine melanoma SLN evaluation protocols be limited to 2 slides: 1 H&E stain and 1 Melan-A stain. This protocol is both time- and cost-efficient and yields high diagnostic accuracy.

Test volume data for 51 most commonly ordered laboratory tests in Calgary, Alberta, Canada

Data presented in this article include the top 51 ordered laboratory tests in Calgary and surrounding area, Alberta, from January to December 2017. This data set was collected from Calgary Laboratory Service’s Laboratory Information System, and included top 51 tests ordered from community (n = 11, 224, 330), inpatient (n = 2,340,594) and emergency (n = 1,670,062) settings. Test order mnemonic that were not true laboratory tests (eg: “extra PST tube”, “extra tube”, etc.) were excluded in the analysis. The top test ordered in all 3 test encounters was the complete blood count test (community encounter, n = 921, 873; inpatient setting, n = 357, 375; and emergency setting, n = 276, 954). This data article was submitted as a companion paper to the related research article, “Estimated costs of 51 commonly ordered laboratory tests in Canada” [1].

Estimated costs of 51 commonly ordered laboratory tests in Canada

INTRODUCTION

Test cost display has been shown to reduce inappropriate laboratory test ordering practices in the United States. Unfortunately, such a system is limited in the Canadian publically funded healthcare environment. Many Canadian physicians inaccurately estimate the cost of laboratory tests, which may contribute to mis-utilization. Here, we provide an estimated cost of over 50 commonly ordered laboratory tests in Canada as an educational tool for physicians.

METHODS

Test volume data was collected from Calgary Laboratory Services' Laboratory Information System in order to determine which laboratory and diagnostic tests are most commonly ordered in Calgary and its surrounding area. Reference median cost (RMC) of fifty one commonly ordered test was calculated by determining the price list of all-inclusive indirect costs from six different clinical laboratories across Canada.

RESULTS

Of the 51 laboratory tests included, the minimum RMC was $5 CAD (eg: albumin, calcium, urea), and the maximum RMC was $300 (surgical pathology report).

CONCLUSIONS

A caveat to the provided list of test costs is that it is only an estimate and may differ from what each individual clinical laboratories charges to third parties or for research purposes. However, this list can serve as an educational tool and raise awareness for Canadian physicians on the relative costs of laboratory tests.

Community data of adults fasting for lipid and diabetes tests in Calgary, Alberta from 2010 to 2016

Data presented in this data article include the proportion and counts of community-based adult men and women who fasted for various lipid and diabetes screening-related tests from January 2010 to June 2016 in Calgary, Alberta, Canada. This data set was collected from Calgary Laboratory Service׳s Laboratory Information System, and included 3,003,667 testing encounters (1,447,720 testing encounters for men and 1,555,947 testing encounters for women) over the age of 18 years, who fasted for a lipid profile, lipid+random blood glucose (RBG), lipid+hemoglobin A_1c (HbA_1c), lipid+RBG+HbA_1c, lipid+fasting blood glucose (FBG), lipid+FBG+RBG, lipid+FBG+HbA_1c, or lipid+FBG+RBG+HbA_1c. Data are related to “Proportion of adults fasting for lipid testing relative to guideline changes in Alberta” (Ma et al., 2017).

1995. Implementation of Helicobacter pylori Stool Antigen Testing in a Large Metropolitan Centre: A Prospective Comparative Diagnostic Trial

Background

Clinical guidelines for H. pylori screening and post-treatment testing endorse the use of urea breath test (UBT), H. pylori stool antigen test (HpSAT), and biopsy-related tests. Due to protracted wait times at our patient service centers and non-compliance in children and elderly with complications for the UBT, we sought to compare UBT and HpSAT in the city of Calgary, Canada with a population close to 1.4 million people.

Methods

To achieve this, a prospective diagnostic trial was performed comparing UBT to HpSAT in patients presenting with dyspepsia. A total of N = 150 patients agreed to undergo UBT (¹³C-UBT kit, Helikit, Isodiagnostika Inc.) and consented to provide a stool specimen for simultaneous HpSAT testing (Diasorin LIAISON® XL H. pylori SA Monoclonal chemiluminescent immunoassay) in our centralized laboratory.

Results

Our data show that concordant results were obtained in 148/150 (98.7%) patients with a positivity rate of 17.4%. One of two discrepants (UBT positive/HpSAT negative) resolved after repeat testing. Using UBT as the gold standard, HpSAT had a sensitivity of 96.30% (95% CI; 81.03% to 99.91%) and specificity of 100% (95% CI; 97.05% to 100.00%). A positive predictive value of 100% and negative predictive value of 99.2% (95% CI; 94.73% to 99.88%) was obtained. For patients where drug information was available, 38/130 (29.2%) had received an antibiotic associated with H. pylori in the preceding 12 months, with UBT and HpSAT providing concordant results in 37/38 (97.4%) of these individuals. Of note, 6/130 (4.6%) patients had received a specific combination anti-H.pylori treatment, and all 6/6 (100%) had concordant negative results suggesting successful eradication. A post-implementation economic evaluation of labor and materials associated with testing demonstrates a cost-savings of approximately USD5.47 per specimen in this locale.

Conclusion

Our study confirms that HpSAT is a viable alternative to UBT for H. pylori screening in our jurisdiction with equivalent test performance and cost-savings. Pre- and post-implementation analysis of test compliance rates, waiting times, and test turn around times will also be presented.

Disclosures

D. Pillai, Diasorin: None, Educational grant.

Incidence of chronic myeloid leukemia in Calgary, Alberta, Canada

OBJECTIVE

The epidemiology of chronic myeloid leukemia is shifting due to the aging global population and the recent discovery and availability of targeted treatment options. This study provides recent data regarding the incidence of CML in Calgary, a major Canadian city. Data from patients diagnosed with CML by bone marrow sample analysis from 2011 to 2015 were collected from the database of the sole centralized cytogenetics facility in service of Calgary and its surrounding area.

RESULTS

With an average of 10.2 newly diagnosed cases per year in Calgary from 2011 to 2015, the incidence rate was calculated to be 0.75 cases per 100,000 person-years (95% CI 0.57-0.99). With age standardization, the incidence was 0.87 cases per 100,000 person-years (95% CI 0.82-0.91) for the Canadian population, which was low compared to other developed Western nations. The highest incidence rates were observed in the older patient categories, however there was a broad age distribution for incident cases and the median age at diagnosis was 48. There was a general male bias for CML most pronounced at the younger ages. Our description of CML incidence will help to inform healthcare planners amidst the dramatically altered treatment of this hematological neoplasm.

Incidence of Myelodysplastic Syndromes in a Major Canadian Metropolitan Area

BACKGROUND

Myelodysplastic syndromes (MDS) are a heterogeneous group of clonal stem cell disorders that can progress to acute myeloid leukemia. In many regions of the world, the epidemiology of MDS is poorly described. This study determines the crude incidence of MDS in Calgary, Alberta, Canada, with new cases diagnosed using the revised 2008 WHO criteria.

METHODS

For the study period of January 1, 2011 to December 31, 2015, incident cases of MDS were identified from a centralized database maintained by Calgary Laboratory Services' Cancer Cytogenetics Laboratory, which receives and analyzes patient bone marrow samples from southern Alberta.

RESULTS

The Calgary metropolitan area had a total incidence rate of 2.60 MDS cases per 100000 person years, corresponding to an age-standardized incidence of 3.69 for Canada. The male-to-female sex ratio was 1.35, and the median age at diagnosis was 75 years. With these results, 1295 new annual cases of MDS were predicted in Canada.

CONCLUSIONS

The reported incidence rate, sex, and age distribution were consistent with data around the world including several developing nations. This is the first study to provide information regarding the epidemiology of MDS within Canada.

Chronic kidney disease in type 2 diabetes: Does an abnormal urine albumin-to-creatinine ratio need to be retested?

OBJECTIVE

To determine the positive predictive value (PPV) of a single random abnormal urine albumin-to-creatinine ratio (ACR) compared with repeat test results in patients with type 2 diabetes to diagnose chronic kidney disease (CKD).

DESIGN

Retrospective, longitudinal secondary data analysis using Calgary Laboratory Services data.

SETTING

Calgary, Alta.

PARTICIPANTS

Patients aged 21 and older with a new diagnosis of diabetes in the study period from January 2008 to December 2015 and with a first abnormal urine ACR followed by another ACR test completed within 120 days.

MAIN OUTCOME MEASURES

The PPV of an abnormal urine ACR (2 to 20 mg/mmol) to diagnose CKD was calculated. A test result was considered a true positive if a subsequent positive test result (≥ 2 mg/mmol) was identified within 120 days of the first positive test result and a false positive if 2 subsequent negative test results were identified within the same time period. The relationship between the first and second urine ACR values to assess the probability of the second urine ACR being abnormal (≥ 2 mg/mmol) based on the values of the first abnormal urine ACR was also explored.

RESULTS

The PPV of the first abnormal urine ACR between 2 and 20 mg/mmol to diagnose CKD was calculated at 96.80% (95% CI 95.37% to 98.21%). Additionally, there was increased predictive probability of the second urine ACR being abnormal at higher values of the first urine ACR (2 to 20 mg/mmol). The data were further analyzed to exclude test results with a new or changed prescription of angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker medications around the time of the first urine ACR test to focus results on screening and not treatment response. With these exclusions, the PPV for first urine ACR between 2 and 20 mg/mmol to diagnose CKD was calculated as 96.23% (95% CI 94.13% to 98.32%).

CONCLUSION

The first random abnormal urine ACR has a good PPV for the diagnosis of CKD in patients with type 2 diabetes, so multiple random urine ACR tests might not be necessary to diagnose patients with type 2 diabetes as having persistent microalbuminuria and CKD. A simpler diagnostic model for diagnosing renal disease might improve patient compliance, efficiency of testing, and implementation of health interventions. Reduced testing would also be expected to result in reduced cost from a health care expenditure perspective.

Sociodemographic correlates of cervical cancer screening rates in Calgary, AB: Matched Trend analysis of 2006, 2011 and 2016

IntroductionCervical Cancer Screening (CCS) has reduced the incidence and mortality rates of cervical cancer (CC). However, the benefits are distributed unevenly since 30% of eligible women have not been screened within three years in Alberta. Women who have never been screened or are screened irregularly are most at risk for CC. Objectives and ApproachThe aim of this study was to understand who gets CCS and who does not, in Calgary, Alberta and analyze the CC policy implications since 2006-2016. CCS information of women aged 25-69 were obtained from Calgary Laboratory Services for the years 2006, 2011 and 2016 and matched with Canadian Census data. Negative binomial regression and Generalized Estimating Equations were used to test associations of CCS rates with socio-demographic variables for eligible women. CCS spatial trends over the years was studied using the GIS Hotspot analysis. ResultsMajor age and geographical variations were observed in CCS rates in Calgary. CCS rates in the recommended age groups varied from 40.6 % to 23.6 %. For age groups between 25 and 54, CCS rates were above 33\%, which implies that many women are having tests more than once every three years. Use was positively associated with median household income, education, Chinese ethnicity and negatively associated with ‘Black’ visible minority status. Women living in lower socio-economic areas of Calgary are screened at lower rates. Hotspot analysis maps revealed heterogeneous testing patterns in the city with relatively higher testing in the downtown, Southeast and Northwest quadrants of the city and relatively decreased CCS in the Northeast quadrant of Calgary Conclusion/ImplicationsScreening programs need to be strengthened with greater focus on including specific demographic groups and reducing overuse. Understanding current testing patterns are important in assessing the benefit to harm ratio of CCS and for monitoring and evaluation of CCS program.

Does the family physicians’ characteristics affect Cervical Cancer Screening rates?

IntroductionWhile the effectiveness of cervical cancer-screening (CCS) programs is well accepted, concern is growing regarding Family physicians (FP) poor adherence to CCS guidelines resulting in over and under screening. In Canada, it is a FP responsibility to ensure that the CCS is done as per guidelines and with appropriate follow-up. Objectives and ApproachTo identify primary care physicians’ characteristics that are associated with over and under CCS for eligible women in Calgary, Alberta. We accessed the Calgary Laboratory Services data for 1475 FPs practicing in Calgary and linked it with the Physicians database of College of Physicians and Surgeons Alberta database. We then matched FP’s gender, country and year of medical school graduation, years since medical school graduation, certification in family medicine and their clinic address with their CCS testing patterns. Using doctors as their own controls, we compared data from 2010-2016 to determine practice variations in CCS patterns subsequent to guideline changes. ResultsWe analyzed approximately 2,400,000 Pap test requisitions (approx. 300,000 per year) to identify screening patterns from 2010-2016 of 1475 family practitioners practicing in Calgary. Our preliminary results identified significant variations in the test ordering patterns of FPs. Approx. half of the male FPs were not performing CCS tests on their eligible female patients. Female FPs ordered more CCS tests than their male counterparts. FP trained in North America, were ordering more pap tests than FPS trained elsewhere. Decreased CSS was also observed among FPs practicing in Northeast Calgary. Conclusion/ImplicationsWe detected three CCS patterns: FPs who never perform CSS on eligible female patients; FPs who followed recommended guidelines for performing CCS tests and FPs who performed CCS tests, not following the guidelines. To ensure appropriate use of CSS, identifying intention-behavior relationships and innovative educational interventions for FPs are required.

Sociodemographic associations with abnormal estimated glomerular filtration rate (eGFR) in a large Canadian city: a cross-sectional observation study

BACKGROUND

Chronic kidney disease (CKD) is often asymptomatic in its early stages but is indicated and is diagnosed with an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2. Certain sociodemographic groups are known to be at risk for CKD, but it is unclear if there are strong associations between these at risk groups with abnormal eGFR test results in Canada. Using only secondary laboratory and Census data, geospatial variation and sociodemographic associations with abnormal eGFR result rate were investigated in Calgary, Alberta.

METHODS

Secondary laboratory data from all adult community patients who received an eGFR test result were collected from Calgary Laboratory Service's Laboratory Information System, which is the sole supplier of laboratory services for the large metropolitan city. Group-level sociodemographic variables were inferred by combining laboratory data with the 2011 Canadian Census data. Poisson regression and relative risk (RR) were used to calculate associations between sociodemographic variables with abnormal eGFR. Geographical distribution of abnormal eGFR result rates were analyzed by geospatial analysis using ArcGIS.

RESULTS

Of the 346,663 adult community patients who received an eGFR test result, 28,091 were abnormal (8.1%; eGFR < 60 ml/min/1.73m2). Geospatial analysis revealed distinct geographical variation in abnormal eGFR result rates in Calgary. Women (RR = 1.11, P < 0.0001), and the elderly (age ≥ 70 years; P < 0.0001) were significantly associated with an increased risk for CKD, while visible minority Chinese (RR = 0.73, P = 0.0011), South Asians (RR = 0.67, P < 0.0001) and those with a high median household income (RR = 0.88, P < 0.0001) had a significantly reduced risk for CKD.

CONCLUSIONS

Presented here are significant sociodemographic risk associations, and geospatial clustering of abnormal eGFR result rates in a large metropolitan Canadian city. Using solely publically available secondary laboratory and Census data, the results from this study aligns with known sociodemographic risk factors for CKD, as certain sociodemographic variables were at a higher risk for having an abnormal eGFR test result, while others were protective in this analysis.

Benjamin Terry and his rapid razor section method for intraoperative diagnosis

Benjamin Taylor Terry (1876-1955), a little-known pathologist, played a critical role in the popularization of intraoperative diagnostic techniques in the 1920s and 1930s. He developed both a stain and his own rapid razor section method. Intraoperative diagnostic techniques were ultimately responsible for the transition of the practice of pathology and laboratory medicine from private commercial laboratories to a hospital-based practice, forever changing the history of pathology and surgery in North America. Although the intraoperative diagnostic technique he personally developed was reportedly better, faster and more economical than frozen sections, the latter ultimately won the battle for intraoperative diagnostic supremacy.