Turn down - turn up: a simple and low-cost protocol for preparing platelet-rich plasma

OBJECTIVE

To describe and analyze a new protocol for the extraction of platelet-rich plasma (PRP) for use in clinical practice and compare this technique with methods that have been previously described in the medical literature.

METHODS

We extracted PRP from 20 volunteers using four different protocols (single spin at 1600 ×g, single spin at 600 ×g, double spin at 300 and 700 ×g, and double spin at 600 and 900 ×g). In another group of 12 individuals, we extracted PRP with our new technique (named 'turn down-turn up') consisting of a double spin (200 ×g and 1600 ×g) closed system using standard laboratory equipment (including an ordinary benchtop centrifuge), where the blood remained in the same tube during all processes, reducing the risk of contamination. Platelet counts adjusted to baseline values were compared using analysis of covariance (ANCOVA).

RESULTS

Using the four previously described protocols (mentioned above), we obtained concentrations of platelets that were 1.15-, 2.07-, 2.18-, and 3.19-fold greater than the baseline concentration, respectively. With the turn down-turn up technique, we obtained a platelet count that was 4.17-fold (95% confidence interval (CI): 3.09 to 5.25) greater than the baseline platelet count (p=0.063 compared with the double spin at 600 and 900 ×g method). The total cost of the disposable materials used in the extraction process was less than US$10.00 per individual.

CONCLUSION

In the present study, we described a simple and safe method for obtaining PRP using low-cost devices.

The vexed question of whether or not to measure levels of direct oral anticoagulants before surgery or invasive procedures

Direct oral anticoagulants (DOAC) possess high bioavailability, and their anticoagulant effect is more predictable than that of vitamin K antagonists, hence they do not require routine dose adjustment based on laboratory testing. However, there are circumstances when laboratory testing may be useful, including patients who need to undergo surgery or invasive procedures. Most guidelines state that patients on DOAC may safely undergo surgery/invasive procedures by stopping anticoagulation for a few days before intervention without testing if renal function is within normal limits. This review article discusses the pros and cons of measuring (or not measuring) DOAC levels before surgery/invasive procedures by a multidisciplinary team of experts with different background, including the thrombosis laboratory, clinical thrombosis, internal medicine, cardiology and nephrology. The conclusion is that measuring DOAC with dedicated tests before surgical or invasive procedures is important for patient safety. It provides the best and most direct evidence to rule in (or to rule out) clinically relevant concentrations of residual drugs. Regulatory agencies should urgently approve their use in clinical practice. Hospital administrators should make them available, and clinical laboratories should set up the relative methods and make them available to clinicians.

The Tail Wagging the Dog (or the Challenges Faced When the Financing of Medicine Gets Ahead of the Science of Medicine)

In their article in this issue of the Journal of Clinical Microbiology, S. R. Dominguez et al. (J Clin Microbiol 56:e00632-18, 2018, https://doi.org/10.1128/JCM.00632-18) describe the performance of PCR detection of herpes simplex virus (HSV) DNA versus viral culture in skin and mucosal samples from 7 neonates with HSV disease. This is a significant contribution to our understanding of the optimal diagnostic approach in babies being evaluated for neonatal HSV disease. Many diagnostic laboratories already have made the change to molecular diagnostics for skin and mucosal swab testing, however, in large part due to the labor costs associated with viral cultures. Thus, important studies such as this one are being conducted to support a decision that has already been made in many locations on mostly economic grounds. This small case series supports the decision to use molecular testing for samples from skin and mucosal sites, but larger studies are needed to more fully define the performance characteristics of PCR in this population. Since a false-positive result would commit a baby to months of management that would be unnecessary and have potential harm, it is critical to base diagnostic decision making on data that support the use of a specific test.

Modelling-based evaluation of the costs, benefits and cost-effectiveness of multipathogen point-of-care tests for sexually transmitted infections in symptomatic genitourinary medicine clinic attendees

OBJECTIVES

To quantify the costs, benefits and cost-effectiveness of three multipathogen point-of-care (POC) testing strategies for detecting common sexually transmitted infections (STIs) compared with standard laboratory testing.

DESIGN

Modelling study.

SETTING

Genitourinary medicine (GUM) services in England.

POPULATION

A hypothetical cohort of 965 988 people, representing the annual number attending GUM services symptomatic of lower genitourinary tract infection.

INTERVENTIONS

The decision tree model considered costs and reimbursement to GUM services associated with diagnosing and managing STIs. Three strategies using hypothetical point-of-care tests (POCTs) were compared with standard care (SC) using laboratory-based testing. The strategies were: A) dual POCT for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG); B) triplex POCT for CT-NG and Mycoplasma genitalium (MG); C) quadruplex POCT for CT-NG-MG and Trichomonas vaginalis (TV). Data came from published literature and unpublished estimates.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were total costs and benefits (quality-adjusted life years (QALYs)) for each strategy (2016 GB, £) and associated incremental cost-effectiveness ratios (ICERs) between each of the POC strategies and SC. Secondary outcomes were inappropriate treatment of STIs, onward STI transmission, pelvic inflammatory disease in women, time to cure and total attendances.

RESULTS

In the base-case analysis, POC strategy C, a quadruplex POCT, was the most cost-effective relative to the other strategies, with an ICER of £36 585 per QALY gained compared with SC when using microcosting, and cost-savings of £26 451 382 when using tariff costing. POC strategy C also generated the most benefits, with 240 467 fewer clinic attendances, 808 fewer onward STI transmissions and 235 135 averted inappropriate treatments compared with SC.

CONCLUSIONS

Many benefits can be achieved by using multipathogen POCTs to improve STI diagnosis and management. Further evidence is needed on the underlying prevalence of STIs and SC delivery in the UK to reduce uncertainty in economic analyses.

[Rationalization of biological tests in cardiology department]

INTRODUCTION

Laboratory tests usually complete clinical examinations for diagnostic, prognostic and even therapeutical care. However, French doctors might too easily prescribe such examinations without knowing their cost. As a matter of fact, the prescription is sometimes excessive or unjustified. Cardiology is not an exception, with costly laboratory tests.

OBJECTIVE

To show that the relevance of each additional test prescription, in a cardiology department, allows a significant reduction of the examination volumes and costs, with no prejudicial effect on patients' care.

METHODS

Two consecutive 2-year periods, between November 1st 2011 and October 31st 2015, - before and after the development of a policy of rationalization of additional tests - were compared. All the patients admitted in our cardiology department during these periods were prospectively included.During 4 years, the volume and the cost of prescription of the most frequent laboratory tests were studied, considering successive half-year periods.

RESULTS

After rationalizing, there was a significant reduction of prescription of the laboratory tests (CBC -72%, BNP -92%, troponin -82%, CRP -89%, liver test -87%, lipid status -80%, TSH -80%, p<0.01).No serious adverse events were reported and no death rate increase was noticed.

CONCLUSION

Rationalizing allows a significant reduction of complementary examinations, with no additional risk for the patient.

Incremental treatment costs for HIV-infected women initiating antiretroviral therapy during pregnancy: A 24-month micro-costing cohort study for a maternal and child health clinic in Kenya

BACKGROUND

To date, little information exists on the costs of providing antiretroviral therapy (ART) within maternal and child health (MCH) clinics in Kenya. The main objective of this analysis was to estimate the annual incremental cost of providing ART within a MCH clinic for adult women initiated on ART during pregnancy over the first one and two years on treatment. The study site was the District Hospital in Kericho, Kenya.

METHODS

A micro-costing approach from the provider's perspective, based on a retrospective review of patient medical records, was used to evaluate incremental costs of care (2012 USD). Cost per patient in two cohorts were evaluated: the MCH clinic group comprised of adult women who initiated ART at the site's MCH clinic during pregnancy between 2008-2011; and for comparison, the ART clinic group comprised of adult, non-pregnant women who initiated ART at the site's ART clinic during 2008-2011. The two groups were matched on age and baseline CD4 count at initiation. Retention at year one/two on ART was defined as having completed a clinic visit at 365/730 days on ART +/- 90 days.

RESULTS

For patients defined as retained in care at year one, average incremental costs per patient were $234 for the MCH clinic group (median: 215; IQR: 186, 282) and $292 in the ART clinic group (median: 227; IQR: 178, 357). ARV and laboratory costs were less on average for the MCH clinic group compared to the ART clinic group (due to lower cost regimens and fewer tests), while personnel costs were higher for the MCH clinic group.

CONCLUSIONS

The annual incremental cost per patient of providing ART were similar in the two clinic settings in 2012. With shifts in recommended ARV regimens and lab monitoring over time, annual costs of care (using 2016 USD unit costs) have remained relatively constant in nominal terms for the MCH clinic group but have fallen substantially for the ART clinic group (from nominal $292 in 2012 to nominal $227 in 2016).

Decreasing Resource Utilization without Compromising Care through Minimizing Preoperative Laboratories

Approximately 18 billion dollars is spent annually on preoperative testing. The purpose of this study was to determine whether implementation of an algorithm aimed at minimizing preoperative tests resulted in decreased costs without compromising care. We performed a pre-post trial comparing January 2016 to April 2016 with May 2016 to July 2017. In May 2016, an algorithm was instituted in which laboratories were canceled based on an algorithm that incorporated patient and procedural factors. Total number of laboratories canceled before orthopedic, urologic, or general surgical procedures was documented. Case cancellations during this time were recorded. There were 22,175 laboratories during the study time frame. There was a significant decrease of 2.4 per cent in expected laboratories in the post-intervention group. There was an overall cost savings of $33,032.00. The per cent of patients who were seen in preoperative testing clinic and still needed medical optimization decreased after algorithm implementation (3.3% vs 2.1% P < 0.01). No cases were canceled because of lack of laboratory information. An algorithm for selective preoperative laboratory testing provides overall cost savings. Decreasing the number of unnecessary laboratories ordered reduced case cancellations. Instituting an algorithm for preoperative laboratory testing is cost-effective without compromising care.

Vitamin D: too much testing and treating?

There is clinical uncertainty as to the testing of serum 25--Hydroxy vitamin D (25[OH]D) concentrations and when to use high-dose supplementation. Data show that there has been a rapid increase in the number of tests performed within the Northumbria Healthcare NHS Foundation Trust over the past 8 years and an increase in high-dose supplementation over the past 5 years. We performed a retrospective analysis of the 25(OH)D test requests over the period from January to -October 2017. A total of 17,405 tests were performed in this time period. The overall average concentration was 57.5 nmol/L and this figure was similar across age groups, although a larger proportion of patients aged over 75 had a concentration <25 nmol/L. Test requests were classified into 'appropriate', 'inappropriate' and 'uncertain' categories based on current expert opinion. We found that between 70.4% and 77.5% of tests could be inappropriate, depending on whether the 'uncertain' categories of falls and osteoporosis are considered to be justified. Tiredness, fatigue or exhaustion was the reason for testing in 22.4% of requests. We suggest that a more rational approach to testing, and subsequent treating, could lead to reductions in costs to the healthcare system and patients.

Out of pocket (OOP) cost of treating hypertension in Karachi, Pakistan

Pakistan is categorized to below to middle income countries where two third of the national annual health expenditure is in the form of out of pocket (OOP) cost. A prevalence based study was conducted to determine the OOP cost treatment of hypertension in Karachi by interviewing 350 hypertensive patients aged >30 years through a validated questionnaire. Hypertension (HTN) was classified into stage 1 and stage 2 and was found to be common in females (53.42%) than males (46.57%). The total costs of stage 1and stage 2 HTN were calculated to be 217869.7PKR and17545457.6 PKR respectively. The average treatment cost of stage 1 was observed to be significantly lower (p=0.006) than the cost of stage 2 HTN. Moreover; the cost of antihypertensive drugs, physician fees and laboratory tests were considerably different however; no variation was seen in cost of transport and loss of productivity through absenteeism from work. Overall, the present study indicates that the antihypertensive treatment has imposed a high burden on the pocket of common man and this is a major reason for treatment non-adherence. Consequently, it increases the risks of cardiovascular events, morbidity and mortality. Therefore, effective strategic planning is need of time to reduce OOP cost for better control on hypertension in Pakistan.

Health Care Expenditure, Laboratory Services and IVD Market

What has been written until now should not be misinterpreted: without doubt there is wastage in the Italian health care expenditure which must be rationalized. Moreover, the public deficit-now over two million billion lira-will probably prevent any reinvestment in health care of resources liberated through the above-mentioned rationalization process. In the near future, the attention of the authorities should be focused on how to reduce public spending, which probably also includes spending on health care. The message which needed to be passed on here does not refuse to recognize the possibility of rationalizing health care expenditure in Italy nor does it reject the need for this course of action. Instead it tries to give the following warning: in the light of the above circumstances-or the fact that even now the authorities cannot admit to spending "much" in the absolute sense, especially with regard to technology, or the fundamental role of IVDs in health care processes, or the difficulties in which the companies of the sector have been placed-it is possible to state that any blind, or worse still, ill-equipped, intervention in this field would have the undoubted effect of damaging the health care sector, or even place many companies on their knees, without receiving the expected benefits on the balance sheet. Benefits in the form of efficiency and saving can only be obtained from an effective reorganisation of the health structures, in line with the reforms provided for by legislative decree n. 502/92 (and subsequent modifications)--which, due to aspects too numerous to mention, is still a dead letter--and by taking steps towards valuing the laboratory services. As already stated, to talk of inefficiency in general terms means talking of unproductive expenditure: this occurs when utilizing factors whose cost is "too high" and/or productivity is "too low". It is with this distinction in mind that intervention must come; assessing factors not individually but rationally integrated in the production process of which they are part. Given the values at issue, any action not specifically aimed at the elimination of process inefficiency penalizes the already "healthy" elements, causes damage to the system and does not result in any significant benefits for expenditure. To summarize further, the need is for: a definition of what and how much to guarantee that can be taken from the National Budget; the realization of models which, surpassing the current macroscopic causes of inefficiency (which reside in structural and process type diseconomies), would make a correct economic assessment of investments and expenditure viable. In this respect, clinical pathology could play a fundamental role, in that the investments in this particular sector, if well programmed, would lead to significant savings for the entire health care system. The path followed until now must be abandoned at all costs; a path which starts by underestimating the needs and continues with the utilization of resources in an irrational manner, finishing with a proposal for the following year to allocate fewer resources to technology, almost as if it were on the same level as the potatoes (with or maybe even get hungry), at least this would resolve balance sheet problems without affecting the running of the services.

Does use of point-of-care testing improve cost-effectiveness of the NHS Health Check programme in the primary care setting? A cost-minimisation analysis

OBJECTIVE

To determine if use of point of care testing (POCT) is less costly than laboratory testing to the National Health Service (NHS) in delivering the NHS Health Check (NHSHC) programme in the primary care setting.

DESIGN

Observational study and theoretical mathematical model with microcosting approach.

SETTING

We collected data on NHSHC delivered at nine general practices (seven using POCT; two not using POCT).

PARTICIPANTS

We recruited nine general practices offering NHSHC and a pathology services laboratory in the same area.

METHODS

We conducted mathematical modelling with permutations in the following fields: provider type (healthcare assistant or nurse), type of test performed (total cholesterol with either lab fasting glucose or HbA1c), cost of consumables and variable uptake rates, including rate of non-response to invite letter and rate of missed [did not attend (DNA)] appointments. We calculated total expected cost (TEC) per 100 invites, number of NHSHC conducted per 100 invites and costs for completed NHSHC for laboratory and POCT-based pathways. A univariate and probabilistic sensitivity analysis was conducted to account for uncertainty in the input parameters.

MAIN OUTCOME MEASURES

We collected data on cost, volume and type of pathology services performed at seven general practices using POCT and a pathology services laboratory. We collected data on response to the NHSHC invitation letter and DNA rates from two general practices.

RESULTS

TEC of using POCT to deliver a routine NHSHC is lower than the laboratory-led pathway with savings of £29 per 100 invited patients up the point of cardiovascular disease risk score presentation. Use of POCT can deliver NHSHC in one sitting, whereas the laboratory pathway offers patients several opportunities to DNA appointment.

CONCLUSIONS

TEC of using POCT to deliver an NHSHC in the primary care setting is lower than the laboratory-led pathway. Using POCT minimises DNA rates associated with laboratory testing and enables completion of NHSHC in one sitting.

An epidemiology-based model as a tool to monitor the outbreak of inappropriateness in tumor marker requests: a national scale study

BACKGROUND

Evaluation of appropriateness of laboratory tests on the basis of individual requests remains a serious problem as the clinical question is usually not reported with the test order. This study explored the comparison of the rate of tumor marker orders with cancer prevalence as a putative indicator of inappropriateness.

METHODS

Tumor marker orders (2011 and 2012) were obtained from the Ministry of Health and cancer prevalence from the Italian Association of Cancer Registries. The rate of tumor marker orders was matched with demographic data and tumor prevalence and examined by using the confidence interval approach. Region-to-region and year-to-year variations were also examined. Focus was placed on CEA, CA125, CA19.9 and CA15.3.

RESULTS

Tumor markers ordered in Italy were 13,207,289 in 2012 (221.3/1000 individuals). Given an estimated prevalence of 2,243,953 cancer cases, 7.04 tumor markers appear to be requested for each prevalent case of epithelial cancer per year. The rate of requests of CEA, CA125, CA19.9 and CA15.3 (in aggregate 5,834,167 requests in 2012, 44.2% of total) from the first and the last ranked region (96 and 244/1000 individuals) are significantly different (p<0.01). Region-to-region differences do not correspond to any known variation of prevalence in the different regions.

CONCLUSIONS

The developed approach provides a proxy indicator of inappropriateness showing that tumor markers are overused in Italy and their ordering pattern is not related to tumor prevalence. The model is suitable to be validated in other laboratory tests used in diseases whose prevalence is known.

Managing inappropriate requests of laboratory tests: from detection to monitoring

OBJECTIVES

The main objectives of this study were to show a simple approach to detect inappropriate requests of laboratory tests and to monitor success after establishing interventions. These objectives were monitored through process and outcome indicators customized according to the type and phase of the appropriateness strategy.

STUDY DESIGN

Quasi-experimental design.

METHODS

Based on evidence regarding laboratory test utilization differences among different geographical areas of Spain, we identified serum calcium (s-Ca) testing to be underrequested and total bilirubin (tBil) testing to be overrequested in primary care patients who undergo testing at the Public University Hospital of San Juan, in San Juan de Alicante, Alicante, Spain. Additionally, the ratio of free thyroxine (FT4) tests to thyrotropin (also called thyroid-stimulating hormone [TSH]) tests was well above the published 0.25 goal in primary care. Finally, numerous laboratory tests were overrequested in hospitalized patients due to repetitive testing. We designed and implemented a variety of strategies to correct such inappropriateness and designed different indicators to monitor the intervention success over time.

RESULTS

After implementation of the different strategies, the absolute number of s-Ca tests increased. The number of tBil tests in primary care, and numerous other tests repeated too frequently in hospitalized patients, decreased. The FT4/TSH indicator goal was reached and maintained over time. Regarding the outcome indicators, the strategy of reducing tBil tests in primary care and reducing the aggregate of unnecessary tests in hospitalized patients resulted in savings of $3543.80 and $9825.50, respectively, from January 2012 to December 2014. The s-Ca strategy, from November 2011 to December 2014, detected 62 subjects' primary hyperparathyroidism at a cost of $137.80 per case.

CONCLUSIONS

The study demonstrates a simple approach to detect inappropriate requests of laboratory tests, and how to assess the potential success of interventions using process and outcome indicators.

A Survey of Physicians' Knowledge and Management of Venous Thromboembolism

A review of all patients diagnosed with venous thromboembolism (VTE) at an academic medical center from 1996 to 1998 revealed a wide variation in management and subsequent patient outcomes and a 30% increase in utilization of the vascular laboratory from the previous 2-year period. The purpose of this study was to determine physicians' knowledge and management strategies before the implementation of integrated care pathways for VIE. Mail surveys were sent to 650 physicians covering 3 academic medical centers. The disciplines targeted were from those physicians who had previously referred patients for any VTE screening examination. One-hundred and twenty-eight physicians (20%) completed the survey. Only 12% of the physicians were able to correctly identify all of the veins routinely imaged as either deep or superficial veins. Fifty-nine percent of the physicians incorrectly identified the superficial femoral vein of the thigh as a superficial vein, and 23% believed the popliteal vein to be a superficial vein. Only 17% of the respondents correctly classified the tibial-peroneal veins as deep veins. Approximately 70% of the physicians stated that they would not treat symptomatic isolated calf vein thrombosis, and, of those, only 42% said that they would obtain serial duplex scans to monitor for proximal propagation. Physicians underestimated the charges for all diagnostic screening tests, and only 14% were able to correctly identify the range of charges for a venous duplex scan. This survey of physicians demonstrated a lack of basic knowledge regarding lower extremity venous anatomy, charges for the different diagnostic tests used to diagnose VIE, and, most importantly, current treatment standards for VTE.

Comparison of Cost-Effectiveness Between Actinomycin D Versus Methotrexate-Folinic Acid in the Treatment of Low-Risk Gestational Trophoblastic Neoplasia

OBJECTIVE

To compare the cost-effectiveness between actinomycin D (Act-D) and methotrexate-folinic acid (MTX-FA) in the treatment of low-risk gestational trophoblastic neoplasia (GTN) in the Thai population.

STUDY DESIGN

A comparative cost-effectiveness analysis was performed from a societal perspective. A decision tree model was developed comparing 2 alternative treatment options: initial 5-day Act-D and 8-day MTX-FA. Treatment would be switched to another regimen in case of resistance. The outcome of interest is number of days to remission. Clinical data was obtained from our previous study in which Act-D demonstrated 100% remission rates as compared to 73.6% for MTX-FA. Cost of treatment data, which includes chemotherapeutics, accessory medications, laboratory tests, and hospital fees, was obtained from a university hospital. Patient-related travel cost and opportunity cost due to absence from work were also included. All costs were calculated to 2015 base year.

RESULT

Costs per treatment cycle were $308.01 and $227.20 US dollars (USD) for 5-day Act-D and 8-day MTX-FA, respectively. Expected time toward treatment completion for Act-D was 12.6 days shorter than for MTX-FA. Expected costs toward remission for initial treatment with Act-D and MTX-FA were $1,078.04 and $1,064.56 USD, respectively, i.e., an incremental cost effectiveness ratio (ICER) of $1.07 USD/day of earlier treatment completion. After sensitivity analysis, remission rate of lower than 72% would make initial treatment with MTX-FA more expensive than with Act-D.

CONCLUSION

Treatment costs of low-risk GTN are almost equal between the 2 treatment options with different time to remission. Initial treatment with MTX-FA is slightly less expensive, but there is longer time to remission. The ICER of initial treatment with Act-D over MTX-FA is $1.07 USD/day of earlier treatment completion.

Impact of Laboratory Test Use Strategies in a Turkish Hospital

Objectives

Eliminating unnecessary laboratory tests is a good way to reduce costs while maintain patient safety. The aim of this study was to define and process strategies to rationalize laboratory use in Ankara Numune Training and Research Hospital (ANH) and calculate potential savings in costs.

Methods

A collaborative plan was defined by hospital managers; joint meetings with ANHTA and laboratory professors were set; the joint committee invited relevant staff for input, and a laboratory efficiency committee was created. Literature was reviewed systematically to identify strategies used to improve laboratory efficiency. Strategies that would be applicable in local settings were identified for implementation, processed, and the impact on clinical use and costs assessed for 12 months.

Results

Laboratory use in ANH differed enormously among clinics. Major use was identified in internal medicine. The mean number of tests per patient was 15.8. Unnecessary testing for chloride, folic acid, free prostate specific antigen, hepatitis and HIV testing were observed. Test panel use was pinpointed as the main cause of overuse of the laboratory and the Hospital Information System test ordering page was reorganized. A significant decrease (between 12.6–85.0%) was observed for the tests that were taken to an alternative page on the computer screen. The one year study saving was equivalent to 371,183 US dollars.

Conclusion

Hospital-based committees including laboratory professionals and clinicians can define hospital based problems and led to a standardized approach to test use that can help clinicians reduce laboratory costs through appropriate use of laboratory tests.

Optimize Your Electronic Medical Record to Increase Value: Reducing Laboratory Overutilization

PURPOSE

The purpose of this study is to decrease overutilization of laboratory testing by eliminating a feature of the electronic ordering system that allowed providers to order laboratory tests to occur daily without review.

METHODS

We collected rates of utilization of a group of commonly ordered laboratory tests (number of tests per patient per day) throughout the entire hospital from June 10, 2013 through June 10, 2015. Our intervention, which eliminated the ability to order daily recurring tests, was implemented on June 11, 2014. We compared pre- and postintervention rates in order to assess the impact and surveyed providers about their experience with the intervention.

RESULTS

We examined 1,296,742 laboratory tests performed on 92,799 unique patients over 434,059 patient days. Before the intervention, the target tests were ordered using this daily recurring mechanism 33% of the time. After the intervention we observed an 8.5% (P <.001) to 20.9% (P <.001) reduction in tests per patient per day. The reduction in rate for some of the target tests persisted during the study period, but not for the 2 most commonly ordered tests. We estimated an approximate reduction in hospital costs of $300,000 due to the intervention.

CONCLUSION

A simple modification to the order entry system significantly and immediately altered provider practices throughout a large tertiary care academic center. This strategy is replicable by the many hospitals that use the same electronic health record system, and possibly, by users of other systems. Future areas of study include evaluating the additive effects of education and real-time decision support.

Active intervention in hospital test request panels pays

BACKGROUND

Ordering laboratory tests by means of test panels is a convenient way of requesting tests, preventing necessary tests from being forgotten. However, it also leads to redundant test ordering, as not all tests in a given panel are required for each patient. As test panels proposed by doctors may contain redundant, overlapping or infrequently used tests, the active involvement of knowledgeable laboratory staff in the organisation of test panels is advisable to promote efficient test use.

METHODS

Laboratory staff initiated an intervention in the organisation of test panels at our hospital in 2009. After a review of the existing panels and the proposals for new panels, we established a total of 60 panels (down from 171 previously). We also stipulated that the laboratory is to be involved with all proposals for new test panels in the future.

RESULTS

The reorganisation reduced the number of tests in the test panels by 17.7% (n=60), which theoretically should have resulted in 4.5% fewer tests being ordered. However, as an estimated 14% of the tests removed were then ordered individually in addition to the panels, 3.9% fewer tests were ordered, yielding an annual saving of about €58,000 (4.5% of the costs of all tests ordered in test panels). The savings amount to 7-8% if the frequently ordered metabolic panel (which was left unchanged) was excluded from the survey.

CONCLUSIONS

Active intervention by the laboratory in the organisation of test panels results in a reduction in the use of tests and in interesting savings.

Cost of care in a paediatric intensive care unit of a tertiary-care university hospital of Pakistan

OBJECTIVE

To assess the cost of treatment for families of children hospitalised in paediatric intensive care unit of a tertiary care teaching hospital.

METHODS

The retrospective cohort study was conducted in Aga Khan University Hospital, Karachi, and comprised record of all children admitted to the paediatric intensive care unit from January 1 to June 30, 2013. Demographic data, diagnosis at the time of admission, co-morbidity, length of stay in intensive care and outcome were recorded. The record of all hospital charges for each day the patient was cared for were also recorded. The finance department itemised the cost into major categories like pharmacy, radiology, laboratory, etc. SPSS 19 was used for statistical analysis.

RESULTS

Record of 148 patients represented the study sample. Of them, 98(66%) were males. Overall median age was 2.7 yrs (interquartile range: 1 month to 16 years) and 93(62.8%) were below 5 years of age. Median length of stay was 3.5 days (range: 2-5 days) and total patient days in intensive care were 622. The median cost per admission was PKR 217,238 (range: (114,550-368,808) and mean cost per day was PKR 57,535 (43,911-85,527). The major cost distributions were bed charges PKR 8,092,080 (18.02%), physician charges PKR 6,398653(14.25%), medical-surgical supplies PKR 8,000772(17.8%), laboratory charges PKR 8,403,615(18.9%) and pharmacy charges PKR 5,852.226(13.03%).

CONCLUSIONS

The cost of paediatric intensive care unit was expensive. Cost distribution was almost evenly distributed. Hence, a better admission policy is needed for resource utilisation and cost-effectiveness.

Improving laboratory test ordering can reduce costs in surgical wards

Background and Aim Laboratory blood tests for hospitalized patients are often overused. Excessive costs and no proof of benefit suggest re-evaluating the current approach to laboratory test ordering. The aim of the study is to improve the decision-making process of test ordering and to investigate what effect a rational, evidence-based use of laboratory test ordering in surgical wards would have on costs and healthcare resources. Methods Three-phase experimental prospective study carried out at the tertiary referral teaching hospital of Parma. Phase 1 (baseline status). The baseline status of laboratory test ordering was evaluated by recording the number of biochemical tests requested for patients undergoing elective surgery. Laboratory tests were grouped in "recommended" (RT) and "non recommended" (nRT) tests on the basis of pertinent literature. Phase 2 (improvement action): new guidelines were introduced into clinical practice. Phase 3 (feedback): Prospective data collection for first and second feedback was performed with no advance notice. Results A highly significant reduction in test ordering was found on occasion of the phases 2 and 3 of the study. The overall number of tests decreased, largely due to a decrease in the use of nRT. Conclusions Analysis was justified by the fact that most test requests proved not to be supported by clinical evidence. Inappropriate ordering of laboratory tests results in an unnecessarily high number of requests, which do not in turn improve patient management. Moreover, more appropriate, evidence-based laboratory test ordering for patients undergoing elective surgery may produce a significant reduction in costs, particularly in high-cost settings. (www.actabiomedica.it).