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).

Comparison of economic and health implications from earlier detection of HIV infection in the United Kingdom and Poland

PURPOSE

To model the financial and survival impact of early HIV infection detection versus late and compare results between the UK and Polish setting among the newly detected patients.

PATIENTS AND METHODS

A Microsoft Excel decision model (SUNRISE) was designed to generate a set of outcomes for a defined population. Survival was modelled on the COHERE study extrapolated to a 5-year horizon as a constant hazard. Hazard rates were specific to age, sex and whether detection was early or late. The primary outcomes for each year up to 5 years were: annual costs, numbers of infected cases, hospital admissions and surviving cases. Total population was observed in UK and Poland. ISPOR Budget Impact Model - Principles of Good Practice were utilised in SUNRISE development.

RESULTS

The projected cumulative cost-savings over 5 years in Poland and UK were 5,823,479 PLN (£1,109,234) and £21,608,562 respectfully. When including the value of life-years saved projected cumulative cost-savings in Poland and UK amounted to 8,374,018 PLN (£1,595,051) and £29,834,679 respectively. Savings were insensitive to transmission rates, but were sensitive in direct proportion to the percentage shift from late to early detection. In UK, savings were in higher proportion to Poland, due to much higher overall cost of HIV treatment (whether early or late HIV detected patient).

CONCLUSION

Estimated cost savings that could be translated into identification of appropriate programmes (providing wider coverage of HIV testing, awareness building) that would lead towards higher proportion of early HIV detected patients are very sensitive to the cost of HIV test and overall HIV treatment cost.

Medicare program; revisions to payment policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, access to identifiable data for the Center for Medicare and Medicaid Innovation Models & other revisions to Part B for CY 2015. Final rule with comment period

This major final rule with comment period addresses changes to the physician fee schedule, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. See the Table of Contents for a listing of the specific issues addressed in this rule.

The laboratory test utilization management toolbox

Efficiently managing laboratory test utilization requires both ensuring adequate utilization of needed tests in some patients and discouraging superfluous tests in other patients. After the difficult clinical decision is made to define the patients that do and do not need a test, a wealth of interventions are available to the clinician and laboratorian to help guide appropriate utilization. These interventions are collectively referred to here as the utilization management toolbox. Experience has shown that some tools in the toolbox are weak and other are strong, and that tools are most effective when many are used simultaneously. While the outcomes of utilization management studies are not always as concrete as may be desired, what data is available in the literature indicate that strong utilization management interventions are safe and effective measures to improve patient health and reduce waste in an era of increasing financial pressure.

[Optimization of healthcare expenditures, centralization of laboratory determinations and laboratory information accessibility]

The optimization of money expenditure for healthcare is leading to the reorganization of the structure of medical organizations, to reducing of small establishments, to centralization of laboratory analyses with cessation of their performing in some hospitals and out patient offices. This tendency is based on medical (enlargement of laboratory tests spectrum) and economical (high productivity, relative reducing of net cost of laboratory determinations) reasons. But the repercussions of switch-over to centralization of laboratory analyses performance must be evaluated from the position of laboratory information accessibility tacking in account the need in express analyses for patient, situated on territories outlying from the centralized laboratory. Using of the portative analytical devices and therefore the possibility to perform the urgent analyses by non-laboratory personal in point of care and by patients themselves as a matter of self-testing can help to solve the problem of accessibility of laboratory tests in conditions of laboratory centralization in some regions.

FibroTest-FibroSURE™: towards a universal biomarker of liver fibrosis?

Among the noninvasive alternatives to liver biopsy, several studies have demonstrated the predictive value and superior benefit/risk ratio to biopsy of two combinations of simple serum biochemical markers in patients infected with hepatitis B and C virus. These include FibroTest (BioPredictive) for the quantitative assessment of fibrosis, and ActiTest (BioPredictive) for the quantitative assessment of necroinflammatory activity (HCV-FibroSURE, LabCorp). The possible causes of false negatives and positives are also better identified. These tests, which are now available in 12 countries, can facilitate the screening and management of the most frequent liver diseases.

Rapid tests for detection of viral markers in blood transfusion

Since the early 1990s, rapid tests have been available for detection of HIV infection. They were intended for field diagnosis, emergency and home testing. In addition, rapid tests for anti-HIV, hepatitis B surface antigen and antihepatitis C virus have been used for blood screening in many resource-poor areas to save resources and overcome lack of funding, equipment and electrical supply. The performance of rapid tests varies widely but some have sensitivity and specificity levels that meet standards established by enzyme immunoassays for anti-HIV. Compared with genomic detection of hepatitis B virus, hepatitis B surface antigen rapid tests and enzyme immunoassays have insufficient sensitivity. The clinical consequences of this performance deficit remain to be clarified. Anti-hepatitis C virus rapid tests detect chronically infected individuals who are viremic, however, further studies are required to fully assess their performance. In settings where few blood donations are collected and equipment is unavailable, rapid tests provide a flexible, technically undemanding and relatively inexpensive approach to ensuring a safer blood supply. When utilized for predonation screening in areas of high endemicity of viral markers, rapid tests provide the means to limit blood bag wasting, store only clinically usable blood and inform and counsel deferred donors. As with any laboratory assay, adequate training and sustained quality assurance programs are critical to maintain a safe supply of blood. As a means of achieving a safe blood supply, rapid tests for viral markers and nucleic acid testing have a place next to classic enzyme immunoassays in the definition of strategies that are adapted to a setting's epidemiology, the size and type of donor base, equipment, staff training and resources.

Cost-effectiveness of novel algorithms for rapid diagnosis of tuberculosis in HIV-infected individuals in Uganda

OBJECTIVE

Xpert MTB/RIF ('Xpert') and urinary lateral-flow lipoarabinomannan (LF-LAM) assays offer rapid tuberculosis (TB) diagnosis. This study evaluated the cost-effectiveness of novel diagnostic algorithms utilizing combinations of Xpert and LF-LAM for the detection of active TB among people living with HIV.

DESIGN

Cost-effectiveness analysis using data from a comparative study of LF-LAM and Xpert, with a target population of HIV-infected individuals with signs/symptoms of TB in Uganda.

METHODS

A decision-analysis model compared multiple strategies for rapid TB diagnosis:sputum smear-microscopy; sputum Xpert; smear-microscopy combined with LF-LAM; and Xpert combined with LF-LAM. Primary outcomes were the costs and DALY's averted for each algorithm. Cost-effectiveness was represented using incremental cost-effectiveness ratios (ICER).

RESULTS

Compared with an algorithm of Xpert testing alone, the combination of Xpert with LF-LAM was considered highly cost-effective (ICER $57/DALY-averted) at a willingness to pay threshold of Ugandan GDP per capita. Addition of urine LF-LAM testing to smear-microscopy was a less effective strategy than Xpert replacement of smear-microscopy, but was less costly and also considered highly cost-effective (ICER $33 per DALY-averted) compared with continued usage of smear-microscopy alone. Cost-effectiveness of the Xpert plus LF-LAM algorithm was most influenced by HIV/ART costs and life-expectancy of patients after TB treatment.

CONCLUSION

The addition of urinary LF-LAM to TB diagnostic algorithms for HIV-infected individuals is highly cost-effective compared with usage of either sputum smear-microscopy or Xpert alone.

Utilization management in toxicology

Recent upward trends in the prevalence of abuse of prescription drugs and illicit substances have resulted in increased demands for toxicology testing to support the emergency department and drug treatment in pain management programs. This review will discuss the challenges faced by clinical laboratories to manage the utilization of toxicology tests, particularly those ordered in managing poisoned patients in the emergency department and chronic pain patients on opioid therapy. Optimal utilization of toxicology tests to support the emergency department relies on selecting the appropriate tests for the patient, and the availability of the results in a timely fashion. Two tiers of toxicology testing systems with different requirements for turnaround time will be discussed. In patients with chronic pain urine drug testing, including screening and confirmation testing are used extensively in pain management to monitor patient compliance. A thorough understanding of the performance characteristics of the test methodologies and drug metabolism is a key to making a proper analytical and clinical interpretation of the test results and will contribute to effective utilization of these tests. In addition, the reimbursement system is an important factor in the decision making process for test selection utilization as significant costs can be incurred by both payers and patients. Collaboration, trust, and effective communication among clinicians, patients, and clinical laboratory professionals are essential for effective utilization of toxicology testing.

A clinician's perspective on laboratory utilization management

BACKGROUND

Excessive laboratory utilization is a common problem in the hospital setting. Physicians control up to 80% of healthcare costs and wield great influence.

METHODS

This review article describes reasons for overutilization of labs and recommends interventional strategies to change clinician ordering behavior.

RESULTS

Powerful factors exist that encourage overutilization, including fear of missing a diagnosis, provider inexperience, peer pressure, financial rewards, practice inertia, and fear of legal punishment. Features of automated order entry, such as bundling and "daily until discontinued" options contribute to wasteful ordering behavior.

CONCLUSION

The most successful and long-lasting interventions are multi-faceted and have included a combination of education, feedback and audit, and administrative changes. The support of senior physicians and top administration is critical to the success of any initiative and ideally, interventions should be original from a multi-disciplinary committee of respected individuals.

Healthcare resource use among heart failure patients in a randomized pilot study of a cognitive training intervention

OBJECTIVES

To compare healthcare resource use of patients with heart failure (HF) randomized to the cognitive training intervention and to the health education active control intervention in a randomized controlled pilot study.

BACKGROUND

Cognitive training interventions may be efficacious and improve patients' memory and abilities to perform instrumental activities of daily living and self-care behaviors that may, in turn, lower healthcare resource use, but the influence of these interventions on healthcare resource use is unknown.

METHODS

Thirty-four HF patients were randomized to the computerized plasticity-based cognitive training intervention called Brain Fitness and to the health education active control intervention and completed the study. The primary outcome variable for the study was memory (recall and delayed recall). The secondary purpose of the study that is the focus of this paper was to compare healthcare resource use between the two groups using the third-party payer perspective. Data were collected at baseline and at 8 and 12 weeks after baseline. Healthcare resources were priced at Medicare payment levels for services and average wholesale price for medications.

RESULTS

Average costs of visits, procedures, and medications were similar between groups. Average costs of hospitalizations and tests, and therefore total costs, were half as much in the Brain Fitness group as compared to the active control group, but this difference was not significantly different from zero (p = 0.24).

CONCLUSIONS

Larger randomized controlled trials are needed that include analyses of program costs and costs associated with medical and non-medical services in order to fully evaluate efficacy of this intervention.

Using fee-for-service testing to generate revenue for the 21st century public health laboratory

OBJECTIVES

The decrease in appropriations for state public health laboratories (SPHLs) has become a major concern as tax revenues and, subsequently, state and federal funding, have decreased. These reductions have forced SPHLs to pursue revenue-generating opportunities to support their work. We describe the current state of funding in a sampling of SPHLs and the challenges these laboratories face as they implement or expand fee-for-service testing.

METHODS

We conducted surveys of SPHLs to collect data concerning laboratory funding sources, test menus, fee-for-service testing, and challenges to implementing fee-for-service testing.

RESULTS

Most SPHLS receive funding through three revenue sources: state appropriation, federal funding, and fee-for-service testing (cash funds). Among SPHLs, state appropriations ranged from $0 to more than $6 per capita, federal funding ranged from $0.10 to $5 per capita, and revenue from fee-for-service testing ranged from $0 to $4 per capita. The tests commonly performed on a fee-for-service basis included assays for sexually transmitted diseases, mycobacterial cultures, newborn screening, and water testing. We found that restrictive legislation, staffing shortages, inadequate software for billing fee-for-service testing, and regulations on how SPHLs use their generated revenue are impediments to implementing fee-for-service testing.

CONCLUSIONS

Some SPHLs are considering implementing or expanding fee-for-service testing as a way to recapture funds lost as a result of state and federal budget cuts. This analysis revealed many of the obstacles to implementing fee-for-service testing in SPHLs and the potential impact on SPHLs of continued decreases in funding.

Mini-FLOTAC, an innovative direct diagnostic technique for intestinal parasitic infections: experience from the field

BACKGROUND

Soil-transmitted helminths and intestinal protozoa infection are widespread in developing countries, yet an accurate diagnosis is rarely performed. The aim of this study was to evaluate the recently developed mini-FLOTAC method and to compare with currently more widely used techniques for the diagnosis of intestinal parasitic infections in different settings.

METHODOLOGY/PRINCIPAL FINDINGS

The study was carried out in Dharamsala, Himachal Pradesh, India, and in Bukumbi, Tanzania. A total of 180 pupils from two primary schools had their stool analyzed (n = 80 in Dharamsala and n = 100 in Bukumbi) for intestinal parasitic infections with three diagnostic methods: direct fecal smear, formol-ether concentration method (FECM) and mini-FLOTAC. Overall, 72% of the pupils were positive for any intestinal parasitic infection, 24% carried dual infections and 11% three infections or more. The most frequently encountered intestinal parasites were Entamoeba coli, Entamoeba histolytica/dispar, Giardia intestinalis, hookworm, (and Schistosoma mansoni, in Tanzania). Statistically significant differences were found in the detection of parasitic infections among the three methods: mini-FLOTAC was the most sensitive method for helminth infections (90% mini-FLOTAC, 60% FECM, and 30% direct fecal smear), whereas FECM was most sensitive for intestinal protozoa infections (88% FECM, 70% direct fecal smear, and 68% mini-FLOTAC).

CONCLUSION/SIGNIFICANCE

We present the first experiences with the mini-FLOTAC for the diagnosis of intestinal helminths and protozoa. Our results suggest that it is a valid, sensitive and potentially low-cost alternative technique that could be used in resource-limited settings--particularly for helminth diagnosis.

[The system of quality management in medical laboratory: the problematic issues of implementation of GOST RKS 9001-2008, GOST R ISO 15189-2009 and GOST R ISO 53079-2008]

The article presents the approaches to development and implementation of system of quality management in laboratory as an integral part of the given system in whole medical institution. The costs of works execution concerning quality support are to be weighted with economic profitability and timeliness of medical care provision to ill people considering pre-analytic stage (out-laboratory and in-laboratory) laboratory analysis. Factually it is a matter of development of system of balanced indicators concerning quality management of institution and laboratory functioning. The problematic issues are presented concerning maintenance of particular requirements of GOSTR ISO 15189 about quality of production. The emphasis is made on the necessity of training of administrations of laboratories in the field of quality management and economics of laboratory business.