Long-term experience with an accelerated protocol for diagnosis of chest pain

CONTEXT

More than 6 million patients present annually with chest pain suggestive of acute coronary syndrome. Rapid and accurate diagnosis is essential for best clinical outcomes, for optimal management of hospital resources, and for minimizing medicolegal exposure.

OBJECTIVE

To evaluate the clinical and cost outcomes of an accelerated protocol for chest pain triage in a community-based hospital of moderate size.

METHODS

One hundred successive patients with chest pain were diagnosed according to the Traditional Chest Pain Protocol, which included testing of serial blood samples for creatine kinase (CK)-MB and total CK. These patients were also subjected to the Accelerated Chest Pain Protocol under evaluation, which included testing at shortened intervals for myoglobin and cardiac troponin I in addition to CK and CK-MB. Diagnostic sensitivity and specificity were compared versus the final assigned diagnosis. The Accelerated Chest Pain Protocol was implemented for routine use. Follow-up evaluations were conducted at 1 month (test group A, N = 180) and 22 months (test group B, N = 180). Costs for diagnosis and treatment of the 2 test groups were compared with those for the control group.

RESULTS

The 2 protocols had equivalent specificity values (99%). The sensitivity of the Accelerated Chest Pain Protocol was higher than that of the Traditional Chest Pain Protocol (95% vs 58%). Cost savings of 29% and a reduction in length of stay of 33% were achieved in test group B versus the control group.

CONCLUSIONS

The Accelerated Chest Pain Protocol improved the accuracy and timeliness of diagnosis of acute coronary syndrome while reducing costs.

Pathology services. Test match

The UK's spending on pathology services is one of the lowest among developed countries. Increased expenditure on pathology would allow better targeting of treatment. Testing in general practice needs to be expanded.

Pathologists' roles in clinical utilization management. A financing model for managed care

In ancillary or laboratory utilization management, the roles of pathologists have not been explored fully in managed care systems. Two possible reasons may account for this: pathologists' potential contributions have not been defined clearly, and effective measurement of and reasonable compensation for the pathologist's contribution remains vague. The responsibilities of pathologists in clinical practice may include clinical pathology and laboratory services (which have long been well-defined and are compensated according to a resource-based relative value system-based coding system), laboratory administration, clinical utilization management, and clinical research. Although laboratory administration services have been compensated with mechanisms such as percentage of total service revenue or fixed salary, the involvement of pathologists seems less today than in the past, owing to increased clinical workload and time constraints in an expanding managed care environment, especially in community hospital settings. The lack of financial incentives or appropriate compensation mechanisms for the services likely accounts for the current situation. Furthermore, the importance of pathologist-driven utilization management in laboratory services lacks recognition among hospital administrators, managed care executives, and pathologists themselves, despite its potential benefits for reducing cost and enhancing quality of care. We propose a financial compensation model for such services and summarize its advantages.

Improved fine needle aspiration (FNA) cytology results with a near patient diagnosis service for breast lesions

This study is a review of the quality of FNA cytology results for breast lesions approximately 18 months before and 10 months after a change from a rapid diagnosis FNA service with consultant pathologist aspirators to a conventional FNA service with clinician aspirators of varied experience. The setting was symptomatic breast clinic in a large hospital in rural New Zealand acting as a tertiary referral centre for a population of 550,000. The results were collected retrospectively and prospectively. The quality of results for pathologist aspirators (total 810) and clinician aspirators (total 403) was compared using the definitions of the NHS Breast Screening Program Guidelines for Cytology Procedures and Reporting in Breast Cancer Screening. There were statistically significant differences in specificity (biopsy cases only) with 73% for pathologists and 49% for clinicians, specificity (full) with 74% and 56%, inadequate rate with 23% and 37%, and complete sensitivity with 76% and 67%. The use of pathologist aspirators allowed the specimens to be reported in a few minutes. Specimens taken by clinicians took at least 30 min to report. The financial aspects of the two approaches are discussed. When compared with clinician aspirators, pathologist aspirators obtained better quality results and these were reported more quickly.

Implementation of a practical digital imaging system for routine gross photography in an autopsy environment

BACKGROUND

The autopsy environment places stringent requirements on a digital imaging system. These requirements must be addressed if the system is to be functional, easy to use, and reliable.

DESIGN

After clearly defining the requirements for such a system, we implemented routine digital imaging in a busy academic autopsy suite.

RESULTS

The new technology was immediately accepted by both the resident staff and the technical staff. Although a 35-mm camera was always available for traditional photography, it was rarely used. An interesting side effect of implementing digital imaging was a nearly twofold increase in the number of images taken per autopsy case. The requirements, features, and utility of a digital imaging system are discussed.

CONCLUSION

Digital imaging in an autopsy environment can be both practical and cost-effective. It provides many advantages over traditional 35-mm photography and can be the first step toward numerous additional improved services.

Cost-based (Part A) pathology physician services. Origin, current spectrum, and future

The authors review pathology cost-based services, how they developed, their current status, and future applications in a managed care environment. Special emphasis is given to the utility of outcomes analysis for pathology cost-based services.

French gynecologic cytology

Diagnostic schema may be developed on a national or global level, but may be varied depending on the local conditions. In this article, the differences between French and North American gynecologic cytology are discussed. This article emphasizes the training, diagnostic, technologic, and regulatory differences that exist in France. By studying such differences, local practices can learn potential benefits and why their currently used systems may be optimal.

The impact of molecular diagnostic tests on patient outcomes

In order for the benefits of molecular pathology to outweigh its inherent costs, the procedures must be integrated into the assessment of the total disease management to realize the true impact of their financial and clinical outcomes. Major financial and patient outcome benefits are achievable from molecular testing by the ability to reduce the use of less-sensitive and less-specific tests and cause a decrease the use of unnecessary diagnostic procedures and ineffective therapies. In this review, the financial and patient care determinants of outcomes for molecular-based testing of disease predisposition, screening, early detection, and directed therapy are presented.

Cost benefit and outcomes analysis for fine-needle aspiration. Why do we know so little?

In many areas of anatomic pathology, there have been little application of health services research methods. Diagnostic fine-needle aspiration has been performed for decades in the United States, but there is still little knowledge of the benefits and limitations of this procedure. This article examines some of the research regarding fine-needle aspiration cytology and hypothesizes why there has been so little evaluation.

The impact of diagnostic immunohistochemistry on patient outcomes

Diagnostic immunohistology (DIHC) is a discipline that has been used clinically for at least two decades, but, because of medicolegal encumbrances, it has not been a part of many formal outcomes analyses during that time. Potential applications of this technology with a direct bearing on response to treatment include the accurate identification of infectious organisms, distinction between morphologically-similar undifferentiated tumors, separation of benign and malignant neoplasms, and prognostication of malignancies. The first two of those four roles may indeed have a quantifiable impact on case outcomes, but the last two applications have only questionable value in this specific context. This is an area of medicine in which formal outcomes analysis is greatly needed to help determine future practice patterns.

Economic, regulatory, and practice issues in molecular pathology and diagnostics

This issue of Pathology Patterns presents a series of review articles in molecular pathology and molecular diagnostics that cover a wide variety of applications of new technologies recently integrated into many clinical laboratories and pathology departments. In order for the benefits of molecular pathology to outweigh its inherent costs, these new procedures must be integrated into the assessment of total disease management to fully observe how the benefits outweigh the costs and effects on patient outcome. Major financial benefits can be achieved with molecular testing because of ability to reduce the use of less sensitive and specific tests, and unnecessary diagnostic procedures and ineffective therapies.

100% rapid (partial) rescreening for quality assurance

OBJECTIVE

To compare the efficiency of two methods for routine quality assurance in gynecologic cytology: random rescreening of 10% of negative gynecologic smears and rapid rescreening of all negative gynecologic smears.

STUDY DESIGN

All gynecologic smears considered to be negative or benign and diagnosed between November 1, 1996, and December 31, 1997, were rescreened using the rapid, partial rescreening technique. Results were compared to those of the 10% random rescreening method.

RESULTS

Comparing the 10% review of negatives to the rapid rescreening in two comparable periods of three months, the former required review by the supervisor of 160 cases in order to find a true false negative. With rapid rescreening, the supervisor had to review fewer than eight cases to find a true false negative. Also, rapid rescreening found about four times more true false negatives than random 10% review.

CONCLUSION

Rapid rescreening of all negative gynecologic smears proved more efficient than 10% random rescreening.

The cost-effectiveness of routine histologic examination

Although the histologic examination of routine tissues, such as hernia sacs and intervertebral disks, has shown a low incidence of detecting clinically significant unsuspected disease, the cost-effectiveness of histologic examination has not been determined. By using a theoretical model that assumed variable costs and gains in life expectancy secondary to detecting clinically significant disease, a threshold incidence of disease detection at which histologic examination is cost-effective was determined. By using the University of lowa (Iowa City) cost of examination (approximately $25), at least 1 of every 2,000 examinations would have to show clinically significant disease for histologic examination to be cost-effective. This threshold incidence decreases as production costs decrease or life-year values increase. Before definitive policy conclusions can be made, additional studies are needed to better define the trade-off between cost and the value of information and the incidence of detecting clinically significant disease.

Histopathologic review of prostate biopsies from patients referred to a comprehensive cancer center: correlation of pathologic findings, analysis of cost, and impact on treatment

BACKGROUND

Clinicians at the Fox Chase Cancer Center (FCCC) base prostate carcinoma treatment decisions regarding need to treat, field size, total dose, and adjuvant hormonal therapy on known prognostic factors including clinical stage, Gleason score (GS), perineural invasion (PNI), and pretreatment prostate specific antigen levels. The pathology of every patient is reviewed at FCCC to confirm a diagnosis of malignancy. The objective of this study was to define differences between pathologic reviews and their impact on treatment between outside institutions and FCCC.

METHODS

The authors reviewed 538 pathology reports of prostate biopsies performed at both outside pathology departments and FCCC on patients evaluated between January 1993 and December 1996. The outside pathology reviews represented 107 community hospitals, academic institutions, and private pathology laboratories. Patients who had received hormonal therapy, cryosurgery, or radical prostatectomy prior to prostate biopsy were excluded from analysis. Final FCCC pathology determinations were compared with pathology reports from outside institutions. Reports then were analyzed to determine whether differences in interpretation would have resulted in different treatment strategies. Differences in percentages according to institutional type were evaluated using the chi-square statistic. The cost was assessed and cost per change in treatment estimated.

RESULTS

The 538 pathology reviews identified a nearly 40% change in GS and a 13% change in > or =2 GS between the FCCC pathology review and 107 outside academic institutions. The results of this study showed that 22% of community hospitals, 10% of private laboratories, and 8% of academic institutions demonstrated at least 2 GS changes compared with the FCCC pathology review (p = 0.001). There was no significant difference observed between types of institutions in the incidence of PNI.

CONCLUSIONS

This analysis provides evidence of a significant difference in the pathologic reviews of prostate biopsies conducted at FCCC and outside pathology departments. There was a nearly 40% change in GS and a 13% change in > or =2 GS between the FCCC pathology review and 107 outside institutions. The second pathology review added approximately $104 per case for a total of $55,952 to review all 538 cases. Overall, the savings in health care dollars resulting from the second pathologic review totaled $12,997. This second review of outside pathology in prostate cancer appears to be justified based on the treatment changes and on cost.