Status and future of clinical pathology in Nepal

Clinical Pathology (CP) in Nepal is still in primitive stage. All most all CP tests are done manually. In many health institutions, even a basic CP test facilities are not available leading to an empirical treatment. Even the so-called big medical centers are lacking many important CP test facilities forcing the patients (those who can afford) to proceed to foreign countries for investigation and treatment of their health problem. With regard to the training of man power in the field of CP, Tribhuvan University Institute of Medicine began an academic training course called Proficiency Certificate Level in Health Laboratory Technology (PCL Health Lab.) in 1972. Presently, undergraduate and post-graduate courses, namely, Bachelor in Medical Laboratory Technology (BMLT) and MD Pathology are also being run since 1987 and 1996, respectively. Presently, CP services in Nepal are being rendered at both public and private sectors. CP services in private sector are provided by small so-called CP laboratories usually attached to a medical shops to a well set laboratories run by qualified man power. All most all private CP laboratories in Nepal function at morning and/or evening as they are run by the people working at the hospitals or other medical institutions during day time. Beside, newly emerged nursing homes are also providing CP services. However, quality control system in CP service in Nepal, is not effective yet. Thus, establishment of a national institution functioning as both referral CP center and quality monitoring body on CP services, and introduction of mandatory CP license examination appears to be an urgent need of the days to provide a qualitative CP service to the needy people.

Near-patient testing for serum cholesterol: attitudes of general practitioners and patients, appropriateness, and costs

OBJECTIVE

To determine the attitudes of general practitioners (GPs) and patients to near-patient testing (NPT) for serum cholesterol level, the appropriateness of NPT, and cost compared with testing in a specialist pathology laboratory.

DESIGN

A descriptive survey of registered Category 5 general practices in Victoria, 1994. Matched questionnaires were completed by GPs providing NPT and patients being tested.

PARTICIPANTS

13 GPs performing NPT and 206 patients having NPT.

RESULTS

Thirteen of the 17 Victorian Category 5-accredited practices participated in this study (77%), and 203 of the 260 GP questionnaires and 206 of the 260 patient questionnaires were returned. NPT of serum cholesterol level was found to be appropriately used by GPs, and recommended management guidelines for lowering cholesterol level were followed. Both GPs and patients strongly supported the role of NPT in general practice on the basis of convenience, issues of patient care, quality, efficiency and cost, but GPs felt the registration and quality assurance fees were unreasonably high. We identified potential cost savings for patients and the Health Insurance Commission with NPT of cholesterol level by GPs compared with testing at specialist pathology laboratories.

CONCLUSIONS

NPT appears to be of benefit to both GPs and patients and to provide cost savings. However, the registration charges and quality assurance fees for NPT laboratories may be limiting GPs' use of NPT.

Pathology slide review in gynecologic oncology

OBJECTIVE

To analyze the diagnostic accuracy and alteration in treatment planning from interinstitution (different institution) pathologic consultation.

METHODS

We reviewed pathologic reports from 720 referred patients. The diagnosis rendered from a gynecologic pathologist was compared with the original diagnosis. Discrepancies were coded as none, minor, or major. A discrepancy was major if it led to treatment alteration. A discrepancy was minor if it did not lead to treatment alteration. The judgment to declare a discrepancy was made by a gynecologic pathologist, a gynecologist, and three gynecologic oncologists. The review cost was $150 per case. The Cochran-Mantel-Haenszel test evaluated any systematic pattern in discrepancies.

RESULTS

Seven hundred twenty specimens consisted of 113 vulvar, 170 uterine, 289 cervical, 105 ovarian, and 43 vaginal tissues. Six hundred one (84%) pathologic diagnoses showed no discrepancy. There were 104 (14%) minor and 15 (2%) major discrepancies. After reviewing 15 major discrepancies, six surgeries were canceled, two surgeries were modified, one adjuvant radiation treatment was added, one chemotherapy treatment was modified, and five adjuvant chemotherapy treatments were cancelled. No systematic error was identified with regard to the sources (tissue origin) or methods of obtaining the specimen (P = .675). The cost of reviewing 720 specimens was $108,000. The cost of identifying each major discrepancy was $7200.

CONCLUSION

Reviewing pathology slides before definitive treatment reveals notable discrepancies in diagnoses. The cost of pathology review is globally expensive but has consequential impact on proper treatment planning for the individual patient.

Capital budgeting techniques

The cost of new medical imaging equipment for a radiology practice is a major capital purchase. Due to rapid advances in technology and imaging techniques, the management decision to purchase new capital equipment can present itself every few years. The present report explains various financial management techniques that are generally used by corporations worldwide to determine their cost of capital. The cost of capital is the return on a capital investment project required by the providers of the capital. The published financial accounts of Sonic Healthcare Limited, Australia's largest pathology company, are reproduced as a numerical example of how the financial accounts of a business may be used to determine its cost of capital. The cost of capital forms an integral part of management's financial decision-making process.

Projecting corporate health plan utilization and charges from annual ICD-9-CM diagnostic rates: a value-added opportunity for pathologists

OBJECTIVE

To develop an allocation method for corporate health plan resources and expenditures based on annual International Classification of Disease, 9th revision, Clinical Modification (ICD-9-CM) diagnostic rate stratification as a surrogate for disease incidence.

DESIGN

A data-mining process was applied to a self-insured corporate health plan database. Annual membership rates of Current Procedural Terminology (CPT) procedure utilization and charges between 1990 and 1994 for a cohort of 7216 continuously employed plan members were stratified according to the annual rates of the 19 major ICD-9-CM diagnostic classifications. The stratified annual CPT utilization and charge rates were analyzed by correlation analysis and one-tailed t test.

RESULTS

Laboratory and pathology procedure utilization and charge rates were highly correlated with specific rankings of ICD-9-CM diagnostic classifications. The health plan diagnostic rate, laboratory utilization rate, and all charge rates increased significantly during the 5 study years.

CONCLUSION

Although all procedure utilization and charge rates in this health plan increased each year, their proportionality consistently was maintained among diagnostically related groups of patients. By restraining global expenditures, managed health plans conflict with historical utilization and charge patterns. Treating ICD-9-CM diagnostic groups as disease management services within a managed care plan allows procedures and expenses to be allocated according to medical necessity in the context of total membership benefits. For pathologists, who recently were mandated by the Health Care Financing Administration and the Office of Inspector General of the Department of Health and Human Services to become stewards of ICD-9-CM coding, this is a unique opportunity to lead an initiative to perfect managed care. The process will require permanent patient numbers, computerized longitudinal patient records, and standardized coded medical terminology.

Outcomes management. New opportunities in a shrinking pathology market

With the increasing prevalence of managed care, the short-term and long-term outlook for the pathology workforce has changed dramatically for the worse. Among the many new opportunities that are available for pathologists, one of the most significant is outcomes management. Outcomes management is a natural evolution for pathologists and requires skills that are typically found in well-respected practicing pathologists. One example of a pathologist-led department of outcomes management is presented.

The ASCP Resident Physician Section: results of surveys pertaining to "graduated responsibility for residents in anatomic pathology". American Society of Cytopathology

Graduated responsibility for residents in anatomic pathology has been the subject of discussion among supervising staff and residents during the past few years. Presently a wide variation exists within pathology residency programs in the United States both in the degree of autonomy given to residents and in the areas of anatomic pathology (ie, surgical pathology, cytopathology, and autopsy pathology) within which the autonomy is granted. Recent surveys of supervising staff and residents have indicated a willingness to increase the level of independence for residents, especially at senior levels. Impediments include reimbursement, credentialing, and medicolegal issues. The results of the ASCP-Resident Physician Section (RPS) surveys pertaining to graduated responsibility for residents in anatomic pathology are discussed.

The Pittsburgh Reference Laboratory Alliance: a model for laboratory medicine in the 21st century

The Pittsburgh Reference Library Alliance (RLA) represents a successful response by hospital laboratories to the new realities of medical economics and practice. By using informatics technology to integrate the laboratory resources of community hospitals and academic medical centers across western Pennsylvania, the RLA has created a large virtual laboratory that can compete for price with large national referral laboratories. More significantly, the combination of medical expertise, the ties to academic and community centers, and the regional medical database of the RLAs allows laboratory medicine to be practiced in a new proactive way. This should provide better and more cost-effective patient care. The success of the RLA is a model for regional cooperation in pathology and potentially in other medical specialties and demonstrates the importance of informatics in the future of medical practice.

Liability issues with the Papanicolaou smear: an insurance industry perspective

To better understand the sources of cervicovaginal cytology malpractice insurance losses, summaries of all new pathology claims for 25 consecutive months at one malpractice insurer were examined. In 56 claims (out of a total of 335), the interpretation of gynecologic smears was a central issue. The estimated dollar value of these claims was about 25% of the estimated value of all new pathology claims during that interval. Some common characteristics of these cases, as well as factors influencing their outcome, are discussed along with the special problems that cytology poses for malpractice insurers.

Workflow computing. Improving management and efficiency of pathology diagnostic services

Traditionally, information technology in health care has helped practitioners to collect, store, and present information and also to add a degree of automation to simple tasks (instrument interfaces supporting result entry, for example). Thus commercially available information systems do little to support the need to model, execute, monitor, coordinate, and revise the various complex clinical processes required to support health-care delivery. Workflow computing, which is already implemented and improving the efficiency of operations in several nonmedical industries, can address the need to manage complex clinical processes. Workflow computing not only provides a means to define and manage the events, roles, and information integral to health-care delivery but also supports the explicit implementation of policy or rules appropriate to the process. This article explains how workflow computing may be applied to health-care and the inherent advantages of the technology, and it defines workflow system requirements for use in health-care delivery with special reference to diagnostic pathology.

Networking pathology services: adjusting to managed care

Health care reform is creating the need for pathologists to find new approaches to providing traditional pathology services in an increasingly competitive environment. This article reviews changes impacting pathology practices and describes a "messenger network" model as a solution for pathology practices desiring to retain and increase market share.