The financial imperative of physicians to control demand of laboratory testing

It is an integral component of doctor's duty of care to understand the significant impact laboratory testing has on the expense an ultimate quality of healthcare patients receive, yet the costs of these tests are poorly perceived. Utilising semi-structured interviews and questionnaires, we assessed surgeon's perceived costs of two commonly encountered clinical scenarios requiring out of hours laboratory testing. Of the 35 participants only 23.3% (n = 7) accurately estimated the overall cost. The most expensive test was "Type and Screen" at Euro 83, with 77.3% (n = 17) underestimating the cost. Non-consultant hospital doctors qualified for 3 years were more likely to underestimate on-call costs (p = 0.042). It is of utmost importance to improve the knowledge of all surgeons of the financial implications of investigations. Through education we can potentially reduce un-warranted costs and fulfill our duty of care in the most cost efficient manner.

Payment for inpatient and outpatient health care professional services at non-departmental facilities and other medical charges associated with non-VA outpatient care. Final rule

This document affirms as final, with changes, a proposed rule that updates the Department of Veterans Affairs (VA) medical regulations concerning the payment methodology used to calculate VA payments for inpatient and outpatient health care professional services and other medical services associated with non-VA outpatient care. The rule has been designed to ensure that it will not have adverse effects on access to care.

Evaluating laboratory diagnostic tests and translational research

In laboratory medicine, the evaluation of an assay is reasonably straightforward and allows broad applicable standards to be established. In contrast, the evaluation of a test is more complex and inherently less susceptible to standardization. The term "test" refers to the use of an assay in the context of a particular disease, in a particular population, and for a particular purpose. Therefore, the true evaluation is to demonstrate its effectiveness in helping a clinician achieve a correct diagnosis or improve patient clinical outcomes. The debate on the current weak framework used for evaluating laboratory tests has been stimulated by recent technological developments, in particular "omics" tests. Currently, consensus has been achieved concerning the proposal to use a model based on at least four steps to be investigated. These are analytical and clinical validity, clinical usefulness and, finally, any ethical, social and legal implications, including economic implications. As the pace of technological advancements in laboratory medicine accelerates, it is time to discuss the role of laboratory testing, and the related role of clinical laboratories. In particular, we should consider whether they should evolve as focused factories of numbers and results, or as knowledge services with an emphasis on improving appropriateness in test requesting, and the interpretation and utilization of laboratory information.

[Software for illustrating a cost-quality balance carried out by clinical laboratory practice]

We have no proper reference indicating the quality of clinical laboratory practice, which should clearly illustrates that better medical tests require more expenses. Japanese Society of Laboratory Medicine was concerned about recent difficult medical economy and issued a committee report proposing a guideline to evaluate the good laboratory practice. According to the guideline, we developed software that illustrate a cost-quality balance carried out by clinical laboratory practice. We encountered a number of controversial problems, for example, how to measure and weight each quality-related factor, how to calculate costs of a laboratory test and how to consider characteristics of a clinical laboratory. Consequently we finished only prototype software within the given period and the budget. In this paper, software implementation of the guideline and the above-mentioned problems are summarized. Aiming to stimulate these discussions, the operative software will be put on the Society's homepage for trial

[Survey of costs of laboratory tests aiming at revision of medical treatment fees and improvement of work]

The costs of laboratory tests were surveyed, aiming at realizing medical treatment fees corresponding to the costs of hospital laboratory tests. Using exclusive application software, the costs of blood cell count, peripheral blood and bone marrow, PT, general urinalysis, urine sediment, AST, glucose, HbA1c, AFP, CEA, microbial, and chromosomal tests were surveyed in 13 hospitals. The costs of tests using automatic devices were lower than the medical treatment fees (operation fees) in many hospitals, but those of tests requiring manual manipulation and the skills of clinical technologists, such as peripheral blood, bone marrow, urine sediment, microbial, and chromosomal tests, exceeded the medical fees (operation fees) in many hospitals. Accurate surveys of costs in many hospitals may lead to the moderation of medical treatment fees, and investigation of the test costs at individual hospitals may be useful for improving the medicoeconomics of hospitals and test-based work. [Rinsho Byori 58 : 920-924, 20101

Cost-effectiveness of laboratory monitoring in sub-Saharan Africa: a review of the current literature

As the global community evaluates the unprecedented investment in the scale-up of human immunodeficiency virus (HIV) therapy and considers future investments in HIV care, it is crucial to identify those HIV interventions that maximize the benefit realized from each dollar spent. The use of laboratory monitoring assays--CD4 cell count and HIV RNA level--in decisions about when to initiate and switch antiretroviral therapy may offer substantial clinical benefit, but their economic value remains controversial. Cost-effectiveness analysis can be used to evaluate the value for money of strategies for HIV care, including alternative approaches to laboratory monitoring. Five published cost-effectiveness analyses address the question of CD4 cell count and HIV RNA level monitoring for HIV-infected patients in Africa, with differing conclusions. We describe the use of cost-effectiveness analysis in resource-limited settings and review the cost-effectiveness literature with regard to monitoring the CD4 cell count and HIV RNA level in Africa, highlighting some of the most critical issues in this debate.

Experience establishing tuberculosis laboratory capacity in a developing country setting

OBJECTIVE

To describe the experience of strengthening laboratory diagnosis of tuberculosis (TB) in a resource-limited country with high TB-HIV (human immunodeficiency virus) and multidrug-resistant TB (MDR-TB) prevalence.

METHODS

In the Kingdom of Lesotho, which is confronted with high levels of TB, MDR-TB and HIV prevalence, between 2006 and 2008 a coalition of the Foundation for Innovative New Diagnostics, Partners In Health and the World Health Organization renovated the National TB Reference Laboratory and reinforced microscopy services, streamlined conventional culture and drug susceptibility testing (DST) and introduced modern TB diagnostic methods.

FINDINGS

It was feasible to establish a biosafety level three facility for solid culture and DST and an external quality assessment programme for smear microscopy within 4 months, all in 2007. Liquid culture and DST were introduced a month later. Preliminary results were comparable to those found in laboratories in industrialised countries. A year later, line-probe assay for the rapid detection of MDR-TB was introduced.

DISCUSSION

Through strong political commitment and collaboration, it is possible to rapidly establish quality assured TB diagnostic capacity, including current methods, in a resource-limited setting. Case detection and management for TB and MDR-TB have been greatly enhanced. From a low baseline, TB culture throughput in the laboratory increased ten-fold and has been sustained. This experience has served as a catalyst to translate policy into practice with new diagnostic technologies. It supports global policy setting to enhance and modernise laboratory work in developing countries.

[Tuberculosis in Romania. Problems and solutions]

The analysis of the Management Unit of the National TB Programme (NTP) database, together with the reports of the TB county managers, allowed to the authors to identify some weaknesses of TB control in Romania in the recent years and to propose the appropriate measures.

PROBLEMS

The marked decrease in the reduction of TB cases reported annually from 2,761 in 2005-2006, to 145 in 2007-2008 and the stagnation of mortality rate: 7.5 per ten thousand in 2007 and 7.6 per ten thousand in 2008. Deficiencies in data recording and reporting through informatic system of the NTP. Lack of financial resources for system maintenance and upgrade. Deficiencies in monitoring and control of mycobacterium resistance to antituberculous drugs phenomenon at national level. Sensitivity testing only for a small percentage of culture confirmed new TB cases (21%). Higher percentage of MDR in new TB cases compared to the results of national survey of mycobacterium drug resistance 2003-2004. Lack of personnel: 16 TB dispensaries without any pulmonologist, vacancies for 259 doctors, 436 nurses and 433 auxiliary personnel. Important deficiencies in the NTP network's infrastructure and logistics countrywide. Discontinuities in the supply with first and second line antituberculous drugs resulting in interruption of treatments. Lack of an officially endorsed protocol for the diagnosis, treatment and monitoring of cases with TB/HIV co-infection. Solutions: Revitalization of monitoring-supervision activities of the NTP running countrywide, provision with necessary financial resources to perform the scheduled visits in counties. Providing maintenance and upgrade of the informatic system for data collection. Implementation of the necessary measures in order to attract and maintain the personnel in the NTP network. Conduct the national survey of mycobacterium susceptibility to first and second line antituberculous drugs and drug susceptibility testing of the most culture confirmed TB cases. Restore the centralized procurement of TB drugs. Finalization and official endorsement of the protocol for TB/HIV co-infection initiated in 2004.

[Medical reimbursement for the management of laboratory testing and a 24-hour system for microbiological testing]

In recent years, annual revenues of hospitals in Japan for their health care services have been declining because of the frequent downward revisions of the reimbursement rates to curb growth in national medical spending, exerting a marked influence on the area of laboratory testing. Particularly, unprofitable microbiological testing has been neglected. However, microbiological laboratory testing is not only essential for the diagnosis and treatment of infections, but also plays an important role in the prevention of hospital-acquired infections. The Japanese Society of Laboratory Medicine has been involved in various activities to help clinical laboratories in hospitals ensure stable health care revenues from their practice, as well as improve the status of clinical laboratory physicians. In response to recent changes in clinical laboratory settings, we will hold a symposium to develop and improve a 24-hour system for microbiological testing.

[Correspondence and effect on the clinical laboratory of the medical examination and treatment reward revision]

Since 2007, the rate of hospital bankruptcy has been rapidly increasing, and we face the crisis of a collapse in the medical care system. Even in hospitals that continue to operate, more than 70% are losing money. In the Department of Clinical Laboratory, the budget cannot be balanced using the present medical service fee payment system in the microbial examination field. Hospital managers may first consider outsourcing medical services from departments showing a budget imbalance. However, they should be aware that a decrease in medical services increases overall medical expenditure in the hospital.

[Reimbursement and rational prescription of laboratory tests]

Following the important growth of the Belgian laboratory medicine budget in the eighties, the mechanisms of reimbursement by the social security system have become more and more complex in the last 20 years. The current system is a dual one, with a lump sum complemented by an amount per test. The rules differ for hospitalized and non-hospitalized patients. New recently launched measures ("reference amounts") intend to decrease the prescription of laboratory tests in hospitals, while others targeting non-hospital practice are being considered. Beside these purely financial initiatives targeting the laboratories, another approach involves fostering a rational prescription of tests according to the results of interventional trials or international guidelines consistent with evidence-based medicine. The recent report of the KCE on laboratory tests prescription by general practitioners is consistent with this strategy.

Improving laboratory monitoring of medications: an economic analysis alongside a clinical trial

OBJECTIVE

To test the efficiency and cost-effectiveness of interventions aimed at enhancing laboratory monitoring of medication.

STUDY DESIGN

Cost-effectiveness analysis.

METHODS

Patients of a not-for-profit, group-model HMO were randomized to 1 of 4 interventions: an electronic medical record reminder to the clinician, an automated voice message to patients, pharmacy-led outreach, or usual care. Patients were followed for 25 days to determine completion of all recommended baseline laboratory monitoring tests. We measured the rate of laboratory test completion and the cost-effectiveness of each intervention. Direct medical care costs to the HMO (repeated testing, extra visits, and intervention costs) were determined using trial data and a mix of other data sources.

RESULTS

The average cost of patient contact was $5.45 in the pharmacy-led intervention, $7.00 in the electronic reminder intervention, and $4.64 in the automated voice message reminder intervention. The electronic medical record intervention was more costly and less effective than other methods. The automated voice message intervention had an incremental cost-effectiveness ratio (ICER) of $47 per additional completed case, and the pharmacy intervention had an ICER of $64 per additional completed case.

CONCLUSIONS

Using the data available to compare strategies to enhance baseline monitoring, direct clinician messaging was not an efficient use of resources. Depending on a decision maker's willingness to pay, automated voice messaging and pharmacy-led efforts can be efficient choices to prompt therapeutic baseline monitoring, but direct clinician messaging is probably a less efficient use of resources.

PROCEED: Prospective Obesity Cohort of Economic Evaluation and Determinants: baseline health and healthcare utilization of the US sample

AIM

To summarize baseline characteristics, health conditions, resource utilization and resource cost for the US population for the 90-day period preceding enrolment, stratified by body mass index (BMI) and the presence of abdominal obesity (AO).

METHODS

PROCEED (Prospective Obesity Cohort of Economic Evaluation and Determinants) is a multinational, prospective cohort of control (BMI 20-24.0 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)) and obese (BMI >or= 30 kg/m(2)) subjects with AO and without AO [non-abdominal obesity (NAO)], defined by waist circumference (WC) >102 and 88 cm for males and females, respectively. Subjects were recruited from an Internet consumer panel. Outcomes were self-reported online. Self-reported anthropometric data were validated. Prevalence of conditions and utilization is presented by BMI class and AO within BMI class. Differences in prevalence and means were evaluated.

RESULTS

A total of 1067 overweight [n = 474 (NAO: n = 254 and AO: n = 220)] and obese [n = 493 (NAO: n = 39 and AO: n = 454)] subjects and 100 controls were recruited. Self-reported weight (r = 0.92) and WC (r = 0.87) were correlated with measured assessments. Prevalence of symptoms was significantly higher in groups with higher BMI, as were hypertension (p < 0.0001), diabetes (p < 0.0001) and sleep apnoea (p < 0.0001). Metabolic risk factors increased with the BMI class. Among the overweight class, subjects with AO had significantly more reported respiratory, heart, nervous, skin and reproductive system symptoms. Overweight subjects with AO reported a significantly higher prevalence of diabetes (13%) compared with overweight subjects with NAO (7%, p = 0.04). Mean healthcare cost was significantly higher in the higher BMI classes [control ($456 +/- 937) vs. overweight ($1084 +/- 3531) and obese ($1186 +/- 2808) (p < 0.0001)].

CONCLUSION

An increasing gradient of symptoms, medical conditions, metabolic risk factors and healthcare utilization among those with a greater degree of obesity was observed. The independent effect of AO on health and healthcare utilization deserves further study with a larger sample size.

Cost-effectiveness of a new interferon-based blood assay, QuantiFERON-TB Gold, in screening tuberculosis contacts

BACKGROUND

Recent approval of interferon-gamma release assays that are more specific for Mycobacterium tuberculosis has given new options for the diagnosis of latent tuberculosis infection (LTBI).

OBJECTIVE

To assess the cost-effectiveness of Quanti-FERON-TB Gold (QFT-G) vs. the tuberculin skin test (TST) in diagnosing LTBI in contacts of active TB cases using a decision analytic Markov model.

METHODS

Three screening strategies--TST alone, QFT-G alone and sequential screening of TST then QFT-G--were evaluated. The model was further stratified according to ethnicity and bacille Calmette-Guérin (BCG) vaccination status. Data sources included published studies and empirical data. Results were reported in terms of the incremental net monetary benefit (INMB) of each strategy compared with the baseline strategy of TST-based screening in all contacts.

RESULTS

The most economically attractive strategy was to administer QFT-G in BCG-vaccinated contacts, and to reserve TST for all others (INMB CA$3.70/contact). The least cost-effective strategy was QFT-G for all contacts, which resulted in an INMB of CA$-11.50 per contact. Assuming a higher prevalence of recent infection, faster conversion of QFT-G, a higher rate of TB reactivation, reduction in utility or greater adherence to preventive treatment resulted in QFT-G becoming cost-effective in more subgroups.

CONCLUSIONS

Selected use of QFT-G appears to be cost-effective if used in a targeted fashion.