The role of economic appraisal in health technology assessment: the Australian case

This paper examines the role and importance of economic appraisal of health technology in Australia, particularly those appraisals conducted under the auspices of a Federal Committee. Eight specific examples are considered: extracorporeal shock wave lithotripsy, office pathology testing, magnetic resonance imaging, cervical cancer screening, bone mineral assessment, automated implantable cardiac defibrillators, liver transplantation and extracorporeal membrane oxygenation. It was found that in most cases the appraisal influenced policy, but that it was harder to assess whether there had been changes in practice or final health outcomes. It is concluded that the roles and relationships of the various players in technology assessment need to be clear, that appropriate incentives are required if socially desirable priorities are to be achieved and that the application of economic appraisal techniques needs to be timely and relevant.

The effect of allowing clinical discretion in ordering biochemical tests. Evaluation by complementary methods

We describe the effects on costs, working patterns, and clinical behavior of installing a DAX "discretionary" biochemistry analyzer. Use of the new analyzer encouraged doctors to be more specific in requesting biochemical tests, which substantially reduced the number of tests requested and slightly reduced overall costs. Doctors preferred being able to order tests in this more specific way.

The evaluation of a portable clinical analyzer in the emergency department

A recently available portable clinical analyzer (PCA), which examines sodium, potassium, chloride, glucose, urea nitrogen, and hematocrit levels on 60 microL of blood and calculates hemoglobin and osmolality levels within 2 minutes, was evaluated. Blood from 574 patients was drawn by emergency department staff, who immediately tested the samples with the PCA and transported them for plasma analysis on a reference analyzer in the clinical laboratory. Correlations between the PCA and the reference analyzer were as follows: R2 = 0.987 for urea nitrogen; R2 = 0.97, glucose; R2 = 0.937, K;R2 = 0.79, hematocrit; R2 = 0.751, sodium; and R2 = 0.689 for chloride. With its rapid turnaround, small sample requirement, and ease of operation, the PCA is most useful in an emergency department setting, where immediate access to clinically relevant laboratory testing is required in support of urgent clinical decision-making.

The reformation of Medicare and its effect on pathology

Medicare policies have gradually restricted the scope of pathologist services payable under the rules applicable to physician services. Recent changes applying relative value scales has provided an opportunity for national standardization of pathology codes, and has permitted the introduction of clinical pathology interpretations as compensable physician services.

Collaborative strategies for survival

Pathology and laboratory medicine face major challenges, including multiplying government regulations, increasing competition, decreasing reimbursement, and loss of directorial control. Other industries facing similar threats have found solutions in a variety of collaborative strategies. Several examples of laboratory collaboration and a template for evaluation of potential joint operations are presented. Successful strategies will make it easier to handle meddlesome regulations, increase productivity and decrease costs, allow pathologists to retain control, and make the laboratory more profitable and competitive.

Telemicroscopy. Design considerations for a key tool in telepathology

The paper introduces telemicroscopy as a mean to establish online telepathology services. It is differentiated between specialized point to point connections with only a few restrictions on one side, and telecommunication links available inexpensive worldwide in the form of the public telephone net on the other side with the restriction of a limited channel capacity. The restrictions imposed by the application of the telephone net (preferentially the ISDN service) are discussed and strategies outlined to overcome these restrictions. It is concluded, that if dedicated broadband connections are available, realtime telemicroscopy links can be realized immediately with available equipment. If a switched and general available telemicroscopy service applying public telecommunication links is favoured, for effective and acceptable ("online") links, computer intelligence has to be introduced to allow effective strategies for data reduction and data transmission. In this field design and development efforts are still necessary.

Cost effectiveness of a fine needle aspiration clinic

The resource implications of a Fine Needle Aspiration (FNA) Clinic at Northampton General Hospital have been evaluated over a 12 month period using a patient management questionnaire. A total of 490 cases from which fine needle aspirates were taken from superficial sites have been assessed (breast 381, thyroid 46, lymph node 44, salivary gland 9, soft tissue 10). Total resource savings (135,544 pounds) exceeded the expenses of the FNA clinic (27,290 pounds). Potential cost savings per case were the greatest for thyroid aspirates. The FNA clinic where the pathologist takes, stains and reports optimally prepared specimens, provides a high quality and accurate service on which clinicians can confidently base clinical management decisions. Unnecessary investigations and operations are avoided, allowing scant resources to be released for other procedures.

Implementing a regulation-complaint quality improvement program on a commercial laboratory information system

Implementing a quality improvement (QI) program on an automated laboratory information system (LIS) in the current regulatory climate requires first that the QI program be defined and second that the selected LIS be able to capture important events and use flexible vendor-provided or user-defined routines to prepare reports. Reports key on specific monitors and thresholds defined in the QI program. The product of a pathology laboratory is communicated information. The QI program focuses on the accuracy, clarity and timeliness with which the whole information-generating process functions. To support peer review the LIS must be able to select reports for evaluation based on user-defined parameters, such as diagnosis keyed through Systematized Nomenclature of Medicine codes, or by random or pattern selection by accession number. Counting and review of revised reports will focus attention on accuracy and skill in communication since these indicators often reflect client satisfaction with the report. To link services--e.g., cytology with surgical pathology--the LIS must be able to gather cases from the accession lists of both services and to flag diagnostic inconsistencies. LIS transaction logging at every step in the information process allows tracking of work load, productivity and resource utilization by functional areas and by individual, thus meeting regulatory requirements. Transaction logging also provides management information, such as segmented turnaround time audits, pinpointing sources of delay by kind and location of work or individual involved. Critical data must be held on-line for at least five years.

A pragmatist's approach to pathology costing: the Welsh Datatree project

The Datatree costing project in Wales has provided the Welsh pathology laboratories with a standard costing package that allows pathologists to understand how their own laboratory's test costs are compiled. The software provides answers to the question "what if? ..." and shows instantly the effect of salary or consumable cost alterations. Resource management at a laboratory level is enhanced by a greater knowledge of costs, particularly in relation to volumes of work. Perhaps this is one of the stepping-stones across the river to the "open market." In the United Kingdom NHS any information of this kind must be regarded as invaluable.

Modifying the request behaviour of clinicians

AIM

To evaluate whether the feedback of laboratory use and cost data to clinicians modifies their request behaviour.

METHODS

Over two years the effect of monthly feedback of clinical chemistry test use and revenue expenditure to three consultant physicians on their clinical chemistry and haematology requesting patterns was evaluated. Two physicians who received no information served as controls.

RESULTS

Feedback over one year led to an immediate and sustained decrease of 15%, 27%, and 21% in clinical chemistry requests (p less than 0.01), tests (p less than 0.001), and revenue expenditure (p less than 0.001), respectively, and a 10% reduction in haematology tests (p less than 0.05) per outpatient visit. These changes persisted in the six months after the feedback was stopped.

CONCLUSIONS

These results suggest that feedback of laboratory data to clinicians modifies their request behaviour and that supplying clinicians with information on what they do can influence the way they make decisions.

A tree-structure model for analyzing laboratory test costs

A method of costing clinical laboratory tests is described in which total laboratory costs are apportioned into 3 components: an 'organizational overhead cost' to describe the cost of running an organization; a 'cost per episode' to describe the costs incurred per request; and a 'cost per test' to describe the actual analytical costs of tests performed. A tree-like structural model is described which allows for distribution of this 'cost per test' component to the contributing tests and the calculation of the true 'cost per test'. The implementation of this model on a computer spreadsheet has been achieved. When combined with the other cost components, the true total costs of laboratory testing can be determined for any particular test. The model also allows calculation of the incremental and marginal costs of a test and permits optimization of laboratory test frequencies and work-load to minimize laboratory analytical costs.

Evaluation of the cost effectiveness of establishing a fine needle aspiration cytology clinic in a hospital out-patient department

In an attempt to reduce the number of inadequate smears processed by our laboratory and the false negative rate of fine needle aspiration cytodiagnosis, we have introduced a fine needle aspiration cytology service where aspirates are taken by the cytopathologist in a clinic. In the 12 month period since the introduction of this service, the number of inadequate smears fell sharply. Nine per cent of the specimens were inadequate compared with 43% of specimens from other sources. The establishment of the clinic resulted in a threefold reduction in the cost of diagnosing breast lesions.

Developments in near-patient testing

Important technologies for near-patient testing include 'desk-top' analysers, kits and systems for continuous monitoring, with the possibility of advances through approaches to genetic testing. Near-patient testing is now used in physicians' office, hospital ward, home care and population screening applications. Analytical performance achieved by operators in these settings may frequently cause concern and has led to increased support for accreditation and educational measures. While near-patient testing has much potential to contribute to health care, hard evidence of benefit is sparse, and the costs of such testing to health care systems may be substantial. The place of this technology still requires critical evaluation, in the context of system performance and relevance to health care.

Biomedical technology, socioeconomics, and biomedical computing: implications for change

Pathology and laboratory medicine have changed rapidly since 1945. Three forces can be recognized as major vectors for change: rapid application of the biotechnology evolving from research in molecular biology, radically changing medical socioeconomics, and the evolving field of medical information science. While these apparently disparate elements affect all of medicine and health care, at the present time they appear to be changing pathology and laboratory medicine to a far greater extent than many other medical specialties. If pathologists fail to make the necessary changes, obsolescence may well overtake the specialty. Planning for the innovative educational and training programs that will be required to meet the future demands of the specialty is essential, not only for those now in practice but for those who will follow us.