1
|
Kannan N, Ramalingam K, Ramani P. Revolutionising Quality Management in the Oral Pathology Laboratory: A Deep Dive Into the Six Sigma Methodology. Cureus 2024; 16:e52651. [PMID: 38380190 PMCID: PMC10877558 DOI: 10.7759/cureus.52651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 02/22/2024] Open
Abstract
Six Sigma Foundations is a statistical standard that indicates an exceptionally high level of quality, along with a customer satisfaction management approach that intends to lower error rates and boost process efficiency. The Define, Measure, Analyse, Improve, and Control (DMAIC) approach is a fundamental component of Six Sigma and provides an organised framework for process improvement. In contrast to conventional techniques that are more manual-based, Six Sigma emphasises and focuses on making decisions based on facts and evidence. The key to the success of Six Sigma is its reliance on statistical methods. Advanced tools like Pareto charts, histograms, regression analysis, and fishbone diagrams are used ardently for the benefit of customers and to reduce the overall error rate. To support clinical decision-making, a clinical laboratory's primary responsibility is to generate test results that are accurate, repeatable, fast, and appropriately interpreted. Ensuring desired clinical outcomes must be the ultimate objective. To accomplish this goal, laboratories must prioritise cost-effectiveness while establishing and maintaining quality in all laboratory procedures. The concept of the Lean Six Sigma (LSS) methodology, which mainly centres on efficiency by discerning and eradicating actions or operations that do not provide any benefit to the organisation, is combined with the proposition of Six Sigma, which emphasises data-driven analyses and optimization. The integration of these powerful concepts aids in the overall improvement of the organisations adopting these techniques. This review provides a brief overview of the benefits of the LSS methodology and its implementation in the oral pathology laboratory.
Collapse
Affiliation(s)
- Neha Kannan
- Oral Pathology and Microbiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - Karthikeyan Ramalingam
- Oral Pathology and Microbiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - Pratibha Ramani
- Oral Pathology and Microbiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| |
Collapse
|
2
|
KILIÇ E, KAYHAN TETİK B, KURT O. Evaluation of Doctors’ Knowledge of Rational Laboratory Use, A Descriptive Study From Turkey. KONURALP TIP DERGISI 2021. [DOI: 10.18521/ktd.791917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
3
|
Deep into Laboratory: An Artificial Intelligence Approach to Recommend Laboratory Tests. Diagnostics (Basel) 2021; 11:diagnostics11060990. [PMID: 34072571 PMCID: PMC8227070 DOI: 10.3390/diagnostics11060990] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/19/2021] [Accepted: 05/27/2021] [Indexed: 01/16/2023] Open
Abstract
Laboratory tests are performed to make effective clinical decisions. However, inappropriate laboratory test ordering hampers patient care and increases financial burden for healthcare. An automated laboratory test recommendation system can provide rapid and appropriate test selection, potentially improving the workflow to help physicians spend more time treating patients. The main objective of this study was to develop a deep learning-based automated system to recommend appropriate laboratory tests. A retrospective data collection was performed at the National Health Insurance database between 1 January 2013, and 31 December 2013. We included all prescriptions that had at least one laboratory test. A total of 1,463,837 prescriptions from 530,050 unique patients was included in our study. Of these patients, 296,541 were women (55.95%), the range of age was between 1 and 107 years. The deep learning (DL) model achieved a higher area under the receiver operating characteristics curve (AUROC micro = 0.98, and AUROC macro = 0.94). The findings of this study show that the DL model can accurately and efficiently identify laboratory tests. This model can be integrated into existing workflows to reduce under- and over-utilization problems.
Collapse
|
4
|
Furundarena JR, Uranga A, González C, Martínez B, Iriondo J, Ondarra L, Arambarri A, San Vicente R, Sarasqueta C, Lombardi C, Altuna A, Rois N. Initial study of anaemia profile for primary care centres with automated laboratory algorithms reduces the demand for ferritin, iron, transferrin, vitamin B 12 and folate tests. J Clin Pathol 2020; 75:94-98. [PMID: 33234695 DOI: 10.1136/jclinpath-2020-207130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/05/2020] [Accepted: 11/09/2020] [Indexed: 12/29/2022]
Abstract
AIM To evaluate the influence of an algorithm designed to incorporate reflex testing according to haemogram results for analytical tests ordered to investigate anaemia. METHODS In 2020, a new request for 'initial study of anaemia' was created in three primary care pilot centres for suspected anaemia or new anaemias. A haemogram was ordered and the remainder of the tests were created in a reflex manner according to an algorithm integrated in the laboratory information system that also generates a comment that is completed and validated by a haematologist. The demand for tests was evaluated over three time periods. RESULTS Of 396 requests, anaemia was detected in 80 (20.2%), with 26 microcytic anaemias (6.57%), 20 iron deficiency anaemias, 41 (10.3%) normocytic anaemias and 13 macrocytic anaemias (3.28%); 4 with folate deficiency; and 1 haemolytic anaemia. No haematological diseases were detected. Twenty-four (6.06%) cases exhibited microcytosis/hypochromia without anaemia, 12 of which exhibited iron deficiency. Four young women exhibiting within-limit haemoglobin levels had iron deficiency. There were 56 (14.1%) cases of macrocytosis without anaemia.With the new profile of 'initial study of anaemia', the demand for tests was reduced and was significantly lower than in the remainder of primary centres for iron, transferrin, ferritin, vitamin B12 and folate. CONCLUSIONS A new profile of 'initial study of anaemia' in the request form with algorithms integrated in the laboratory information system enabled submission of orders and decreased the demand for unnecessary iron, transferrin, ferritin, vitamin B12 and folate tests.
Collapse
Affiliation(s)
- J R Furundarena
- Hematology Laboratory, Donostia University Hospital Aranzazu Building, San Sebastian, País Vasco, Spain
| | - Alasne Uranga
- Hematology Laboratory, Donostia University Hospital Aranzazu Building, San Sebastian, País Vasco, Spain
| | - Carmen González
- Hematology Laboratory, Donostia University Hospital Aranzazu Building, San Sebastian, País Vasco, Spain
| | - Bruno Martínez
- Hematology Laboratory, Donostia University Hospital Aranzazu Building, San Sebastian, País Vasco, Spain
| | - June Iriondo
- Hematology Laboratory, Donostia University Hospital Aranzazu Building, San Sebastian, País Vasco, Spain
| | - Laida Ondarra
- Hematology Laboratory, Donostia University Hospital Aranzazu Building, San Sebastian, País Vasco, Spain
| | - Amaia Arambarri
- Hematology Laboratory, Donostia University Hospital Aranzazu Building, San Sebastian, País Vasco, Spain
| | - Ricardo San Vicente
- Hematology Laboratory, Donostia University Hospital Aranzazu Building, San Sebastian, País Vasco, Spain
| | - Cristina Sarasqueta
- Hematology Laboratory, Biodonostia Health Research Institute, Donostia-San Sebastian, Guipuzcoa, Spain
| | - Clara Lombardi
- Hematology Laboratory, Donostia University Hospital Aranzazu Building, San Sebastian, País Vasco, Spain
| | - Ane Altuna
- Hematology Laboratory, Donostia University Hospital Aranzazu Building, San Sebastian, País Vasco, Spain
| | - Nicolas Rois
- Hematology Laboratory, Donostia University Hospital Aranzazu Building, San Sebastian, País Vasco, Spain
| |
Collapse
|
5
|
Del Amo Del Arco N, Márquez Liétor E, Ramos Corral R, Guillén Santos R, Bernabeu Andreu FA, Cava Valenciano F. [Effectiveness of an intervention to improve demand management of laboratory tests related to anaemia in primary care]. J Healthc Qual Res 2020; 35:291-296. [PMID: 32718869 DOI: 10.1016/j.jhqr.2019.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 12/16/2019] [Accepted: 12/21/2019] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To evaluate the appropriateness oflaboratory test requests for the diagnosis and monitoring of anaemia in Primary Care. As a secondary objective, a decrease in variability was sought byunifying the test profile performed. MATERIAL AND METHODS A decision algorithm based on scientific evidence for test requests related to anaemia in Primary Care was implemented, so that the profile of tests performed is conditioned by haemoglobin results and mean corpuscular volume. A multidisciplinary laboratory-Primary Care team was created for the design, execution and evaluation of the results obtained. In addition, there was computer support for the development and inclusion of the rules in the laboratory and Primary Care computer systems. RESULTS Through the directed algorithm, the necessary tests for the diagnosis and follow-up of anaemia were performed sequentially, even so this meant an average monthly decrease in the number of tests of 70% for folic acid, 66% for vitamin B12, 92% for transferrin, 43% foriron and 42% for ferritin. It was also possible to unify the profile of tests performed, regardless of the centre of origin. CONCLUSIONS Better use of the biochemical tests related to anaemia was achieved, since only the necessary tests for the patient were performed. Variability is reduced by unifying the request profile in all centres.
Collapse
Affiliation(s)
- N Del Amo Del Arco
- Servicio de Análisis Clínicos, Laboratorio Clínico Central de la Comunidad de Madrid, Hospital Infanta Sofía, San Sebastián de los Reyes (Madrid), España.
| | - E Márquez Liétor
- Servicio de Análisis Clínicos, Laboratorio Clínico Central de la Comunidad de Madrid, Hospital Infanta Sofía, San Sebastián de los Reyes (Madrid), España
| | - R Ramos Corral
- Servicio de Análisis Clínicos, Laboratorio Clínico Central de la Comunidad de Madrid, Hospital Infanta Sofía, San Sebastián de los Reyes (Madrid), España
| | - R Guillén Santos
- Servicio de Análisis Clínicos, Laboratorio Clínico Central de la Comunidad de Madrid, Hospital Infanta Sofía, San Sebastián de los Reyes (Madrid), España
| | - F A Bernabeu Andreu
- Servicio de Análisis Clínicos, Hospital Puerta de Hierro, Majadahonda (Madrid), España
| | - F Cava Valenciano
- Servicio de Análisis Clínicos, Laboratorio Clínico Central de la Comunidad de Madrid, Hospital Infanta Sofía, San Sebastián de los Reyes (Madrid), España
| |
Collapse
|
6
|
van Laar SA, Gombert-Handoko KB, Guchelaar HJ, Zwaveling J. An Electronic Health Record Text Mining Tool to Collect Real-World Drug Treatment Outcomes: A Validation Study in Patients With Metastatic Renal Cell Carcinoma. Clin Pharmacol Ther 2020; 108:644-652. [PMID: 32575147 PMCID: PMC7484987 DOI: 10.1002/cpt.1966] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 06/15/2020] [Indexed: 12/28/2022]
Abstract
Real‐world evidence can close the inferential gap between marketing authorization studies and clinical practice. However, the current standard for real‐world data extraction from electronic health records (EHRs) for treatment evaluation is manual review (MR), which is time‐consuming and laborious. Clinical Data Collector (CDC) is a novel natural language processing and text mining software tool for both structured and unstructured EHR data and only shows relevant EHR sections improving efficiency. We investigated CDC as a real‐world data (RWD) collection method, through application of CDC queries for patient inclusion and information extraction on a cohort of patients with metastatic renal cell carcinoma (RCC) receiving systemic drug treatment. Baseline patient characteristics, disease characteristics, and treatment outcomes were extracted and these were compared with MR for validation. One hundred patients receiving 175 treatments were included using CDC, which corresponded to 99% with MR. Calculated median overall survival was 21.7 months (95% confidence interval (CI) 18.7–24.8) vs. 21.7 months (95% CI 18.6–24.8) and progression‐free survival 8.9 months (95% CI 5.4–12.4) vs. 7.6 months (95% CI 5.7–9.4) for CDC vs. MR, respectively. Highest F1‐score was found for cancer‐related variables (88.1–100), followed by comorbidities (71.5–90.4) and adverse drug events (53.3–74.5), with most diverse scores on international metastatic RCC database criteria (51.4–100). Mean data collection time was 12 minutes (CDC) vs. 86 minutes (MR). In conclusion, CDC is a promising tool for retrieving RWD from EHRs because the correct patient population can be identified as well as relevant outcome data, such as overall survival and progression‐free survival.
Collapse
Affiliation(s)
- Sylvia A van Laar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kim B Gombert-Handoko
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Juliëtte Zwaveling
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
7
|
Mrazek C, Simundic AM, Salinas M, von Meyer A, Cornes M, Bauçà JM, Nybo M, Lippi G, Haschke-Becher E, Keppel MH, Oberkofler H, Felder TK, Cadamuro J. Inappropriate use of laboratory tests: How availability triggers demand - Examples across Europe. Clin Chim Acta 2020; 505:100-107. [PMID: 32084382 DOI: 10.1016/j.cca.2020.02.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 02/17/2020] [Accepted: 02/17/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The appropriate use of laboratory diagnostics is increasingly at stake. The aim of this study was to depict some paradigmatic examples of under- and overutilization, as well as possible solutions across Europe. METHODS We collected six examples from five European countries where a rise or decline of orders for specific laboratory parameters was observed after organizational changes but without evidence of changes in patient collective characteristics as source of this variation. RESULTS The collected examples were the following: 1-Germany) Switch from a Brain-Natriuretic-Peptide assay to NT-pro Brain-Natriuretic-Peptide assay, resulting in a 374% increase in these analytics; 2-Spain) Implementation of a gatekeeping strategy in tumor marker diagnostics, resulting in a 15-61% reduction of these diagnostics; 3-Croatia) Stepwise elimination of creatine-kinase-MB assay from the laboratory portfolio; 4-UK) Removal of γ-glutamyl transferase from a "liver function" profile, resulting in 82% reduction of orders; 5-Austria) Implementation of a new device for rapid Influenza-RNA detection, resulting in a 450% increase of Influenza testing; 6-Spain) Insourcing of 1,25-(OH)2-Vitamin D measurements, leading to a 378% increase of these analyses. CONCLUSION The six paradigmatic examples described in this manuscript show that availability of laboratory resources may considerably catalyze the demand, thus underscoring that inappropriate use of laboratory resources may be commonplace in routine laboratories all across Europe and most probably beyond. They also demonstrate that the application of simple strategies may assist in overcoming this issue. We believe that laboratory specialists need to refocus on the extra-analytical parts of the testing process and engage more in interdisciplinary patient-care.
Collapse
Affiliation(s)
- Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Ana-Maria Simundic
- Department of Medical Laboratory Diagnostics, University Hospital Sveti Duh, Zagreb, Croatia; Faculty of Pharmacy and Biochemistry, University of Zagreb, Croatia
| | - Maria Salinas
- Clinical Laboratory, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Alexander von Meyer
- Institute of Laboratory Medicine, Kliniken Nordoberpfalz AG and Klinikum St. Marien, Weiden and Amberg, Germany
| | - Michael Cornes
- Biochemistry Department, Worcester Acute Hospitals NHS Trust, Worcester, UK
| | - Josep Miquel Bauçà
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Spain
| | - Mads Nybo
- Dept. of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | | | - Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Hannes Oberkofler
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Thomas K Felder
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria.
| |
Collapse
|
8
|
Ibarz M, Cadamuro J, Sumarac Z, Guimaraes JT, Kovalevskaya S, Nybo M, Cornes MP, Vermeersch P, Simundic AM, Lippi G. Clinicians' and laboratory medicine specialists' views on laboratory demand management: a survey in nine European countries. ACTA ACUST UNITED AC 2020; 8:111-119. [PMID: 31990661 DOI: 10.1515/dx-2019-0081] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/05/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Laboratory tests are an essential aspect of current medical practice and their use has grown exponentially. Several studies however have demonstrated inappropriate use of laboratory testing. This inappropriateness can lead to delayed or wrong diagnosis, negatively impacting patient safety and an increase in health care expenditure. The aim of the present small-scale survey was to obtain information on the current status of demand management in European laboratories, as well as the opinions of laboratory and clinical professionals in this regard. METHODS Two surveys were developed, one for laboratory specialists and one for clinicians, covering information on current use, knowledge and opinions on the possible impact of different demand management strategies on patient outcome and health care costs. Additionally, we asked for the current state and willingness on collaboration of laboratory specialists and clinicians. RESULTS One hundred and fifty responses, 72 laboratory specialists and 78 clinicians, from nine countries were received. Developing local ordering protocols/profiles in collaboration with clinicians was the most used strategy (80.3% of laboratories). Of clinicians, 85.6% considered measures to ensure appropriate use of tests necessary and 100% were interested in advice/information about their indication. Of the laboratory specialists 97.2% were either already participating or willing to participate in multidisciplinary groups on the appropriateness of test demand as were 60.3% of clinicians, and 85.9% of clinicians were interested in attending activities about laboratory test demand management. CONCLUSIONS The results of our survey show that tools to improve the appropriate use of laboratory tests are already regularly used today. Laboratory medicine specialists as well as clinicians are willing to undertake additional shared activities aimed at improving patient-centered laboratory diagnostic workup.
Collapse
Affiliation(s)
- Mercedes Ibarz
- Department of Clinical Laboratory, University Hospital Arnau de Vilanova, IRBLleida, Rovira Roure 80, 25198 Lleida, Spain
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Zorica Sumarac
- Center for Medical Biochemistry, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Pharmacy, Novi Sad, Serbia
| | - Joao Tiago Guimaraes
- Department of Clinical Pathology, Sao Joao Hospital Center, University of Porto, Porto, Portugal.,Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal.,EPIUnit, Institute of Public Health, University of Porto, Porto, Portugal
| | - Svetlana Kovalevskaya
- Clinical Laboratory Diagnostic Department with Course of Molecular Medicine, 1st Pavlov State Medical University, St-Petersburg, Russia
| | - Mads Nybo
- Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Michael P Cornes
- Department of Clinical Biochemistry, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Pieter Vermeersch
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Ana-Maria Simundic
- Department of Medical Laboratory Diagnostics, Clinical Hospital "Sveti Duh", Zagreb, Croatia
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| |
Collapse
|
9
|
Katzman BM, Karon BS. Test Utilization Proposal for Reflex Bilirubin Testing: Why Order Two Tests When One Will Do? J Appl Lab Med 2020; 6:980-984. [PMID: 33454760 DOI: 10.1093/jalm/jfaa211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/20/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Reflex testing algorithms are effective tools to reduce unnecessary laboratory testing. Direct (conjugated) bilirubin (DB) and total bilirubin (TB) are often ordered together at our institution. Therefore, the objective of our study was to evaluate the potential impact of performing reflex testing for DB when TB is elevated. METHODS We performed a retrospective review of test orders (patients ≥18 years of age) for DB, TB, or for both DB and TB on the same accession number received in our stat laboratory from January through April 2017. The orders were binned into 4 categories depending on the results from each individual test: (a) DB normal and TB normal, (b) DB normal and TB high, (c) DB high and TB normal, and (d) DB high and TB high. The percentage of orders and median (range) test result for each category was calculated. RESULTS During the months evaluated, a total of 4828 stat orders were placed for DB, TB, or both DB and TB. A total of 4296 stat orders (89%) were placed with both DB and TB on the same accession number for 4158 unique patients. Of those orders, the vast majority of tests (87.3%) contained normal results for both analytes; only 12.7% of orders contained ≥1 abnormal result. CONCLUSIONS The majority of all bilirubin tests ordered stat for emergency department and hospitalized patients have values within the reference interval. Consequently, if reflex testing were executed on elevated TB, a large number of DB tests could be avoided.
Collapse
Affiliation(s)
- Brooke M Katzman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Brad S Karon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
10
|
Gouzi F, Hédon C, Blervaque L, Passerieux E, Kuster N, Pujol T, Mercier J, Hayot M. Interactive whiteboard use in clinical reasoning sessions to teach diagnostic test ordering and interpretation to undergraduate medical students. BMC MEDICAL EDUCATION 2019; 19:424. [PMID: 31729989 PMCID: PMC6858719 DOI: 10.1186/s12909-019-1834-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 10/03/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Over-testing of patients is a significant problem in clinical medicine that can be tackled by education. Clinical reasoning learning (CRL) is a potentially relevant method for teaching test ordering and interpretation. The feasibility might be improved by using an interactive whiteboard (IWB) during the CRL sessions to enhance student perceptions and behaviours around diagnostic tests. Overall, IWB/CRL could improve their skills. METHODS Third-year undergraduate medical students enrolled in a vertically integrated curriculum were randomized into two groups before clinical placement in either a respiratory disease or respiratory physiology unit: IWB-based CRL plus clinical mentoring (IWB/CRL + CM: n = 40) or clinical mentoring only (CM-only: n = 40). Feasibility and learning outcomes were assessed. In addition, feedback via questionnaire of the IWB students and their classmates (n = 233) was compared. RESULTS Analyses of the IWB/CRL sessions (n = 40, 27 paperboards) revealed that they met validated learning objectives. Students perceived IWB as useful and easy to use. After the IWB/CRL + CM sessions, students mentioned more hypothesis-based indications in a test ordering file (p < 0.001) and looked for more nonclinical signs directly on raw data tests (p < 0.01) compared with students in the CM-only group. Last, among students who attended pre- and post-assessments (n = 23), the number of diagnostic tests ordered did not change in the IWB/CRL + CM group (+ 7%; p = N.S), whereas it increased among CM-only students (+ 30%; p < 0.001). Test interpretability increased significantly in the IWB/CRL + CM group (from 4.7 to 37.2%; p < 0.01) but not significantly in the CM-only group (from 2.4 to 9.8%; p = 0.36). CONCLUSIONS Integrating IWB into CRL sessions is feasible to teach test ordering and interpretation to undergraduate students. Moreover, student feedback and prospective assessment suggested a positive impact of IWB/CRL sessions on students' learning.
Collapse
Affiliation(s)
- Fares Gouzi
- PhyMedExp, INSERM U1046, CNRS UMR 9214, Montpellier University HospitalMontpellier University, F-34295, Montpellier, France.
- French College of University Teachers in Health, (College Français des Enseignants Universitaires de Physiologie en Santé - CFEUPS), Montpellier, France.
| | - Christophe Hédon
- PhyMedExp, INSERM U1046, CNRS UMR 9214, Montpellier University HospitalMontpellier University, F-34295, Montpellier, France
- French College of University Teachers in Health, (College Français des Enseignants Universitaires de Physiologie en Santé - CFEUPS), Montpellier, France
| | - Léo Blervaque
- PhyMedExp, INSERM U1046, CNRS UMR 9214, Montpellier University HospitalMontpellier University, F-34295, Montpellier, France
| | - Emilie Passerieux
- PhyMedExp, INSERM U1046, CNRS UMR 9214, Montpellier University HospitalMontpellier University, F-34295, Montpellier, France
| | - Nils Kuster
- PhyMedExp, INSERM U1046, CNRS UMR 9214, Montpellier University HospitalMontpellier University, F-34295, Montpellier, France
- Laboratoire d'Innovation Pédagogique et de Création d'Outils Multimédia (LIPCOM), Montpellier University, Montpellier, France
| | - Thierry Pujol
- Laboratoire d'Innovation Pédagogique et de Création d'Outils Multimédia (LIPCOM), Montpellier University, Montpellier, France
| | - Jacques Mercier
- PhyMedExp, INSERM U1046, CNRS UMR 9214, Montpellier University HospitalMontpellier University, F-34295, Montpellier, France
- French College of University Teachers in Health, (College Français des Enseignants Universitaires de Physiologie en Santé - CFEUPS), Montpellier, France
| | - Maurice Hayot
- PhyMedExp, INSERM U1046, CNRS UMR 9214, Montpellier University HospitalMontpellier University, F-34295, Montpellier, France
- French College of University Teachers in Health, (College Français des Enseignants Universitaires de Physiologie en Santé - CFEUPS), Montpellier, France
| |
Collapse
|
11
|
Cadamuro J, Ibarz M, Cornes M, Nybo M, Haschke-Becher E, von Meyer A, Lippi G, Simundic AM. Managing inappropriate utilization of laboratory resources. ACTA ACUST UNITED AC 2019; 6:5-13. [PMID: 30096052 DOI: 10.1515/dx-2018-0029] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 06/27/2018] [Indexed: 12/29/2022]
Abstract
Background The inappropriate use of laboratory resources, due to excessive number of tests not really necessary for patient care or by failure to order the appropriate diagnostic test, may lead to wrong, missed or delayed diagnosis, thus potentially jeopardizing patient safety. It is estimated that 5-95% of tests are currently used inappropriately, depending on the appropriateness criteria, thus significantly contributing to the potential of generating medical errors, the third leading cause of death in the US. Content In this review, we discuss the reasons as well as the medical and financial consequences of inappropriate utilization of laboratory tests. We then provide demand management (DM) tools as a means for overcoming this issue and also discuss their benefits, challenges, limitations and requirements for successful implementation. Summary and outlook When based on current evidence, adapted to local conditions and developed in close collaboration with clinicians, DM is a reasonable strategy for progressing toward better management of over- and underuse of laboratory resources.
Collapse
Affiliation(s)
- Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Müllner Hauptstr. 48, 5020 Salzburg, Austria, Phone: +43-57255-57263, Fax: +43-57255-23199
| | - Mercedes Ibarz
- Laboratory Medicine Department, University Hospital Arnau de Vilanova, IRBLleida, Lleida, Spain
| | - Michael Cornes
- Clinical Chemistry Department, Worcester Acute Hospitals NHS Trust, Worcester, UK
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | | | - Alexander von Meyer
- Institute of Laboratory Medicine, Kliniken Nordoberpfalz AG and Klinikum St. Marien, Weiden and Amberg, Germany
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Ana-Maria Simundic
- Department of Medical Laboratory Diagnostics, University Hospital "Sveti Duh", Zagreb, Croatia
| |
Collapse
|
12
|
Abstract
Abstract
Current efforts focusing on better defining the prevalence of diagnostic errors, their causes and remediation strategies should address the role of laboratory testing and its contribution to high-quality care as well as a possible source of diagnostic errors. Data collected in the last few years highlight the vulnerability of extra-analytical phases of the testing cycle and the need for programs aiming to improve all steps of the process. Further studies have clarified the nature of laboratory-related errors, namely the evidence that both system-related and cognitive factors account for most errors in laboratory medicine. Technology developments are effective in decreasing the rates of system-related errors but organizational issues play a fundamental role in assuring a real improvement in quality and safety in laboratory processes. Educational interventions as well as technology-based interventions have been proposed to reduce the risk of cognitive errors. However, to reduce diagnostic errors and improve patient safety, clinical laboratories have to embark on a paradigmatic shift restoring the nature of laboratory services as an integral part of the diagnostic and therapy process.
Collapse
Affiliation(s)
- Mario Plebani
- Department of Laboratory Medicine , University-Hospital of Padova , Padova 35128 , Italy
| |
Collapse
|
13
|
Gao ZH. Chairing an academic pathology department: challenges and opportunities. J Clin Pathol 2018; 72:206-212. [PMID: 29705737 DOI: 10.1136/jclinpath-2017-204963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/08/2018] [Accepted: 04/10/2018] [Indexed: 11/04/2022]
Abstract
Understanding the heterogeneity of departmental structure, service model and job descriptions for different pathology chairs, this review highlights some common challenges and opportunities facing most pathology chairs in academic institutions. The review is divided into three sections: clinical service, academic development and administration. The views and insights from this review may provide guidance to new chairs and emerging leaders in pathology and other relevant specialties.
Collapse
Affiliation(s)
- Zu-Hua Gao
- Department of Pathology, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
14
|
Zemlin AE. Errors in the Extra-Analytical Phases of Clinical Chemistry Laboratory Testing. Indian J Clin Biochem 2018; 33:154-162. [PMID: 29651205 PMCID: PMC5891449 DOI: 10.1007/s12291-017-0657-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 04/28/2017] [Indexed: 01/06/2023]
Abstract
The total testing process consists of various phases from the pre-preanalytical to the post-postanalytical phase, the so-called brain-to-brain loop. With improvements in analytical techniques and efficient quality control programmes, most laboratory errors now occur in the extra-analytical phases. There has been recent interest in these errors with numerous publications highlighting their effect on service delivery, patient care and cost. This interest has led to the formation of various working groups whose mission is to develop standardized quality indicators which can be used to measure the performance of service of these phases. This will eventually lead to the development of external quality assessment schemes to monitor these phases in agreement with ISO15189:2012 recommendations. This review focuses on potential errors in the extra-analytical phases of clinical chemistry laboratory testing, some of the studies performed to assess the severity and impact of these errors and processes that are in place to address these errors. The aim of this review is to highlight the importance of these errors for the requesting clinician.
Collapse
Affiliation(s)
- Annalise E. Zemlin
- Division of Chemical Pathology, National Health Laboratory Service (NHLS) and University of Stellenbosch, Tygerberg Hospital, Cape Town, 7505 South Africa
| |
Collapse
|
15
|
Livingston M, Kalansooriya A, Hartland A, Fryer AA, Gupta J, Heald AH. Reduction of unnecessary N-terminal pro-brain natriuretic peptide (NT-proBNP) tests: A further lesson in demand management. Int J Clin Pract 2018; 72:e13071. [PMID: 29878475 DOI: 10.1111/ijcp.13071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | | | - Andrew Hartland
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - Anthony A Fryer
- Department of Clinical Biochemistry, University Hospitals of North Midlands, Stoke-on-Trent, UK
- Institute of Applied Clinical Sciences, Keele University, Staffordshire, UK
| | - Jayant Gupta
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| |
Collapse
|
16
|
Rubinstein M, Hirsch R, Bandyopadhyay K, Madison B, Taylor T, Ranne A, Linville M, Donaldson K, Lacbawan F, Cornish N. Effectiveness of Practices to Support Appropriate Laboratory Test Utilization: A Laboratory Medicine Best Practices Systematic Review and Meta-Analysis. Am J Clin Pathol 2018; 149:197-221. [PMID: 29471324 PMCID: PMC6016712 DOI: 10.1093/ajcp/aqx147] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objectives To evaluate the effectiveness of practices used to support appropriate clinical laboratory test utilization. Methods This review followed the Centers for Disease Control and Prevention (CDC) Laboratory Medicine Best Practices A6 cycle method. Eligible studies assessed one of the following practices for effect on outcomes relating to over- or underutilization: computerized provider order entry (CPOE), clinical decision support systems/tools (CDSS/CDST), education, feedback, test review, reflex testing, laboratory test utilization (LTU) teams, and any combination of these practices. Eligible outcomes included intermediate, systems outcomes (eg, number of tests ordered/performed and cost of tests), as well as patient-related outcomes (eg, length of hospital stay, readmission rates, morbidity, and mortality). Results Eighty-three studies met inclusion criteria. Fifty-one of these studies could be meta-analyzed. Strength of evidence ratings for each practice ranged from high to insufficient. Conclusion Practice recommendations are made for CPOE (specifically, modifications to existing CPOE), reflex testing, and combined practices. No recommendation for or against could be made for CDSS/CDST, education, feedback, test review, and LTU. Findings from this review serve to inform guidance for future studies.
Collapse
Affiliation(s)
| | | | | | | | - Thomas Taylor
- Centers for Disease Control and Prevention, Atlanta, GA
| | - Anne Ranne
- Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | - Nancy Cornish
- Centers for Disease Control and Prevention, Atlanta, GA
| |
Collapse
|
17
|
Sriram KB, Fountain Z, Hockenhull J, Zagami D. Evaluating the appropriateness of hospital doctors' requests for pulmonary function tests beyond basic spirometry: results from a prospective observational study. Hosp Pract (1995) 2017; 45:118-122. [PMID: 28399675 DOI: 10.1080/21548331.2017.1318033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 04/07/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Hospitalists request 'complete' pulmonary function tests (PFTs), typically comprising of spirometry, diffusion capacity of the lung for carbon monoxide (DLCO) and absolute lung volumes (ALVs), the results of which assist in the management of patients with respiratory disorders. Recently, concerns have been raised about over-requesting of 'complete' PFTs, but there is a paucity of information on the proportion of requests that can be considered clinically inappropriate. This study prospectively evaluated the 'complete' PFTs requested in a hospital service and assessed the impact of medical review of the requests. METHODS A six-month prospective study on requests to two teaching hospital PFT laboratories from non-respiratory doctors was undertaken. Requests at one laboratory underwent review by a respiratory doctor ('intervention laboratory') while requests at the second laboratory were not reviewed ('control laboratory'). The appropriateness of requests was measured against pre-specified criteria. RESULTS PFT requests for 335 subjects were included in the study. In the intervention laboratory, 8 of 110 ALV and 122 of 134 DLCO requests fulfilled pre-specified criteria for appropriate test indications. Fewer ALV (7% vs. 100%, p < 0.001) and DLCO tests (91% vs. 100%, p = 0.031) could have been performed in the intervention laboratory compared to the control laboratory. CONCLUSION A considerable proportion of 'complete' PFT requests from non-respiratory hospital doctors may be unwarranted. Using a simple screening method, the number of unnecessary PFTs could be reduced, resulting in substantial time and cost savings for hospital PFT laboratories.
Collapse
Affiliation(s)
- Krishna Bajee Sriram
- a Department of Respiratory Medicine , Gold Coast University Hospital , Southport , Australia
- b School of Medicine, Parklands Drive , Griffith University , Southport , Australia
| | - Zoe Fountain
- a Department of Respiratory Medicine , Gold Coast University Hospital , Southport , Australia
| | - Jessica Hockenhull
- a Department of Respiratory Medicine , Gold Coast University Hospital , Southport , Australia
| | - Debbie Zagami
- a Department of Respiratory Medicine , Gold Coast University Hospital , Southport , Australia
| |
Collapse
|
18
|
Rudolf JW, Dighe AS, Coley CM, Kamis IK, Wertheim BM, Wright DE, Lewandrowski KB, Baron JM. Analysis of Daily Laboratory Orders at a Large Urban Academic Center: A Multifaceted Approach to Changing Test Ordering Patterns. Am J Clin Pathol 2017; 148:128-135. [PMID: 28898984 DOI: 10.1093/ajcp/aqx054] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We sought to address concerns regarding recurring inpatient laboratory test order practices (daily laboratory tests) through a multifaceted approach to changing ordering patterns. METHODS We engaged in an interdepartmental collaboration to foster mindful test ordering through clinical policy creation, electronic clinical decision support, and continuous auditing and feedback. RESULTS Annualized daily order volumes decreased from approximately 25,000 to 10,000 during a 33-month postintervention review. This represented a significant change from preintervention order volumes (95% confidence interval, 0.61-0.64; P < 10-16). Total inpatient test volumes were not affected. CONCLUSIONS Durable changes to inpatient order practices can be achieved through a collaborative approach to utilization management that includes shared responsibility for establishing clinical guidelines and electronic decision support. Our experience suggests auditing and continued feedback are additional crucial components to changing ordering behavior. Curtailing daily orders alone may not be a sufficient strategy to reduce in-laboratory costs.
Collapse
Affiliation(s)
| | - Anand S Dighe
- Departments of Pathology
- Harvard Medical School, Boston, MA
| | - Christopher M Coley
- Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
| | - Irina K Kamis
- Information Systems, Partners HealthCare, Boston, MA
| | - Bradley M Wertheim
- Harvard Medical School, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Douglas E Wright
- Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
| | | | - Jason M Baron
- Departments of Pathology
- Harvard Medical School, Boston, MA
| |
Collapse
|
19
|
Pema AK, Kiabilua O, Pillay TS. Demand management by electronic gatekeeping of test requests does not influence requesting behaviour or save costs dramatically. Ann Clin Biochem 2017; 55:244-253. [DOI: 10.1177/0004563217707980] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Healthcare budgets face constraints, and laboratories have developed strategies to adapt to the concomitant increase in workload. Some of the tests (7.4%) may be attributed to unnecessary repeat testing. Electronic gatekeeping has been implemented at selected laboratories in South Africa to limit unnecessary repeat testing. We performed a study of chemistry tests subjected to electronic gatekeeping to determine its effectiveness as a sustainable demand management tool. Methods A 22-month retrospective study of chemistry test requests at a Pretoria hospital was performed. Tests violating electronic gatekeeping rules were rejected upon registration before analysis, and cost-savings were estimated from electronic gatekeeping-held tests. The impact of electronic gatekeeping on the test requesting pattern of clinicians was derived from the percentage cost of electronic gatekeeping-held tests. Results The total savings generated from electronic gatekeeping test rejections amounted to $84,380. Greatest savings were generated from high-cost tests: glycated haemoglobin ($14,139), urea ($8661) and thyroid-stimulating hormone ($7514). The average number of electronic gatekeeping-held tests as a percentage of their total requested number over 22 months was 3.18%. Discussion The savings from electronic gatekeeping-held tests were not as dramatic as anticipated, but were modest and may have some impact in a cost-constrained setting. Electronic gatekeeping was concluded not to have a substantial effect on the clinician test requesting pattern, demonstrated by the largely unchanged monthly percentage of electronic gatekeeping-held tests. As a solitary demand management strategy, electronic gatekeeping does not appear to be as effective as anticipated or as demonstrated in other studies.
Collapse
Affiliation(s)
- Aarti K Pema
- Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria and National Health Laboratory Service, Tshwane Academic Division, Pretoria, South Africa
| | - Olivia Kiabilua
- Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria and National Health Laboratory Service, Tshwane Academic Division, Pretoria, South Africa
| | - Tahir S Pillay
- Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria and National Health Laboratory Service, Tshwane Academic Division, Pretoria, South Africa
- Division of Chemical Pathology, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
20
|
Livingston M, Kalansooriya A, Heald AH. Clinical appropriateness of C-reactive protein requests: Reduction in unnecessary repeats. Int J Clin Pract 2017; 71. [PMID: 28371018 DOI: 10.1111/ijcp.12941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | | | - Adrian H Heald
- Department of Endocrinology, Leighton Hospital, Crewe, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| |
Collapse
|
21
|
Inal TC, Goruroglu Ozturk O, Kibar F, Cetiner S, Matyar S, Daglioglu G, Yaman A. Lean six sigma methodologies improve clinical laboratory efficiency and reduce turnaround times. J Clin Lab Anal 2017; 32. [PMID: 28205271 DOI: 10.1002/jcla.22180] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 01/21/2017] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Organizing work flow is a major task of laboratory management. Recently, clinical laboratories have started to adopt methodologies such as Lean Six Sigma and some successful implementations have been reported. This study used Lean Six Sigma to simplify the laboratory work process and decrease the turnaround time by eliminating non-value-adding steps. METHODS The five-stage Six Sigma system known as define, measure, analyze, improve, and control (DMAIC) is used to identify and solve problems. The laboratory turnaround time for individual tests, total delay time in the sample reception area, and percentage of steps involving risks of medical errors and biological hazards in the overall process are measured. RESULTS The pre-analytical process in the reception area was improved by eliminating 3 h and 22.5 min of non-value-adding work. Turnaround time also improved for stat samples from 68 to 59 min after applying Lean. Steps prone to medical errors and posing potential biological hazards to receptionists were reduced from 30% to 3%. CONCLUSION Successful implementation of Lean Six Sigma significantly improved all of the selected performance metrics. This quality-improvement methodology has the potential to significantly improve clinical laboratories.
Collapse
Affiliation(s)
- Tamer C Inal
- Department of Medical Biochemistry, Medical Faculty, Çukurova University, Adana, Turkey
| | | | - Filiz Kibar
- Department of Medical Microbiology, Medical Faculty, Çukurova University, Adana, Turkey
| | - Salih Cetiner
- Hospital Central Laboratory, Medical Faculty, Çukurova University, Adana, Turkey
| | - Selcuk Matyar
- Medical Biochemistry Laboratory, Adana Numune Teaching Hospital, Adana, Turkey
| | - Gulcin Daglioglu
- Hospital Central Laboratory, Medical Faculty, Çukurova University, Adana, Turkey
| | - Akgun Yaman
- Department of Medical Microbiology, Medical Faculty, Çukurova University, Adana, Turkey
| |
Collapse
|
22
|
van der Horst A, van de Wijngaart DJ, Scherrenburg J, van Dijk N, Janssens PM. Practical motives are prominent in test-ordering in the Emergency Department. ACTA ACUST UNITED AC 2017; 55:1523-1529. [DOI: 10.1515/cclm-2016-1092] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 01/05/2017] [Indexed: 11/15/2022]
Abstract
AbstractBackground:Laboratory test ordering under time pressure may impact test-ordering behavior.Methods:To investigate the test-ordering behavior of doctors working under such pressure, we designed a questionnaire for trainees and staff in the Emergency Department (ED). This questionnaire addressed topics such as necessity of requested tests, time spent on ordering, costs and availability of tests, and the time of the day. We hypothesized that ordering behavior would be guided predominantly by the medical need of tests and aimed at identifying practical motives that also have an effect.Results:Remarkably, two-third of the respondents (67%) admitted that tests were ordered that would not influence treatment policy directly and 48% of the doctors stated that tests were ordered that do not impact treatment at all. The frequency of such orders was “sometimes” and “frequent” in a 50:50 ratio. Interestingly, tests that could prove relevant at a later stage are often ordered simultaneously to reduce burden on the patient. None of the respondents spent more than 3 min on the ordering process and very few (8%) desired more time for ordering. Most respondents (81%) declared to have limited knowledge of the costs of laboratory tests. A random survey covering four tests confirmed this. Generally, turnaround time did influence ordering behavior while time of the day did not.Conclusions:In conclusion, doctors in an ED – besides first of all medical motives – heavily exploit practical (non-medical) reasoning for laboratory test ordering, e.g. taking availability of tests into account and ordering non-immediate tests.
Collapse
|
23
|
Utilization Management in a Large Community Hospital. UTILIZATION MANAGEMENT IN THE CLINICAL LABORATORY AND OTHER ANCILLARY SERVICES 2017. [PMCID: PMC7123185 DOI: 10.1007/978-3-319-34199-6_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The utilization management of laboratory tests in a large community hospital is similar to academic and smaller community hospitals. There are numerous factors that influence laboratory utilization. Outside influences like hospitals buying physician practices, increasing numbers of hospitalists, and hospital consolidation will influence the number and complexity of the test menu that will need to be monitored for over and/or under utilization in the central laboratory and reference laboratory. CLIA’88 outlines the four test categories including point-of-care testing (waived) and provider-performed microscopy that need laboratory test utilization management. Incremental cost analysis is the most efficient method for evaluating utilization reduction cost savings. Economies of scale define reduced unit cost per test as test volume increases. Outreach programs in large community hospitals provide additional laboratory tests from non-patients in physician offices, nursing homes, and other hospitals. Disruptive innovations are changing the present paradigms in clinical diagnostics, like wearable sensors, MALDI-TOF, multiplex infectious disease panels, cell-free DNA, and others. Obsolete tests need to be universally defined and accepted by manufacturers, physicians, laboratories, and hospitals, to eliminate access to their reagents and testing platforms.
Collapse
|
24
|
Sales MM, Taniguchi LU, Fonseca LAM, Ferreira-Junior M, Aguiar FJB, Sumita NM, Lichtenstein A, Duarte AJS. Laboratory Tests Ordering Pattern by Medical Residents From a Brazilian University Hospital. Am J Clin Pathol 2016; 146:694-700. [PMID: 27940426 DOI: 10.1093/ajcp/aqw188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The adequacy of laboratory test orders by medical residents is a longstanding issue. The aim of this study is to analyze the number, types, and pattern of repetition of tests ordered by medical residents. METHODS We studied all tests ordered over a 1-year period for inpatients of an internal medicine ward in a university hospital. Types, results, and repetition pattern of tests were analyzed in relation to patients' diagnoses. RESULTS We evaluated 117,666 tests, requested for 1,024 inpatients. The mean number of tests was 9.5 per day. The test repetition pattern was similar, regardless of patients' diagnoses, previous test results, or duration of stay. The probability of an abnormal result after a sequence of three normal tests was lower than 25%, regardless of the diagnosis. CONCLUSIONS Number of tests and repetition were both high, imposing costs, discomfort, and risks to patients, thus warranting further investigation.
Collapse
Affiliation(s)
- Maria M Sales
- From the Division of Clinical Pathology, Department of Pathology,
| | | | - Luiz A M Fonseca
- Department of Internal Medicine, Clinical Immunology and Allergy Service
| | - Mario Ferreira-Junior
- Department of Internal Medicine, General Practice and Propedeutic Service, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Nairo M Sumita
- From the Division of Clinical Pathology, Department of Pathology
| | - Arnaldo Lichtenstein
- Department of Internal Medicine, General Practice and Propedeutic Service, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | |
Collapse
|
25
|
Seegmiller AC, Kim AS, Mosse CA, Shaver AC, Thompson MA, Li S, Head DR, Zutter MM. Data-Driven Iterative Refinement of Bone Marrow Testing Protocols Leads to Progressive Improvement in Cytogenetic and Molecular Test Utilization. Am J Clin Pathol 2016; 146:585-593. [PMID: 27769956 DOI: 10.1093/ajcp/aqw180] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES To determine the effect of iterative refinement of standard ordering protocols on test utilization and results for bone marrow biopsy specimens. METHODS Eighteen months of test utilization and result data were used to revise the protocols that determine cytogenetic and molecular test selection on bone marrow specimens and then compared with data obtained following protocol revision. RESULTS Revision of protocols resulted in reduction in total tests and associated charges, due to a decrease in tests both concordant and discordant with the protocols. These reductions only occurred in diseases for which revisions were made and were limited to cases in which reflex testing was performed. There was an increase in the fraction of positive tests, which was also limited to reflex testing. CONCLUSIONS Data-driven iterative revision of protocols further improves test utilization and performance, while reducing cost. Analysis of testing data can be used to continuously improve test ordering decisions.
Collapse
|
26
|
McCoy RG, Van Houten HK, Ross JS, Montori VM, Shah ND. HbA1c overtesting and overtreatment among US adults with controlled type 2 diabetes, 2001-13: observational population based study. BMJ 2015; 351:h6138. [PMID: 26646052 PMCID: PMC4673101 DOI: 10.1136/bmj.h6138] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2015] [Indexed: 01/19/2023]
Abstract
STUDY QUESTION What is the extent and effect of excessive testing for glycated hemoglobin (HbA1c) among adults with controlled type 2 diabetes? METHODS A retrospective analysis of data from a national administrative claims database included commercially insured individuals in the USA, 2001-13. Study patients were aged 18 years or older, had type 2 diabetes with stable glycemic control (two consecutive tests showing HbA1c<7.0% within 24 months), did not use insulin, had no history of severe hypoglycemia or hyperglycemia, and were not pregnant. HbA1c testing frequency was measured within 24 months after the second (index) HbA1c test, and classified as guideline recommended (≤ 2 times/year), frequent (3-4 times/year), and excessive (≥ 5 times/year). Changes in treatment regimen were ascertained within three months of the index test. STUDY ANSWER AND LIMITATIONS Of 31,545 patients in the study cohort (mean age 58 years; mean index HbA1c 6.2%), HbA1c testing frequency was excessive in 6% and frequent in 55%. Despite good glycemic control at baseline, treatment was further intensified by addition of glucose lowering drugs or insulin in 8.4% of patients (comprising 13%, 9%, and 7% of those tested excessively, frequently, and per guidelines, respectively; P<0.001). Compared with guideline recommended testing, excessive testing was associated with treatment intensification (odds ratio 1.35 (95% confidence interval 1.22 to 1.50)). Excessive testing rates remained unchanged in 2001-08, but fell significantly after 2009. The odds of excessive testing was 46% lower in 2011 than in 2001-02. The study population is not representative of all US patients with type 2 diabetes because it was restricted to commercially insured adults with stable and controlled diabetes not receiving insulin treatment. The study design did not capture the underuse of HbA1c testing. WHAT THIS STUDY ADDS In this US cohort of adults with stable and controlled type 2 diabetes, more than 60% received too many HbA1c tests, a practice associated with potential overtreatment with hypoglycemic drugs. Excessive testing contributes to the growing problem of waste in healthcare and increased patient burden in diabetes management. FUNDING, COMPETING INTERESTS, DATA SHARING NDS and RGM are funded partly by the Agency for Healthcare Research and Quality (R18HS18339) and AcademyHealth Delivery System Science Fellowship (2013), respectively. No competing interests declared. Additional data are available from mccoy.rozalina@mayo.edu.
Collapse
Affiliation(s)
- Rozalina G McCoy
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic
| | - Holly K Van Houten
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic Robert D and Patricia E Kern Center for Science of Health Care Delivery, Mayo Clinic
| | - Joseph S Ross
- Section of General Internal Medicine and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven
| | - Victor M Montori
- Division of Endocrinology Metabolism and Nutrition, Department of Medicine, Mayo Clinic Knowledge and Evaluation Research Unit, Mayo Clinic
| | - Nilay D Shah
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic Optum Labs, Cambridge, MA, USA
| |
Collapse
|
27
|
Cadogan SL, Browne JP, Bradley CP, Cahill MR. The effectiveness of interventions to improve laboratory requesting patterns among primary care physicians: a systematic review. Implement Sci 2015; 10:167. [PMID: 26637335 PMCID: PMC4670500 DOI: 10.1186/s13012-015-0356-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 11/30/2015] [Indexed: 11/10/2022] Open
Abstract
Background Laboratory testing is an integral part of day-to-day primary care practice, with approximately 30 % of patient encounters resulting in a request. However, research suggests that a large proportion of requests does not benefit patient care and is avoidable. The aim of this systematic review was to comprehensively search the literature for studies evaluating the effectiveness of interventions to improve primary care physician use of laboratory tests. Methods A search of PubMed, Cochrane Library, Embase and Scopus (from inception to 09/02/14) was conducted. The following study designs were considered: systematic reviews, randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series analysis (ITSs). Studies were quality appraised using a modified version of the Effective Practice and Organisation of Care (EPOC) checklist. The population of interest was primary care physicians. Interventions were considered if they aimed to improve laboratory testing in primary care. The outcome of interest was a volume of laboratory tests. Results In total, 6,166 titles and abstracts were reviewed, followed by 87 full texts. Of these, 11 papers were eligible for inclusion in the systematic review. This included four RCTs, six CBAs and one ITS study. The types of interventions examined included education, feedback, guidelines, education with feedback, feedback with guidelines and changing order forms. The quality of included studies varied with seven studies deemed to have a low risk of bias, three with unclear risk of bias and one with high risk of bias. All but one study found significant reductions in the volume of tests following the intervention, with effect sizes ranging from 1.2 to 60 %. Due to heterogeneity, meta-analysis was not performed. Conclusions Interventions such as educational strategies, feedback and changing test order forms may improve the efficient use of laboratory tests in primary care; however, the level of evidence is quite low and the quality is poor. The reproducibility of findings from different laboratories is also difficult to ascertain from the literature. Some standardisation of both interventions and outcome measures is required to enable formal meta-analysis. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0356-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Sharon L Cadogan
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland.
| | - John P Browne
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland.
| | - Colin P Bradley
- Department of General Practice, University College Cork, Cork, Ireland.
| | - Mary R Cahill
- Department of Haematology, Cork University Hospital, Cork, Ireland.
| |
Collapse
|
28
|
Thomas RE, Vaska M, Naugler C, Turin TC. Interventions at the laboratory level to reduce laboratory test ordering by family physicians: Systematic review. Clin Biochem 2015; 48:1358-65. [PMID: 26436568 DOI: 10.1016/j.clinbiochem.2015.09.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 09/29/2015] [Accepted: 09/29/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To assess the effectiveness of interventions by laboratories and to increase rational and reduce unnecessary family physician test ordering. DESIGN AND METHODS MEDLINE [1946-present], EMBASE [1980-present], EBM Reviews [1991-present](Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, - Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Health Technology Assessment, NHS Economic Evaluation Database), PubMed [1966-present], PubMed Central [1900-present], Scopus [1960-present], Web of Science [1900-present] and CINAHL [1982-present] were searched with no language or publication limits. Non-randomised studies were assessed with the Newcastle-Ottawa scale. RESULTS The search identified 9282 titles and abstracts, 238 were read in full-text and 3 cohort and 7 before- and after-studies were included. Most focused on changing a few tests and evaluated the interventions over several months. Seven changed laboratory forms (the two largest involved 5.2 million and 3.2 million tests), one negotiated a test ordering protocol with family physicians, and two required laboratory approval. They achieved an average 35% reduction in the 19 targeted tests, with a wide range (0%-100% reduction). CONCLUSIONS Ten studies were identified which tested interventions by laboratories to reduce test ordering by family physicians, and achieved an average 35% reduction in the 19 targeted tests. The rationale for choosing specific tests for intervention was often not explained, most studies targeted a few tests for several months, the tests and test volumes differed widely across studies, no author improved the results of previous interventions or asked participants their opinions about the intervention or assessed factors impeding change.
Collapse
Affiliation(s)
- Roger E Thomas
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta T2N 4N1, Canada.
| | - Marcus Vaska
- Knowledge Resource Service, Holy Cross Centre, Room 615A, 2210 2nd St. S.W., Calgary, Alberta T2S 3C3, Canada,.
| | - Christopher Naugler
- Department of Pathology & Laboratory Medicine and Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta T2N 4N1, Canada; Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta T2N 4N1, Canada.
| | - Tanvir C Turin
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta T2N 4N1, Canada.
| |
Collapse
|
29
|
Ferraro S, Mozzi R, Panteghini M. Tumor Marker Ordering: Do Not Lose Control: A Prospective Clinical Trial. Am J Clin Pathol 2015; 144:649-58. [PMID: 26386087 DOI: 10.1309/ajcpnzapjrb3t6kk] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES In this study, we evaluated the extent of inappropriate tumor marker (TM) ordering in a secondary care setting, approximately 6 years after the introduction of local guidelines, and we identified the main factors potentially influencing clinicians when performing an inappropriate TM request. METHODS For this purpose, we regularly checked all requests containing more than two TMs. During the 21-month audit, the rate of rejected requests amounted to 3.6%. Several of those were performed for diagnostic purposes. The most frequent and inappropriately requested TMs were carcinoembryonic antigen and carbohydrate antigen 19.9. RESULTS The inappropriateness of requests appeared to be linked to the need for more education and knowledge on their clinical applicability and limitations. The clinical motivation was generally associated with patients displaying nonspecific signs/symptoms (ie, weight loss with worsening general conditions), having an incidentally positive result to some recently performed TM tests, or being tested by a TM to avoid more expensive diagnostic imaging procedures. CONCLUSIONS Our data show that real-time control and management of inappropriate requests by laboratory professionals may be relevant to increase the clinical efficacy of TM testing and useful in perspective to drive the introduction of new validated biomarkers.
Collapse
Affiliation(s)
- Simona Ferraro
- Clinical Pathology Unit, ‘Luigi Sacco’ University Hospital, and Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Roberta Mozzi
- Clinical Pathology Unit, ‘Luigi Sacco’ University Hospital, and Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Mauro Panteghini
- Clinical Pathology Unit, ‘Luigi Sacco’ University Hospital, and Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| |
Collapse
|
30
|
Using Arden Syntax Medical Logic Modules to reduce overutilization of laboratory tests for detection of bacterial infections-Success or failure? Artif Intell Med 2015; 92:43-50. [PMID: 26476896 DOI: 10.1016/j.artmed.2015.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 09/12/2015] [Accepted: 09/12/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Bacterial infections frequently cause prolonged intensive care unit (ICU) stays. Repeated measurements of the procalcitonin (PCT) biomarker are typically used for early detection and follow up of bacterial infections and sepsis, but those PCT measurements are costly. To avoid overutilization, we developed and evaluated a clinical decision support system (CDSS) in Arden Syntax which computes necessary and preventable PCT orders. METHODS The CDSS implements a rule set based on the latest PCT value, the time period since this measurement, and the PCT trend scenario. We assessed the CDSS effects on the daily rate of ordered PCT tests within a prospective study having two ON and two OFF phases in a surgical ICU. In addition, we performed interviews with the participating physicians to investigate their experience with the CDSS advice. RESULTS Prior to the deployment of the CDSS, 22% of the performed PCT tests were potentially preventable according to the rule set. During the first ON phase the daily rate of ordered PCT tests per patient decreased significantly from 0.807 to 0.662. In subsequent OFF, ON and OFF phases, however, PCT utilization reached again daily rates of 0.733, 0.803, and 0.792, respectively. The interviews demonstrated that the physicians were aware of the problem of PCT overutilization, which they primarily attributed to acute time constraints. The responders assumed that the majority of preventable measurements are indiscriminately ordered for patients during longer ICU stays. CONCLUSION We observed an 18% reduction of PCT tests within the first four weeks of CDSS support in the investigated ICU. This reduction may have been influenced by raised awareness of the overutilization problem; the extent of this influence cannot be determined in our study design. No reduction of PCT tests could be observed during the second ON phase. The physician interviews indicated that time critical ICU situations can prevent extensive reflection about the necessity of individual tests. In order to achieve an enduring effect on PCT utilization, we will have to proceed to electronic order entry.
Collapse
|
31
|
Smit I, Zemlin AE, Erasmus RT. Demand management: an audit of chemical pathology test rejections by an electronic gate-keeping system at an academic hospital in Cape Town. Ann Clin Biochem 2014; 52:481-7. [DOI: 10.1177/0004563214567688] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2014] [Indexed: 11/15/2022]
Abstract
Background Demand management is an area of laboratory activity, which is becoming increasingly important. Within the health-care system, demand management can be defined as the use of health resources to maximise its utility. Tygerberg Hospital has introduced an electronic gate-keeping system. Chemistry tests which generate the highest cost are subjected to this system and may be automatically rejected according to a set of rules. This study aimed: (1) to identify the number of chemistry tests rejected by the eGK; (2) to identify which of these rejected tests were subsequently restored and (3) to assess the impact of rejections on clinical outcome and cost-saving. Methods A retrospective audit was conducted to determine the number of chemistry tests rejected and subsequently restored over a 6-month period. The case-notes of patients for whom requested tests previously rejected had been restored were randomly selected and investigated to assess clinical impact. Any cost-saving was calculated. Results A total of 68,480 tests were subjected to gate-keeping, and 4605 tests (6.7%) were rejected while 679 (14.7%) of these were restored by the requestor phoning the laboratory after obtaining authorisation. After examining a subset of clinical notes it was found that in most cases (80%), patient care was unaffected. The total cost saved was £25,387. Conclusions The majority of the rejected tests were unnecessary and following rejection, real savings were made. Electronic gate-keeping is a simple, effective and sustainable method of demand management.
Collapse
Affiliation(s)
- Ida Smit
- Division of Chemical Pathology, Faculty of Health Sciences, National Health Laboratory Service (NHLS) and Stellenbosch University, Cape Town, South Africa
| | - Annalise E Zemlin
- Division of Chemical Pathology, Faculty of Health Sciences, National Health Laboratory Service (NHLS) and Stellenbosch University, Cape Town, South Africa
| | - Rajiv T Erasmus
- Division of Chemical Pathology, Faculty of Health Sciences, National Health Laboratory Service (NHLS) and Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
32
|
Perrotta PL, Jones R, Souers RJ, Darcy TP, Howanitz PJ. Frequency monitoring of hemoglobin A1c, low-density lipoprotein, and urine protein laboratory testing: a College of American Pathologists Q-Probes study. Arch Pathol Lab Med 2014; 138:1009-14. [PMID: 25076291 DOI: 10.5858/arpa.2013-0349-cp] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Ensuring laboratory tests are performed at intervals consistent with established, evidence-based guidelines in diabetic patients is an important aspect of laboratory utilization. OBJECTIVES To measure how frequently diabetes mellitus patients are tested for hemoglobin A1c (HbA1c), low-density lipoprotein, and urine protein and to determine whether the frequencies with which these analytes are tested are consistent with recognized guidelines. DESIGN Participants prospectively identified up to 40 patients with a current HbA1c result and at least 2 previous measurements within the past 24 months. For each patient identified with at least 3 HbA1c measurements during a 24-month period, participants also determined the number of low-density lipoprotein and spot or random urine protein tests that were performed during those 24 months. RESULTS Participants from 49 institutions submitted a total of 1915 cases that met the study criteria of at least 3 HbA1c test results within the past 24 months. Approximately 95% of patients had 8 or fewer HbA1c tests in the past 24 months; 79% of patients with at least 3 HbA1c tests had at least 2 low-density lipoprotein tests and 27% had at least 2 urine protein tests reported during the 24-month study period. CONCLUSION Participating laboratories were generally successful in documenting appropriate utilization of HbA1c testing in diabetes mellitus monitoring, but had more difficulty documenting that diabetes mellitus patients had annual testing for low-density lipoprotein and urine protein.
Collapse
Affiliation(s)
- Peter L Perrotta
- From the Department of Pathology, West Virginia University, Morgantown (Dr Perrotta and Mr Jones); the Biostatistics Department, College of American Pathologists, Northfield, Illinois (Ms Souers); the Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison (Dr Darcy); and the Department of Pathology, SUNY Downstate, Brooklyn, New York (Dr Howanitz)
| | | | | | | | | |
Collapse
|
33
|
Vidyarthi AR, Hamill T, Green AL, Rosenbluth G, Baron RB. Changing resident test ordering behavior: a multilevel intervention to decrease laboratory utilization at an academic medical center. Am J Med Qual 2014; 30:81-7. [PMID: 24443317 DOI: 10.1177/1062860613517502] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hospital laboratory test volume is increasing, and overutilization contributes to errors and costs. Efforts to reduce laboratory utilization have targeted aspects of ordering behavior, but few have utilized a multilevel collaborative approach. The study team partnered with residents to reduce unnecessary laboratory tests and associated costs through multilevel interventions across the academic medical center. The study team selected laboratory tests for intervention based on cost, volume, and ordering frequency (complete blood count [CBC] and CBC with differential, common electrolytes, blood enzymes, and liver function tests). Interventions were designed collaboratively with residents and targeted components of ordering behavior, including system changes, teaching, social marketing, academic detailing, financial incentives, and audit/feedback. Laboratory ordering was reduced by 8% cumulatively over 3 years, saving $2 019 000. By involving residents at every stage of the intervention and targeting multiple levels simultaneously, laboratory utilization was reduced and cost savings were sustained over 3 years.
Collapse
Affiliation(s)
- Arpana R Vidyarthi
- Duke-NUS Graduate Medical School, Singapore Healthcare Leadership College, Singapore SingHealth Pvt Ltd, Singapore
| | | | | | | | | |
Collapse
|
34
|
Kiechle FL, Arcenas RC, Rogers LC. Establishing benchmarks and metrics for disruptive technologies, inappropriate and obsolete tests in the clinical laboratory. Clin Chim Acta 2014; 427:131-6. [PMID: 23732401 PMCID: PMC7124233 DOI: 10.1016/j.cca.2013.05.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 05/24/2013] [Accepted: 05/25/2013] [Indexed: 12/31/2022]
Abstract
Benchmarks and metrics related to laboratory test utilization are based on evidence-based medical literature that may suffer from a positive publication bias. Guidelines are only as good as the data reviewed to create them. Disruptive technologies require time for appropriate use to be established before utilization review will be meaningful. Metrics include monitoring the use of obsolete tests and the inappropriate use of lab tests. Test utilization by clients in a hospital outreach program can be used to monitor the impact of new clients on lab workload. A multi-disciplinary laboratory utilization committee is the most effective tool for modifying bad habits, and reviewing and approving new tests for the lab formulary or by sending them out to a reference lab.
Collapse
Affiliation(s)
- Frederick L Kiechle
- Memorial Healthcare System, Pathology Consultants of South Broward, LLP, Department of Pathology, 3501 Johnson Street, Hollywood, FL 33021, USA.
| | | | | |
Collapse
|
35
|
Melanson SE. Establishing benchmarks and metrics for utilization management. Clin Chim Acta 2014; 427:127-30. [DOI: 10.1016/j.cca.2013.09.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Accepted: 09/20/2013] [Indexed: 10/26/2022]
|
36
|
Plebani M, Zaninotto M, Faggian D. Utilization management: A European perspective. Clin Chim Acta 2014; 427:137-41. [DOI: 10.1016/j.cca.2013.03.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 02/28/2013] [Accepted: 03/02/2013] [Indexed: 11/24/2022]
|
37
|
Cuda G, Guzzi PH, Gallo L, Lentini M, Lucia F, Giacinto-Carinci L, Mancuso S, Sinopoli R, Cannataro M, Costanzo F. Evaluating the inappropriateness of repeated laboratory testing in a teaching hospital of South Italy. Clin Chem Lab Med 2013; 52:e43-4. [PMID: 24108203 DOI: 10.1515/cclm-2013-0592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 09/09/2013] [Indexed: 11/15/2022]
|
38
|
Harendza S, Alofs L, Huiskes J, Wijnen-Meijer M. Ordering patterns for laboratory and radiology tests by students from different undergraduate medical curricula. BMC MEDICAL EDUCATION 2013; 13:109. [PMID: 23945311 PMCID: PMC3751874 DOI: 10.1186/1472-6920-13-109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 08/12/2013] [Indexed: 05/28/2023]
Abstract
BACKGROUND The overuse of laboratory tests and radiology imaging and their possible hazards to patients and the health care system is observed with growing concern in the medical community. With this study the authors wished to determine whether ordering patterns for laboratory and radiology tests by medical students close to their graduation are related to undergraduate training. METHODS We developed an assessment for near graduates in the setting of a resident's daily routine including a consultation hour with five simulated patients, three hours for patient work up with simulated distracting tasks, and thirty minutes for reporting of patient management to a supervisor. In 2011, 60 students participated in this assessment: 30 from a vertically integrated (VI) curriculum (Utrecht, The Netherlands) and 30 from a traditional, non-VI curriculum (Hamburg, Germany). We assessed and compared the number of laboratory and radiology requests and correlated the results with the scores participants received from their supervisors for the facet of competence "scientifically and empirically grounded method of working". RESULTS Students from a VI curriculum used significantly (p < .01) less total laboratory requests (N = 283 versus N = 466) which correlated with their scores for a "scientifically and empirically grounded method of working" (Pearson's r = .572). A significantly (p < .01) higher number of radiology imaging was ordered with a large effect size (V = .618) by near graduates from a non-VI curriculum (N = 156 versus N = 97) even when this was not supporting the diagnostic process. CONCLUSION The focused ordering patterns from VI students might be a result of their early exposure to the clinical environment and a different approach to clinical decision making during their undergraduate education which further studies should address in greater detail.
Collapse
Affiliation(s)
- Sigrid Harendza
- Department of Internal Medicine, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Lonneke Alofs
- Center for Research and Development of Education, UMC Utrecht, P.O. Box 85500, Utrecht, GA 3508 The Netherlands
| | - Jorike Huiskes
- Center for Research and Development of Education, UMC Utrecht, P.O. Box 85500, Utrecht, GA 3508 The Netherlands
| | - Marjo Wijnen-Meijer
- Center for Research and Development of Education, UMC Utrecht, P.O. Box 85500, Utrecht, GA 3508 The Netherlands
| |
Collapse
|
39
|
Roberts-Wilson TK, Spencer JB, Fantz CR. Using an algorithmic approach to secondary amenorrhea: Avoiding diagnostic error. Clin Chim Acta 2013; 423:56-61. [DOI: 10.1016/j.cca.2013.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 04/02/2013] [Accepted: 04/03/2013] [Indexed: 12/25/2022]
|
40
|
Robinson PA, Epperson WB. Farm animal practitioners' views on their use and expectations of veterinary diagnostic laboratories. Vet Rec 2013; 172:503. [DOI: 10.1136/vr.101366] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- P. A. Robinson
- Veterinary Epidemiology Unit; Department of Agriculture & Rural Development; Upper Newtownards Rd Belfast BT4 3SB UK
| | - W. B. Epperson
- Department of Pathobiology & Population Medicine; College of Veterinary Medicine; Mississippi State University; Starkville MS USA
| |
Collapse
|
41
|
Benkov K, Lu Y, Patel A, Rahhal R, Russell G, Teitelbaum J. Role of thiopurine metabolite testing and thiopurine methyltransferase determination in pediatric IBD. J Pediatr Gastroenterol Nutr 2013; 56:333-40. [PMID: 23287804 DOI: 10.1097/mpg.0b013e3182844705] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thiopurines have been used in inflammatory bowel disease (IBD) for >30 years, and measurements of both thiopurine methyltransferase (TPMT) and thiopurine (TP) metabolites, 6-thioguanine nucleotides (6-TGN) and 6-methylmercaptopurine (6-MMP), have been readily available. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) Committee on Inflammatory Bowel Disease thought it appropriate to review the present indications for use of TPMT and TP metabolite testing. Substantial evidence demonstrates that TP therapy is useful for both Crohn disease and ulcerative colitis. Review of the existing data yielded the following recommendations. TPMT testing is recommended before initiation of TPs to identify individuals who are homozygote recessive or have extremely low TPMT activity, with the latter having more reliability than the former. Individuals who are homozygous recessive or have extremely low TPMT activity should avoid the use of TPs because of concerns for significant leukopenia. TMPT testing does not predict all cases of leukopenia and has no value to predict hypersensitivity adverse effects such as pancreatitis. Any potential value to reduce the risk of malignancy has not been studied. All individuals taking TPs should have routine monitoring with complete blood cell count and white blood cell count differential to evaluate for leukopenia regardless of TPMT testing results. Metabolite testing can be used to determine adherence with TP therapy. Metabolite testing can be used to guide dose increases or modifications in patients with active disease. Consideration would include either increasing the dose, changing therapy or for those with elevated transaminases or an elevated 6-MMP, using adjunctive allopurinol to help raise 6-thioguanine metabolites and suppress formation of 6-MMP. Routine and repetitive metabolite testing has little or no role in patients who are doing well and taking an acceptable dose of a TP.
Collapse
Affiliation(s)
- Keith Benkov
- Mount Sinai School of Medicine, New York, NY 10029, USA.
| | | | | | | | | | | | | |
Collapse
|
42
|
Willis EA, Datta BN. Effect of an educational intervention on requesting behaviour by a medical admission unit. Ann Clin Biochem 2013; 50:166-8. [PMID: 23345588 DOI: 10.1258/acb.2012.012100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Previous studies have shown that of all the tests requested of hospital laboratories, 25-40% are thought to be unnecessary. Our hospital laboratory observed that a significant number of requests from the medical admissions unit (MAU) were probably inappropriate. In an attempt to improve requesting behaviour this observation was investigated and an educational intervention employed. METHODS We performed a survey of requesting behaviour by the MAU and a local protocol was designed as an audit standard. The influence of the educational intervention on requesting behaviour was audited. RESULTS The generation of local guidelines and an educational intervention to promote them, significantly changed requesting behaviour. The main effect was the reduction in requesting of thyroid function tests, lipid profiles and coagulation screens. CONCLUSIONS This process highlighted inappropriate requesting behaviour from the MAU which, following a process of investigation and education, resulted in a significant change with an associated cost benefit.
Collapse
Affiliation(s)
- Eloise A Willis
- ST2 Chemical Pathology, Department of Medical Biochemistry, University Hospital of Wales, Heath Park, Cardiff CF14 4XW
| | | |
Collapse
|
43
|
Abstract
Healthcare budgets worldwide are facing increasing pressure to reduce costs and improve efficiency, while maintaining quality. Laboratory testing has not escaped this pressure, particularly since pathology investigations cost the National Health Service £2.5 billion per year. Indeed, the Carter Review, a UK Department of Health-commissioned review of pathology services in England, estimated that 20% of this could be saved by improving pathology services, despite an average annual increase of 8%-10% in workload. One area of increasing importance is managing the demands for pathology tests and reducing inappropriate requesting. The Carter Review estimated that 25% of pathology tests were unnecessary, representing a huge potential waste. Certainly, the large variability in levels of requesting between general practitioners suggests that inappropriate requesting is widespread. Unlocking the key to this variation and implementing measures to reduce inappropriate requesting would have major implications for patients and healthcare resources alike. This article reviews the approaches to demand management. Specifically, it aims to (a) define demand management and inappropriate requesting, (b) assess the drivers for demand management, (c) examine the various approaches used, illustrating the potential of electronic requesting and (d) provide a wider context. It will cover issues, such as educational approaches, information technology opportunities and challenges, vetting, duplicate request identification and management, the role of key performance indicators, profile composition and assessment of downstream impact of inappropriate requesting. Currently, many laboratories are exploring demand management using a plethora of disparate approaches. Hence, this review seeks to provide a 'toolkit' with the view to allowing laboratories to develop a standardised demand management strategy.
Collapse
Affiliation(s)
- Anthony A Fryer
- Department of Clinical Biochemistry, Keele University School of Medicine, University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | | |
Collapse
|
44
|
Driskell OJ, Holland D, Hanna FW, Jones PW, Pemberton RJ, Tran M, Fryer AA. Inappropriate Requesting of Glycated Hemoglobin (Hb A1c) Is Widespread: Assessment of Prevalence, Impact of National Guidance, and Practice-to-Practice Variability. Clin Chem 2012; 58:906-15. [DOI: 10.1373/clinchem.2011.176487] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Estimates suggest that approximately 25% of requests for pathology tests are unnecessary. Even in diabetes, for which international guidance provides recommended testing frequency, considerable variability in requesting practice exists. Using the diabetes marker, Hb A1c, we examined (a) the prevalence of under- and overrequesting, (b) the impact of international guidance on prevalence, and (c) practice-to-practice variability.
METHODS
We examined Hb A1c requests (519 664 requests from 115 730 patients, January 2001 to March 2011) processed by the Clinical Biochemistry Department, University Hospital of North Staffordshire, and prevalence of requesting outside guidance from intervals between requests was calculated. Requests were classified as “appropriate,” “too soon,” or “too late.” We also assessed the effect of demographic factors and publication of guidance, along with between-practice variability, on prevalence.
RESULTS
Only 49% of requests conformed to guidance; 21% were too soon and 30% were too late. Underrequesting was more common in primary care, in female patients, in younger patients, and in patients with generally poorer control (all P < 0.001); the reverse generally was true for overrequesting. Publication of guidance (e.g., American Diabetes Association, UK National Institute for Health and Clinical Excellence) had no significant impact on under- or overrequesting rates. Prevalence of inappropriate requests varied approximately 6-fold between general practices.
CONCLUSIONS
Although overrequesting was common, underrequesting was more prevalent, potentially affecting longer-term health outcomes. National guidance appears to be an ineffective approach to changing request behavior, supporting the need for a multisystem approach to reducing variability.
Collapse
Affiliation(s)
- Owen J Driskell
- Department of Clinical Biochemistry, Keele University School of Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - David Holland
- National Pathology Benchmarking Service, Department of Medicines Management, and
| | - Fahmy W Hanna
- Department of Diabetes and Endocrinology, Norton Unit, University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - Peter W Jones
- School of Computing and Mathematics, Keele University, Staffordshire, UK
| | - R John Pemberton
- Diabetes UK North Staffordshire Branch, Newcastle-under-Lyme, Staffordshire, UK
| | - Martin Tran
- Department of Clinical Biochemistry, Keele University School of Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - Anthony A Fryer
- Department of Clinical Biochemistry, Keele University School of Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, UK
| |
Collapse
|
45
|
Huang Y, Don-Wauchope AC, Grey VL, Mansour M, Brill H, Armstrong D. Improving serological test ordering patterns for the diagnosis of celiac disease through clinical laboratory audit of practice. Clin Biochem 2012; 45:455-9. [PMID: 22285379 DOI: 10.1016/j.clinbiochem.2012.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 01/05/2012] [Accepted: 01/07/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical Practice Guidelines (CPG) from both adult medicine and pediatrics recommend tTG to screen for celiac disease (CD). DESIGN AND METHODS Serological test orders for celiac disease were evaluated against the guidelines. Ordering physicians were categorized as gastroenterologists, immunologists, pediatricians, other hospital physicians and non-hospital physicians. Interventions based on initial audit were implemented, including interacting with physicians, revising test menu and changing test ordering policy. After implementation of interventions, test orders were re-evaluated. RESULTS After corrective interventions celiac panel (CP) orders were decreased from 48.4% to 3.6% in children, and from 72.3% to 28.1% in adults. Physicians ordered tTG alone for more than 90% of children. In adults the ordering of tTG alone was significantly increased from 7.2% to 61.3% (from 8.9% to 63.9% for gastroenterologists and from 8.1% to 44.4% for other physicians (p<0.05)). CONCLUSIONS The audit reduced the CPG-practice gap that existed in the screening of CD.
Collapse
Affiliation(s)
- Yun Huang
- Department of Pathology and Molecular Medicine, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada L8S 4K1
| | | | | | | | | | | |
Collapse
|