1
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Colombini A, Divieto C, Tomaiuolo R, Mortati L, Petiti J, Di Resta C, Banfi G. The total testing process harmonization: the case study of SARS-CoV-2 serological tests. Clin Chem Lab Med 2023; 61:2084-2093. [PMID: 37540644 DOI: 10.1515/cclm-2023-0353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/19/2023] [Indexed: 08/06/2023]
Abstract
The total testing process harmonization is central to laboratory medicine, leading to the laboratory test's effectiveness. In this opinion paper the five phases of the TTP are analyzed, describing, and summarizing the critical issues that emerged in each phase of the TTP with the SARS-CoV-2 serological tests that have affected their effectiveness. Testing and screening the population was essential for defining seropositivity and, thus, driving public health policies in the management of the COVID-19 pandemic. However, the many differences in terminology, the unit of measurement, reference ranges and parameters for interpreting results make analytical results difficult to compare, leading to the general confusion that affects or completely precludes the comparability of data. Starting from these considerations related to SARS-CoV-2 serological tests, through interdisciplinary work, the authors have highlighted the most critical points and formulated proposals to make total testing process harmonization effective, positively impacting the diagnostic effectiveness of laboratory tests.
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Affiliation(s)
| | - Carla Divieto
- Istituto Nazionale di Ricerca Metrologica INRIM, Turin, Italy
| | - Rossella Tomaiuolo
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | | | - Jessica Petiti
- Istituto Nazionale di Ricerca Metrologica INRIM, Turin, Italy
| | | | - Giuseppe Banfi
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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2
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Ferraro S, Cereda C, Zuccotti G, Marcovina S, Plebani M, Biganzoli EM. Striving for a pragmatic contribution of biomarkers results to lifelong health care. Clin Chem Lab Med 2023; 61:1395-1403. [PMID: 36798037 DOI: 10.1515/cclm-2022-1294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/07/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND The increased role of preventive medicine in healthcare and the rapid technological advancements, have deeply changed the landscape of laboratory medicine. In particular, increased investments in newborn screening tests and policies have been observed. Aim of this paper is to characterize how laboratory professionals engaged in clinical chemistry or newborn screening, in collaboration with experts in econometric, bioinformatics, and biostatistics may address a pragmatic use of laboratory results in the decision-making process oriented toward improvement of health care outcomes. CONTENT The effectiveness of biomarkers on healthcare depends on several factors such as analytical performance, prevalence of the disease, integration of the test within the diagnostic algorithm, associated costs, and social/economic impact of false positive and false negative results. Cost-effectiveness analysis needs to be performed and reliability achieved, by overcoming analytical pitfalls and by improving interpretative criteria. These are challenging issues common to clinical chemistry and newborn screening tests. Following the experience in clinical chemistry, one of the main issues to be approached in newborn screening tests, is the lack of harmonization of results obtained by different methods and the limited healthcare effectiveness. SUMMARY The focus on prevention is a crucial opportunity for laboratory medicine to change how to approach the effectiveness of biomarkers on healthcare. The consolidation within clinical laboratories of professionals with different technical and methodological expertise coupled with the need to produce and manage large sets of data, require the cooperation of professionals from other disciplines to characterize the impact of the tests on epidemiological outcomes for health care policy making process.
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Affiliation(s)
- Simona Ferraro
- Department of Pediatrics, Center of Functional Genomics and Rare Diseases, Buzzi Children's Hospital, Milan, Italy
- Department of Pediatrics, Center of Functional Genomics and Rare Diseases, Buzzi Children's Hospital, Milan, Italy
| | - Cristina Cereda
- Department of Pediatrics, Center of Functional Genomics and Rare Diseases, Buzzi Children's Hospital, Milan, Italy
- Pediatric Department, Buzzi Children's Hospital, Milan, Italy
| | - Gianvincenzo Zuccotti
- Pediatric Department, Buzzi Children's Hospital, Milan, Italy
- Department of Biomedical and Clinical Science, University of Milan, Milan, Italy
| | | | - Mario Plebani
- Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Elia Mario Biganzoli
- Department of Biomedical and Clinical Sciences L. Sacco, Medical Statistics Unit, "Luigi Sacco" University Hospital, University of Milan, Milan, Italy
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3
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Queraltó J, Brady J, Carobene A, Homšak E, Wieringa G. The European Register of Specialists in Clinical Chemistry and Laboratory Medicine: code of conduct, version 3 - 2023. Clin Chem Lab Med 2023; 61:981-988. [PMID: 36724108 DOI: 10.1515/cclm-2023-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 02/02/2023]
Abstract
Whilst version 2 focussed on the professional conduct expected of a Specialist in Laboratory Medicine, version 3 builds on the responsibilities for ethical conduct from point of planning to point of care. Particular responsibilities that are outlined include: - The need for evidence when planning a new service, providing assurance that a new test does not do harm - Maintaining respect for patient confidentiality, their religious/ethnic beliefs, the need for informed consent to test, agreement on retrospective use of samples as part of governance envelopes in the pre-analytical phase - Ensuring respect for patient autonomy in the response to untoward results generated in the analytical phase - Supporting the safety of patients in the post-analytical phase through knowledge-based interpretation and presentation of results - The duty of candour to disclose and respond to error across the total testing process - Leading initiatives to harmonise and standardise pre-analytical, analytical and post-analytical phases to ensure more consistent clinical decision making with utilisation of demand management to ensure more equitable access to scarce resources - Working with emerging healthcare providers beyond the laboratory to ensure consistent application of high standards of clinical care In identifying opportunities for wider contributions to resolving ethical challenges across healthcare the need is also highlighted for more external quality assurance schemes and ethics-based quality indicators that span the total testing process.
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Affiliation(s)
- Josep Queraltó
- SEQCML - The Spanish Society of Laboratory Medicine SEQCML Barcelona, Spain
| | - Jennifer Brady
- Department of Paediatric Laboratory Medicine, UCD School of Medicine, Children's Health Ireland (CHI) Dublin, Ireland
| | - Anna Carobene
- Laboratory Medicine Department, IRCCS San Raffaele Hospital Milan, Italy
| | - Evgenija Homšak
- European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Milan, Italy
| | - Gijsbert Wieringa
- European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Milan, Italy
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4
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Panteghini M, Dolci A, Birindelli S, Szoke D, Aloisio E, Caruso S. Pursuing appropriateness of laboratory tests: a 15-year experience in an academic medical institution. Clin Chem Lab Med 2022; 60:1706-1718. [PMID: 35998662 DOI: 10.1515/cclm-2022-0683] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/08/2022] [Indexed: 02/04/2023]
Abstract
Appropriateness in Laboratory Medicine has been the object of various types of interventions. From published experiences, it is now clear that to effectively manage the laboratory test demand it is recommended to activate evidence-based preventative strategies stopping inappropriate requests before they can reach the laboratory. To guarantee appropriate laboratory test utilization, healthcare institutions should implement and optimize a computerized provider order entry (CPOE), exploiting the potential of electronic requesting as "enabling factor" for reinforcing appropriateness and sustaining its effects over time. In our academic institution, over the last 15 years, our medical laboratory has enforced various interventions to improve test appropriateness, all directly or indirectly based on CPOE use. The following types of intervention were implemented: (1) applying specific recommendations supported by monitoring by CPOE as well as a continuous consultation with clinicians (tumour markers); (2) removing outdated tests and avoiding redundant duplications (cardiac markers, pancreatic enzymes); (3) order restraints to selected wards and gating policy (procalcitonin, B-type natriuretic peptide, homocysteine); (4) reflex testing (bilirubin fractions, free prostate-specific antigen, aminotransferases, magnesium in hypocalcemia); and (5) minimum retesting interval (D-Dimer, vitamin B12, C-reactive protein, γ-glutamyltranspeptidase). In this paper, we reviewed these interventions and summarized their outcomes primarily related to the changes in total test volumes and cost savings, without neglecting patient safety. Our experience confirmed that laboratory professionals have an irreplaceable role as "stewards" in designing, implementing, evaluating, and maintaining interventions focused to improving test appropriateness.
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Affiliation(s)
- Mauro Panteghini
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy.,Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi, Milan, Italy
| | - Alberto Dolci
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy.,Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi, Milan, Italy
| | - Sarah Birindelli
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Dominika Szoke
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Elena Aloisio
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Simone Caruso
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy
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5
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Caruso S, Szoke D, Panteghini M. 'Penelope test': a practical instrument for checking appropriateness of laboratory tests. Clin Chem Lab Med 2022; 60:1342-1349. [PMID: 35785546 DOI: 10.1515/cclm-2022-0368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/22/2022] [Indexed: 11/15/2022]
Abstract
In medical laboratories, the appropriateness challenge directly revolves around the laboratory test and its proper selection, data analysis, and result reporting. However, laboratories have also a role in the appropriate management of those phases of total testing process (TTP) that traditionally are not under their direct control. So that, the laboratory obligation to act along the entire TTP is now widely accepted in order to achieve better care management. Because of the large number of variables involved in the overall TTP structure, it is difficult to monitor appropriateness in real time. However, it is possible to retrospectively reconstruct the body of the clinical process involved in the management of a specific laboratory test to track key passages that may be defective or incomplete in terms of appropriateness. Here we proposed an appropriateness check-list scheme along the TTP chain to be potentially applied to any laboratory test. This scheme consists of a series of questions that healthcare professionals should answer to achieve laboratory test appropriateness. In the system, even a single lacking answer may compromise the integrity of all appropriateness evaluation process as the inability to answer may involve a significant deviation from the optimal trajectory, which compromise the test appropriateness and the quality of subsequent steps. Using two examples of the check-list application, we showed that the proposed instrument may offer an objective help to avoid inappropriate use of laboratory tests in an integrated way involving both laboratory professionals and user clinicians.
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Affiliation(s)
- Simone Caruso
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Dominika Szoke
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Mauro Panteghini
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
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6
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Ferraro S, Biganzoli EM, Plebani M. Reply to: Spurious results for total and free prostate-specific antigen (PSA); sometimes really "a riddle wrapped in a mystery inside an enigma". Clin Chem Lab Med 2022; 60:e95-e96. [PMID: 35258238 DOI: 10.1515/cclm-2022-0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Simona Ferraro
- Endocrinology Laboratory Unit, "Luigi Sacco" University Hospital, Milan, Italy
| | - Elia Mario Biganzoli
- Medical Statistics Unit, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Mario Plebani
- Department of Medicine-DIMED, University of Padova, Padova, Italy
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7
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Tola EK, Dabi YT, Dano GT. Assessment of Types and Frequency of Errors in Diagnostic Laboratories Among Selected Hospitals in East Wollega Zone, Oromia, Ethiopia. PATHOLOGY AND LABORATORY MEDICINE INTERNATIONAL 2022. [DOI: 10.2147/plmi.s351851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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8
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Padoan A, Clerico A, Zaninotto M, Trenti T, Tozzoli R, Aloe R, Alfano A, Rizzardi S, Dittadi R, Migliardi M, Bagnasco M, Plebani M. Percentile transformation and recalibration functions allow harmonization of thyroid-stimulating hormone (TSH) immunoassay results. Clin Chem Lab Med 2021; 58:1663-1672. [PMID: 31927515 DOI: 10.1515/cclm-2019-1167] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/09/2019] [Indexed: 01/22/2023]
Abstract
Background The comparability of thyroid-stimulating hormone (TSH) results cannot be easily obtained using SI-traceable reference measurement procedures (RPMs) or reference materials, whilst harmonization is more feasible. The aim of this study was to identify and validate a new approach for the harmonization of TSH results. Methods Percentile normalization was applied to 125,419 TSH results, obtained from seven laboratories using three immunoassays (Access 3rd IS Thyrotropin, Beckman Coulter Diagnostics; Architect System, Abbott Diagnostics and Elecsys, Roche Diagnostics). Recalibration equations (RCAL) were derived by robust regressions using bootstrapped distribution. Two datasets, the first of 119 EQAs, the second of 610, 638 and 639 results from Access, Architect and Elecsys TSH results, respectively, were used to validate RCAL. A dataset of 142,821 TSH values was used to derive reference intervals (RIs) after applying RCAL. Results Access, Abbott and Elecsys TSH distributions were significantly different (p < 0.001). RCAL intercepts and slopes were -0.003 and 0.984 for Access, 0.032 and 1.041 for Architect, -0.031 and 1.003 for Elecsys, respectively. Validation using EQAs showed that before and after RCAL, the coefficients of variation (CVs) or among-assay results decreased from 10.72% to 8.16%. The second validation dataset was used to test RCALs. The median of between-assay differences ranged from -0.0053 to 0.1955 mIU/L of TSH. Elecsys recalibrated to Access (and vice-versa) showed non-significant difference. TSH RI after RCAL resulted in 0.37-5.11 mIU/L overall, 0.49-4.96 mIU/L for females and 0.40-4.92 mIU/L for males. A significant difference across age classes was identified. Conclusions Percentile normalization and robust regression are valuable tools for deriving RCALs and harmonizing TSH values.
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Affiliation(s)
- Andrea Padoan
- Department of Medicine (DIMED), University of Padova, via Giustiniani 2, 35128, Padova, Italy.,Department of Laboratory Medicine, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, Italy
| | - Aldo Clerico
- Laboratory of Cardiovascular Endocrinology and Cell Biology, Department of Laboratory Medicine, Fondazione CNR-Regione Toscana Gabriele Monasterio, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
| | - Tommaso Trenti
- Dipartimento di Medicina di Laboratorio e Anatomia Patologica, Azienda Ospedaliera Universitaria e USL di Modena, Modena, Italy
| | - Renato Tozzoli
- Clinical Pathology Laboratory, Department of Laboratory Medicine, Azienda per l'Assistenza Sanitaria n.5, Pordenone Hospital, Pordenone, Italy
| | - Rosalia Aloe
- Dipartimento di Biochimica ad Elevata Automazione, Dipartimento Diagnostico, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Antonio Alfano
- Clinical Pathology, Hospital ASL TO4, Ciriè, Turin, Italy
| | - Sara Rizzardi
- Laboratorio Analisi Aziendale (SC), Azienda Socio-Sanitaria Territoriale di Cremona, Istituti Ospitalieri, Cremona, Italy
| | - Ruggero Dittadi
- U.O.C. Laboratorio Analisi, Ospedale dell'Angelo, AULSS3 Serenissima, Mestre, Venezia, Italy
| | - Marco Migliardi
- S.C. Laboratorio Analisi, A.O. Ordine Mauriziano di Torino, Turin, Italy
| | | | - Mario Plebani
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy.,Department of Medicine (DIMED), University of Padova, Padova, Italy
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9
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López Yeste ML, Pons Mas AR, Guiñón Muñoz L, Izquierdo Álvarez S, García FM, Blanco Font A, Pascual Gómez NF, Sánchez Gancedo L, García Álvarez A, Bernabeu Andreu FA, Chueca Rodríguez MP, Álvarez Domínguez L. Management of post-analytical processes in the clinical laboratory according to ISO 15189:2012. Considerations about the management of clinical samples, ensuring quality of post-analytical processes, and laboratory information management. ADVANCES IN LABORATORY MEDICINE 2021; 2:373-389. [PMID: 37362414 PMCID: PMC10197280 DOI: 10.1515/almed-2021-0044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/07/2021] [Indexed: 06/28/2023]
Abstract
ISO 15189:2012 establishes the requirements for clinical sample management, ensuring quality of process and laboratory information management. The accreditation authority, ENAC in Spain, established the requirements for the authorized use of the label in reports issued by accredited laboratories. These recommendations are applicable to the postanalytical processes and the professionals involved. The Standard requires laboratories to define and document the duration and conditions of sample retention. Laboratories are also required to design an internal quality control scheme to verify whether postanalytical activities attain the expected standards. Information management requirements are also established and laboratories are required to design a contingency plan to ensure the communication of laboratory results. Instructions are finally provided about the correct use of the accreditation label in laboratory reports. A range of nations and scientific societies support that clinical laboratories should be required to obtain accreditation. With ISO 15189 being the most specific standard for demonstrating technical performance, a clear understanding of its requirements is essential for proper implementation.
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Affiliation(s)
| | - Antonia R. Pons Mas
- Clinical Analysis Service, Hospital Universitari Son Espases, Mallorca, Spain
| | - Leonor Guiñón Muñoz
- Quality Department, Laboratories, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Fernando Marqués García
- Clinical Biochemistry Department, Metropolitan North Clinical Laboratory (LUMN), Germans Trias i Pujol Universitary Hospital, Badalona, Barcelona, Spain
| | - Aurora Blanco Font
- Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | | | | | - Francisco A. Bernabeu Andreu
- Service of Clinical Analysis – Clinical Biochemistry, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Luisa Álvarez Domínguez
- Laboratory Accreditation Board of the Spanish Society of Laboratory Medicine, Barcelona, Spain
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10
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Fierz W, Bossuyt X. Likelihood Ratios as Value Proposition for Diagnostic Laboratory Tests. J Appl Lab Med 2020; 5:1061-1069. [PMID: 32500145 DOI: 10.1093/jalm/jfaa064] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 03/30/2020] [Indexed: 02/05/2023]
Abstract
The clinical and health economic value of clinical laboratory diagnostics has been debated increasingly in recent years without resulting in practical recommendations for measuring the effectiveness of diagnostic tests. One way to achieve such a goal could be to enrich the mere data of laboratory test results with additional information about their likelihood ratios for diagnosis. The diagnostic significance of test results can be judged subjectively based on the experience of the treating physician or expressed objectively in the form of likelihood ratios. The provision of likelihood ratios by the laboratory would increase the impact of laboratory diagnostics in healthcare and thus have positive economic value. Consequently, likelihood ratios should be taken into account in reimbursement strategies.
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Affiliation(s)
- Walter Fierz
- Schweizerischer Verband der Diagnostikindustrie (SVDI-ASID), Bern, Switzerland
| | - Xavier Bossuyt
- Department of Laboratory Medicine, Katholieke Universiteit Leuven, University Hospitals Leuven, Leuven, Belgium.,Clinical and Diagnostic Immunology, Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, University Hospitals Leuven, Leuven, Belgium
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11
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Lippi G, Plebani M. Integrated diagnostics: the future of laboratory medicine? Biochem Med (Zagreb) 2019; 30:010501. [PMID: 31839719 PMCID: PMC6904966 DOI: 10.11613/bm.2020.010501] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/12/2019] [Indexed: 01/01/2023] Open
Abstract
The current scenario of in vitro and in vivo diagnostics can be summarized using the “silo metaphor”, where laboratory medicine, pathology and radiology are three conceptually separated diagnostic disciplines, which will increasingly share many comparable features. The substantial progresses in our understanding of biochemical-biological interplays that characterize many human diseases, coupled with extraordinary technical advances, are now generating important multidisciplinary convergences, leading the way to a new frontier, called integrated diagnostics. This new discipline, which is currently defined as convergence of imaging, pathology and laboratory tests with advanced information technology, has an enormous potential for revolutionizing diagnosis and therapeutic management of human diseases, including those causing the largest number of worldwide deaths (i.e. cardiovascular disease, cancer and infectious diseases). However, some important drawbacks should be overcome, mostly represented by insufficient information technology infrastructures, costs and enormous volume of different information that will be integrated and delivered. To overcome these hurdles, some specific strategies should be defined and implemented, such as planning major integration of exiting information systems or developing innovative ones, combining bioinformatics and imaging informatics, using health technology assessment for assessing cost and benefits, providing interpretative comments in integrated reports, developing and using expert systems and neural networks, overcoming cultural and political boundaries for generating multidisciplinary teams and integrated diagnostic algorithms.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
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12
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Performance evaluation of 14 specific proteins measurement checked by an External Quality Assessment Scheme. Clin Chim Acta 2019; 502:73-83. [PMID: 31836500 DOI: 10.1016/j.cca.2019.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/18/2019] [Accepted: 11/18/2019] [Indexed: 11/23/2022]
Abstract
AIMS OF THE STUDY To evaluate the state-of-the-art of 14 specific proteins measurement; to evaluate the laboratories' performance and the degree of harmonization in reporting results of participants in the External Quality Assessment Program of the Centre of Biomedical Research (CRB). METHODS Overall and system-related inter-laboratory analytical variability (mean CVs%) and between-system differences (mean bias%) were evaluated from data of six EQA cycles 2013-2018. Moreover, we evaluated the analytical performance of participants as well as the units used to express proteins results. RESULTS Overall inter-laboratory variability ranged from 3.8% for haptoglobin (HPT) to 12.5% for α1-antitrypsin (AAT) and decreased for IgA, α2-macroglobulin (A2M) and transferrin (TRF). Mean CVs% were generally higher for Siemens BN and Beckman Immage immunonephelometric systems, but <7.0% for all proteins. Mean bias > 7.0% was observed for BN (IgA, C4, AAT, transthyretin TTR), Siemens Vista (IgA, C4) and Immage (C4), whereas mean bias < -7.0% was found for Immage (AAT), Beckman AU (IgM) and Roche Cobas (C4, TTR, C-reactive protein). The laboratories' performance within the limits ranged from 85.1% of albumin (ALB) to 97.2% of HPT. The census of units employed in 2018, demonstrated that ~ 70% of laboratories still express the results in mg/dL. CONCLUSIONS Despite a reduction in inter-laboratory variability for some proteins, different analytical systems showed both proportional and constant bias between methods. Units used by participants have not been substantially changed and dL is still largely used. The CRB EQA Program, with its performance data sets, is a valuable resource for laboratories and IVD manufacturers and support the goals of harmonization.
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13
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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.
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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
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14
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McCune JS, Quinones CM, Ritchie J, Carpenter PA, van Maarseveen E, Yeh RF, Anasetti C, Boelens JJ, Hamerschlak N, Hassan M, Kang HJ, Kanda Y, Paci A, Perales MA, Shaw PJ, Seewaldt VL, Savani BN, Hsieh A, Poon B, Mohty M, Pulsipher MA, Pasquini M, Dupuis LL. Harmonization of Busulfan Plasma Exposure Unit (BPEU): A Community-Initiated Consensus Statement. Biol Blood Marrow Transplant 2019; 25:1890-1897. [PMID: 31136799 DOI: 10.1016/j.bbmt.2019.05.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/26/2019] [Accepted: 05/21/2019] [Indexed: 12/12/2022]
Abstract
Busulfan therapeutic drug monitoring (TDM) is often used to achieve target plasma exposures. Variability in busulfan plasma exposure units (BPEU) is a potential source for misinterpretation of publications and protocols and is a barrier to data capture by hematopoietic cell transplantation (HCT) registry databases. We sought to harmonize to a single BPEU for international use. Using Delphi consensus methodology, iterative surveys were sent to an increasing number of relevant clinical stakeholders. In survey 1, 14 stakeholders were asked to identify ideal properties of a BPEU. In survey 2, 52 stakeholders were asked (1) to evaluate BPEU candidates according to ideal BPEU properties established by survey 1 and local position statements for TDM and (2) to identify potential facilitators and barriers to adoption of the harmonized BPEU. The most frequently used BPEU identified, in descending order, were area under the curve (AUC) in μM × min, AUC in mg × h/L, concentration at steady state (Css) in ng/mL, AUC in μM × h, and AUC in μg × h/L. All respondents conceptually agreed on the ideal properties of a BPEU and to adopt a harmonized BPEU. Respondents were equally divided between selecting AUC in μM × min versus mg × h/L for harmonization. AUC in mg × h/L was finally selected as the harmonized BPEU, because it satisfied most of the survey-determined ideal properties for the harmonized BPEU and is read easily understood in the clinical practice environment. Furthermore, 10 major professional societies have endorsed AUC in mg × h/L as the harmonized unit for reporting to HCT registry databases and for use in future protocols and publications.
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Affiliation(s)
- Jeannine S McCune
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Pharmaceutics, University of Washington, Seattle, WA, USA; Molecular Prevention, Intervention and Technology Division, Beckman Research Institute, City of Hope, Duarte, CA, USA.
| | - Christine M Quinones
- Molecular Prevention, Intervention and Technology Division, Beckman Research Institute at City of Hope, Duarte, CA, USA
| | - James Ritchie
- Pathology & Laboratory Medicine Department, Emory University, Atlanta, GA, USA
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Pharmaceutics, University of Washington, Seattle, WA, USA
| | - Erik van Maarseveen
- Clinical Pharmacology, University Medical Center Utrecht, Utrecht, Princess Maxima Center for Pediatric Oncology, Utrecht and Drug Analysis and Toxicology division (KKGT) of the Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Utrecht, Netherlands
| | - Rosa F Yeh
- Pharmacokinetics Laboratory, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Claudio Anasetti
- Department of Blood and Marrow Transplant, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Molecular Prevention, Intervention and Technology Division, Beckman Research Institute, City of Hope, Duarte, CA, USA
| | - Jaap J Boelens
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, Princess Maxima Center for Pediatric Oncology, Utrecht, Netherlands; Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nelson Hamerschlak
- Hematology and Bone Marrow Transplantation Department, Hospital Israelita Albert Einstein, São Paulo Area, Brazil
| | - Moustapha Hassan
- Division of Experimental Cancer Medicine, Department of Laboratory Medicine at Karolinska Institutet and Division of Clinical Research Centrum at Karolinska University Hospital, Stockholm, Sweden
| | - Hyoung Jin Kang
- Department of Pediatrics, Seoul National Univeristy College of Medicine, Seoul National University Cancer Research Institute, Seoul National University Children's Hospital, Seoul, Korea
| | - Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University and Division of Hematology, Saitama Medical Center, Jichi Medical University, Japan
| | - Angelo Paci
- Department of Pharmacology, Institute Gustave Roussy Cancer Center, Grand Paris, School of Pharmacy - Paris Sud University, France
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center and Department of Medicine, Weill Cornell Medical College New York, NY, USA
| | - Peter J Shaw
- BMT Services, The Children's Hospital at Westmead, Westmead, New South Wales, and Discipline of Child and Adolescent Health, University of Sydney, Australia
| | - Victoria L Seewaldt
- Molecular Prevention, Intervention and Technology Division, Beckman Research Institute at City of Hope, Duarte, CA, USA
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Angela Hsieh
- Medical Content Manager at McKesson Specialty Health, Seattle, WA, USA
| | - Betsy Poon
- Department of Pharmacy, AdventHealth for Children, Orlando, FL, USA
| | - Mohamad Mohty
- Department of Hematology and Cell Therapy, Acute Leukemia Working Party EBMT Paris Office, Hôpital Saint-Antoine, Paris, France
| | - Michael A Pulsipher
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Marcelo Pasquini
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - L Lee Dupuis
- Department of Pharmacy and Research Institute, The Hospital for Sick Children and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
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15
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Abstract
Laboratory tests are an integral part of the electronic health record (EHR). Providing clinical decision support (CDS) for the ordering, collection, reporting, viewing, and interpretation of laboratory testing is a fundamental function of the EHR. The implementation of a sustainable, effective laboratory CDS program requires a commitment to standardization and harmonization of the laboratory dictionaries that are the foundation of laboratory-based CDS. In this review, the authors provide an overview of the tools available within the EHR to improve decision making throughout the entire laboratory testing process, from test order to clinical action.
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Affiliation(s)
- Joseph W Rudolf
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, 420 Delaware Street Southeast, MMC 609 Mayo, Minneapolis, MN 55455, USA
| | - Anand S Dighe
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, USA.
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16
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Faria DK, Taniguchi LU, Fonseca LAM, Ferreira-Junior M, Aguiar FJB, Lichtenstein A, Sumita NM, Duarte AJS, Sales MM. Improving serum calcium test ordering according to a decision algorithm. Clin Mol Pathol 2019; 72:232-236. [DOI: 10.1136/jclinpath-2018-205026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/09/2018] [Accepted: 03/20/2018] [Indexed: 11/04/2022]
Abstract
AimTo detect differences in the pattern of serum calcium tests ordering before and after the implementation of a decision algorithm.MethodsWe studied patients admitted to an internal medicine ward of a university hospital on April 2013 and April 2016. Patients were classified as critical or non-critical on the day when each test was performed. Adequacy of ordering was defined according to adherence to a decision algorithm implemented in 2014.ResultsTotal and ionised calcium tests per patient-day of hospitalisation significantly decreased after the algorithm implementation; and duplication of tests (total and ionised calcium measured in the same blood sample) was reduced by 49%. Overall adequacy of ionised calcium determinations increased by 23% (P=0.0001) due to the increase in the adequacy of ionised calcium ordering in non-critical conditions.ConclusionsA decision algorithm can be a useful educational tool to improve adequacy of the process of ordering serum calcium tests.
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17
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Trenti T, Plebani M. Diagnostic test accuracy: a valuable tool for promoting quality and patient safety. ACTA ACUST UNITED AC 2018; 5:175-178. [PMID: 30307895 DOI: 10.1515/dx-2018-0091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Tommaso Trenti
- Laboratory Medicine and Pathology Department, Ospedale Sant'Agostino Estense, via Giardini 1355, 41126 Modena, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University-Hospital, Padova, Italy
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18
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Plebani M. Harmonization in laboratory medicine: more than clinical chemistry? Clin Chem Lab Med 2018; 56:1579-1586. [DOI: 10.1515/cclm-2017-0865] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Abstract
The goal of harmonizing laboratory information is to contribute to quality in patient care, ultimately improving upon patient outcomes and safety. The main focus of harmonization and standardization initiatives has been on analytical processes within the laboratory walls, clinical chemistry tests in particular. However, two major evidences obtained in recent years show that harmonization should be promoted not only in the analytical phase but also in all steps of the testing process, encompassing the entire field of laboratory medicine, including innovative areas (e.g. “omics”) rather than just conventional clinical chemistry tests. A large body of evidence demonstrates the vulnerability of the extra-analytical phases of the testing cycle. Because only “good biological samples” can assure good analytical quality, a closer interconnection between the different phases of the cycle is needed. In order to provide reliable and accurate laboratory information, harmonization activities should cover all steps of the cycle from the “pre-pre-analytical” phase (right choice of test at right time for right patient) through the analytical steps (right results with right report) to the “post-post-analytical” steps (right and timely acknowledgment of laboratory information, right interpretation and utilization with any necessary advice as to what to do next with the information provided). In addition, modern clinical laboratories are performing a broad menu of hundreds of tests, covering both traditional and innovative subspecialties of the discipline. In addition, according to a centered viewpoint, harmonization initiatives should not be addressed exclusively to clinical chemistry tests but should also include all areas of laboratory medicine.
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Affiliation(s)
- Mario Plebani
- Department of Laboratory Medicine , University-Hospital of Padova , Via Nicolo Giustiniani 2 , 35128 Padova , Italy
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19
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den Elzen WP, Brouwer N, Thelen MH, Le Cessie S, Haagen IA, Cobbaert CM. NUMBER: standardized reference intervals in the Netherlands using a ‘big data’ approach. ACTA ACUST UNITED AC 2018; 57:42-56. [DOI: 10.1515/cclm-2018-0462] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/21/2018] [Indexed: 01/24/2023]
Abstract
Abstract
Background
External quality assessment (EQA) programs for general chemistry tests have evolved from between laboratory comparison programs to trueness verification surveys. In the Netherlands, the implementation of such programs has reduced inter-laboratory variation for electrolytes, substrates and enzymes. This allows for national and metrological traceable reference intervals, but these are still lacking. We have initiated a national endeavor named NUMBER (Nederlandse UniforMe Beslisgrenzen En Referentie-intervallen) to set up a sustainable system for the determination of standardized reference intervals in the Netherlands.
Methods
We used an evidence-based ‘big-data’ approach to deduce reference intervals using millions of test results from patients visiting general practitioners from clinical laboratory databases. We selected 21 medical tests which are either traceable to SI or have Joint Committee for Traceability in Laboratory Medicine (JCTLM)-listed reference materials and/or reference methods. Per laboratory, per test, outliers were excluded, data were transformed to a normal distribution (if necessary), and means and standard deviations (SDs) were calculated. Then, average means and SDs per test were calculated to generate pooled (mean±2 SD) reference intervals. Results were discussed in expert meetings.
Results
Sixteen carefully selected clinical laboratories across the country provided anonymous test results (n=7,574,327). During three expert meetings, participants found consensus about calculated reference intervals for 18 tests and necessary partitioning in subcategories, based on sex, age, matrix and/or method. For two tests further evaluation of the reference interval and the study population were considered necessary. For glucose, the working group advised to adopt the clinical decision limit.
Conclusions
Using a ‘big-data’ approach we were able to determine traceable reference intervals for 18 general chemistry tests. Nationwide implementation of these established reference intervals has the potential to improve unequivocal interpretation of test results, thereby reducing patient harm.
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Affiliation(s)
- Wendy P.J. den Elzen
- Department of Clinical Chemistry and Laboratory Medicine , Leiden University Medical Center , Postal Zone E2-P, P.O. Box 9600 , 2300 RC Leiden , The Netherlands , Phone: +31 71 526 2278
| | - Nannette Brouwer
- Diagnost-IQ, Expert Centre for Clinical Chemistry , Purmerend , The Netherlands
| | - Marc H. Thelen
- Amphia Ziekenhuis, Laboratory for Clinical Chemistry and Haematology , Breda , The Netherlands
- Stichting Kwaliteitsbewaking Medische Laboratoriumdiagnostiek , Nijmegen , The Netherlands
| | - Saskia Le Cessie
- Department of Clinical Epidemiology , Leiden University Medical Center , Leiden , The Netherlands
- Department of Medical Statistics and Bioinformatics , Leiden University Medical Center , Leiden , The Netherlands
| | - Inez-Anne Haagen
- Department of Hematology and Clinical Chemistry Laboratories, OLVG , Amsterdam , The Netherlands
| | - Christa M. Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine , Leiden University Medical Center , Leiden , The Netherlands
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20
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Plebani M. Quality and future of clinical laboratories: the Vico’s whole cyclical theory of the recurring cycles. Clin Chem Lab Med 2018; 56:901-908. [DOI: 10.1515/cclm-2018-0009] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Abstract
In the last few decades, laboratory medicine has undergone monumental changes, and laboratory technology, which has made enormous advances, now has new clinical applications thanks to the identification of a growing number of biomarkers and risk factors conducive to the promotion of predictive and preventive interventions that have enhanced the role of laboratory medicine in health care delivering. However, the paradigm shift in the past 50 years has led to a gap between laboratory and clinic, with an increased risk of inappropriateness in test request and interpretation, as well as the consolidation of analytical work in focused factories and megastructurers oriented only toward achieving greater volumes, decreasing cost per test and generating a vision of laboratory services as simple commodities. A careful historical revision of the changing models for delivering laboratory services in the United States leads to the prediction that there are several reasons for counteracting the vision of clinical laboratory as a commodity, and restoring the true nature of laboratory services as an integral part of the diagnosis and therapy process. The present study, which reports on internal and external drivers for change, proposes an integrated vision of quality in laboratory medicine.
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Affiliation(s)
- Mario Plebani
- Department of Medicine-DIMED , University of Padova , Padova , Italy
- Department of Laboratory Medicine , University-Hospital of Padova , Padova , Italy
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21
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Secchiero S, Sciacovelli L, Plebani M. Harmonization of units and reference intervals of plasma proteins: state of the art from an External Quality Assessment Scheme. ACTA ACUST UNITED AC 2018; 57:95-105. [DOI: 10.1515/cclm-2017-1172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/03/2018] [Indexed: 01/29/2023]
Abstract
Abstract
Background:
The need to harmonize laboratory information is particularly intense in the field of plasma proteins, considering their clinical impact and relevance in monitoring diseases.
Methods:
We evaluated units and reference intervals (RIs) utilized by participants of the External Quality Assessment Scheme (EQAS) for plasma proteins of the Centre of Biomedical Research. Moreover, we evaluated inter-laboratory analytical variability from 2001 to 2017.
Results:
The census of participants’ units employed in 2017 showed that for albumin (ALB), ~66% of laboratories still used dL instead of L, and for most other proteins, ~70% still expressed the results in mg/dL. Laboratories primarily used the RIs reported in the packaging inserts of their analytical systems, but for each protein, there was a wide variability of RIs, also among laboratories using the same analytical method. Mean CVs% of the 13 certified proteins in the last five EQA cycles ranged from 3.8% of haptoglobin (HPT) to 12.4% of α1-antitrypsin (AAT) and decreased from 2001 to 2017 for most of them, in particular for C3, ALB, α2-macroglobulin (A2M), HPT and transferrin (TRF).
Conclusions:
In the face of a reduction in inter-laboratory variability for a lot of proteins, there has not been a substantial change in the units and in the RIs used by the participants. To change old habits is difficult and requires coordination and collaboration. The EQAS plays an important role in the assessment and monitoring of all elements that contribute to the formulation of laboratory information and may be useful to contribute to their harmonization.
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Affiliation(s)
- Sandra Secchiero
- Centre of Biomedical Research – Department of Laboratory Medicine , University-Hospital of Padova , Via Giustiniani, 2 , 35128 Padova , Italy , Phone: +39-049-821-4490, Fax: +39-049-821-7916
| | - Laura Sciacovelli
- Centre of Biomedical Research , University-Hospital of Padova , Padova , Italy
| | - Mario Plebani
- Centre of Biomedical Research , University-Hospital of Padova , Padova , Italy
- Department of Laboratory Medicine , University-Hospital of Padova , Padova , Italy
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22
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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: 52] [Impact Index Per Article: 8.7] [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.
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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
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23
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Buoro S, Da Rin G, Fanelli A, Lippi G. Harmonization of interpretative comments in laboratory hematology reporting: the recommendations of the Working Group on Diagnostic Hematology of the Italian Society of Clinical Chemistry and Clinical Molecular Biology (WGDH-SIBioC). ACTA ACUST UNITED AC 2018; 57:66-77. [DOI: 10.1515/cclm-2017-0972] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 01/02/2018] [Indexed: 12/13/2022]
Abstract
Abstract
The goal of harmonizing laboratory testing is contributing to improving the quality of patient care and ultimately ameliorating patient outcome. The complete blood and leukocyte differential counts are among the most frequently requested clinical laboratory tests. The morphological assessment of peripheral blood cells (PB) through microscopic examination of properly stained blood smears is still considered a hallmark of laboratory hematology. Nevertheless, a variable inter-observer experience and the different terminology used for characterizing cellular abnormalities both contribute to the current lack of harmonization in blood smear revision. In 2014, the Working Group on Diagnostic Hematology of the Italian Society of Clinical Chemistry and Clinical Molecular Biology (WGDH-SIBioC) conducted a national survey, collecting responses from 78 different Italian laboratories. The results of this survey highlighted a lack of harmonization of interpretative comments in hematology, which prompted the WGDH-SIBioC to develop a project on “Harmonization of interpretative comments in the laboratory hematology report”, aimed at identifying appropriate comments and proposing a standardized reporting system. The comments were then revised and updated according to the 2016 revision of the World Health Organization classification of hematologic malignancies. In 2016, the Working Group on Diagnostic Hematology of the Italian Society of Clinical Chemistry and Clinical Molecular Biology (WGDH SIBioC) published its first consensus based recommendation for interpretative comments in laboratory hematology reporting whit the purpose of evaluating comments and the aim to (a) reducing their overall number, (b) standardizing the language, (c) providing information that could be easily comprehended by clinicians and patients, (d) increasing the quality of the clinical information, and (e) suggesting additional diagnostic tests when necessary. This paper represents a review of the recommendations of the former document.
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Affiliation(s)
- Sabrina Buoro
- Clinical Chemistry Laboratory, Hospital Papa Giovanni XXIII , Bergamo , Italy
| | - Giorgio Da Rin
- Laboratory Medicine, San Bassiano Hospital , AULSS 7 Pedemontana, Via dei Lotti, 40 , 36061 Bassano del Grappa , Italy
| | | | - Giuseppe Lippi
- Section of Clinical Biochemistry , University Hospital of Verona , Verona , Italy
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24
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Demarteau M, Cammaert P, Vandevelde NM, Callewaert N, Coucke W, China B, Verstraete AG. A pragmatic bottom-up approach to harmonize the units of clinical chemistry tests among Belgian clinical laboratories, focusing on immunoassays. ACTA ACUST UNITED AC 2018; 57:12-19. [DOI: 10.1515/cclm-2017-0824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 12/18/2017] [Indexed: 11/15/2022]
Abstract
Abstract
Background:
Harmonization of units is an important step to improve the comparability of clinical chemistry results, but few examples exist of successful harmonization efforts. We present the results of a pragmatic approach that was implemented in Belgium from 2012.
Methods:
After a large consultation and information of stakeholders, preferred units were proposed for 140 assays, including the 23 immunoassays discussed in more detail here. The change occurred in two phases, first involving assays for which there was no change in the numerical result, then changes involving a change in numerical results. Laboratories were invited to participate in this harmonization on a voluntary basis. The project was based on a bottom-up approach, large consultation and the pragmatic choice of the proposed units, including conventional and SI units.
Results:
The large heterogeneity of units was drastically reduced; adoption of the preferred units increased from 3% (insulin) – 45% (HCG) to 70% (insulin) – 96% (LH and FSH). Adoption of the preferred units was higher if it involved no change in numerical values (90%) than when there was a change (76%).
Conclusions:
We believe that the harmonization effort has reached its goals. Without aiming at implementing SI units for all parameters, our strategy was successful with a large majority of the laboratories switching to the proposed units. Moreover, the harmonization program is still progressing, with additional laboratories converting to the consensus units.
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Affiliation(s)
- Marianne Demarteau
- Scientific Institute of Public Health , Department of Quality of Medical Laboratories , Brussels , Belgium
| | | | - Nathalie M. Vandevelde
- Scientific Institute of Public Health , Department of Quality of Medical Laboratories , Brussels , Belgium
| | | | - Wim Coucke
- Scientific Institute of Public Health , Department of Quality of Medical Laboratories , Brussels , Belgium
| | - Bernard China
- Scientific Institute of Public Health , Department of Quality of Medical Laboratories , Brussels , Belgium
| | - Alain G. Verstraete
- Department of Laboratory Medicine , Ghent University Hospital and Department of Clinical Chemistry, Microbiology and Immunology, Ghent University , Ghent , Belgium
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25
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Pyo SS, Nam HS, Cha YJ, Lee S, Lee HK. Harmonization of Hemolysis Index in Clinical Chemistry Laboratory and Its Application as a Result Verification Tool. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2017. [DOI: 10.15324/kjcls.2017.49.4.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Sang Shin Pyo
- Department of Laboratory Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Korea
| | - Hyun Su Nam
- Department of Laboratory Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Korea
| | - Young Jong Cha
- Department of Laboratory Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Korea
| | - Seungkwan Lee
- Department of Health and Environmental Science, College of Health Science, KoreaUniversity, Seoul, Korea
| | - Hae Kyung Lee
- Department of Laboratory Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Korea
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26
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Bogavac-Stanojevic N, Jelic-Ivanovic Z. The Cost-effective Laboratory: Implementation of Economic Evaluation of Laboratory Testing. J Med Biochem 2017; 36:238-242. [PMID: 30568540 PMCID: PMC6287218 DOI: 10.1515/jomb-2017-0036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 06/06/2017] [Indexed: 12/12/2022] Open
Abstract
Laboratory testing as a part of laboratory in vitro diagnostic (IVD) has become required tool in clinical practice for diagnosing, monitoring and prognosis of diseases, as well as for prediction of treatment response. The number of IVD tests available in laboratory practice has increased over the past decades and is likely to further increase in the future. Consequently, there is growing concern about the overutilization of laboratory tests and rising costs for laboratory testing. It is estimated that IVD accounts for between 1.4 and 2.3% of total healthcare expenditure and less than 5% of total hospital cost (Lewin Group report). These costs are rather low when compared to pharmaceuticals and medical aids which account for 15 and 5%, respectively. On the other hand, IVD tests play an important role in clinical practice, as they influence from 60% to 70% of clinical decision-making. Unfortunately, constant increases in healthcare spending are not directly related to healthcare benefit. Since healthcare resources are limited, health payers are interested whether the benefits of IVD tests are actually worth their cost. Many articles have introduced frameworks to assess the economic value of IVD tests. The most appropriate tool for quantitative assessment of their economic value is cost-effectiveness (CEA) and cost-utility (CUA) analysis. The both analysis determine cost in terms of effectiveness or utilities (combine quantity and quality of life) of new laboratory test against its alternative. On the other hand, some investigators recommended calculation of laboratory test value as product of two ratios: Laboratory test value = (Technical accuracy/Turnaround time) × (Utility/Costs). Recently, some researches used multicriteria decision analysis which allows comparison of diagnostic strategies in terms of benefits, opportunities, costs and risks. All analyses are constructed to identify laboratory test that produce the greatest healthcare benefit with the resources available. Without solid evidence that certain laboratory tests are cost-effective, laboratory services cannot be improved. Consequently, simple policy measures such as cost cutting may be imposed upon many laboratories while patients will have limited access to laboratory service.
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Affiliation(s)
| | - Zorana Jelic-Ivanovic
- University of Belgrade - Faculty of Pharmacy, Department of Medical Biochemistry, Belgrade, Serbia
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27
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Krintus M, Plebani M, Panteghini M. Improving clinical laboratory performance through quality indicators. Clin Biochem 2017; 50:547-549. [DOI: 10.1016/j.clinbiochem.2017.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 05/05/2017] [Indexed: 01/06/2023]
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28
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Dolci A, Giavarina D, Pasqualetti S, Szőke D, Panteghini M. Total laboratory automation: Do stat tests still matter? Clin Biochem 2017; 50:605-611. [PMID: 28390779 DOI: 10.1016/j.clinbiochem.2017.04.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 04/04/2017] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
Abstract
During the past decades the healthcare systems have rapidly changed and today hospital care is primarily advocated for critical patients and acute treatments, for which laboratory test results are crucial and need to be always reported in predictably short turnaround time (TAT). Laboratories in the hospital setting can face this challenge by changing their organization from a compartmentalized laboratory department toward a decision making-based laboratory department. This requires the implementation of a core laboratory, that exploits total laboratory automation (TLA) using technological innovation in analytical platforms, track systems and information technology, including middleware, and a number of satellite specialized laboratory sections cooperating with care teams for specific medical conditions. In this laboratory department model, the short TAT for all first-line tests performed by TLA in the core laboratory represents the key paradigm, where no more stat testing is required because all samples are handled in real-time and (auto)validated results dispatched in a time that fulfills clinical needs. To optimally reach this goal, laboratories should be actively involved in managing all the steps covering the total examination process, speeding up also extra-laboratory phases, such sample delivery. Furthermore, to warrant effectiveness and not only efficiency, all the processes, e.g. specimen integrity check, should be managed by middleware through a predefined set of rules defined in light of the clinical governance.
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Affiliation(s)
- Alberto Dolci
- Clinical Pathology Unit, "Luigi Sacco" University Hospital, Milan, Italy.
| | - Davide Giavarina
- Clinical Chemistry and Hematology Laboratory, "San Bortolo" Hospital, Vicenza, Italy
| | - Sara Pasqualetti
- Clinical Pathology Unit, "Luigi Sacco" University Hospital, Milan, Italy
| | - Dominika Szőke
- Clinical Pathology Unit, "Luigi Sacco" University Hospital, Milan, Italy
| | - Mauro Panteghini
- Clinical Pathology Unit, "Luigi Sacco" University Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan Medical School, Milan, Italy
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Abstract
A body of evidence collected in the last few decades demonstrates that the pre- and post-analytical phases of the testing cycle are more error-prone than the analytical phase. However, the paradigm of errors and quality in laboratory medicine has been questioned, analytical mistakes continuing to be a major cause of adverse clinical outcomes and patient harm. Although the brain-to-brain concept is widely recognized in the community of laboratory professionals, there is lack of clarity concerning the inter-relationship between the different phases of the cycle, interdependence between the pre-analytical phase and analytical quality, and the effect of the post-analytical steps on the quality of ultimate laboratory information. Analytical quality remains the "core business" of clinical laboratories, but laboratory professionals and clinicians alike should never lose sight of the fact that pre-analytical variables are often responsible for erroneous test results and that quality biospecimens are pre-requisites for a reliable analytical phase. In addition, the pressure for expert advice on test selection and interpretation of results has increased hand in hand with the ever-increasing complexity of tests and diagnostic fields. Finally, the data on diagnostic errors and inappropriate clinical decisions made due to delay or misinterpretation of laboratory data underscore the current need for greater collaboration at the clinical-laboratory interface.
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Ferraro S, Panteghini M. The role of laboratory in ensuring appropriate test requests. Clin Biochem 2017; 50:555-561. [PMID: 28284827 DOI: 10.1016/j.clinbiochem.2017.03.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/03/2017] [Accepted: 03/04/2017] [Indexed: 12/15/2022]
Abstract
This review highlights the role of laboratory professionals and the strategies to be promoted in strict cooperation with clinicians for auditing, monitoring and improving the appropriateness of test request. The introduction of local pathways and care maps in agreement with international and national guidelines as well as the implementation of reflex testing and algorithms have a central role in guiding test request and in correcting the overuse/misuse of tests. Furthermore, removing obsolete tests from laboratory menu and vetting of restricted tests is recommended to increase cost-effectiveness. This saves costs and permits to introduce new biomarkers with increased diagnostic accuracy with a better impact on patient outcome. An additional issue is concerning the periodicity of (re)testing, accounting that only a minority of tests may be ordered as often as necessary. In the majority of cases, a minimum retesting interval should be introduced. The availability of effective computerised order entry systems is relevant in ensuring appropriate test requests and in providing an aid by automated rules that may stop inappropriate requests before they reach the laboratory.
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Affiliation(s)
- Simona Ferraro
- Clinical Pathology Unit, 'Luigi Sacco' University Hospital, University of Milan, Milan, Italy.
| | - Mauro Panteghini
- Clinical Pathology Unit, 'Luigi Sacco' University Hospital, University of Milan, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
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Clerico A, Ripoli A, Fortunato A, Alfano A, Carrozza C, Correale M, Dittadi R, Gessoni G, Migliardi M, Rizzardi S, Prontera C, Masotti S, Zucchelli G, Guiotto C, Iacovazzi PA, Iervasi G. Harmonization protocols for TSH immunoassays: a multicenter study in Italy. ACTA ACUST UNITED AC 2017; 55:1722-1733. [DOI: 10.1515/cclm-2016-0899] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 01/25/2017] [Indexed: 11/15/2022]
Abstract
AbstractBackground:Systematic difference between thyroid-stimulating hormone (TSH) immunoassays may produce misleading interpretation when samples of the same patients are measured with different methods. The study aims were to evaluate whether systematic differences are present among TSH immunoassays, and whether it is possible to obtain a better harmonization among TSH methods using results obtained in external quality assessment (EQA) schemes.Methods:Seven Italian clinical laboratories measured TSH in 745 serum samples of healthy subjects and patients with thyroid disorders. These samples were also re-measured by two reference laboratories of the study with the six TSH immunoassays most popular in Italy after 2 months of storage at −80 °C. Moreover, these data were compared to 53,823 TSH measurements, obtained by laboratories participant to 2012–2015 EQA annual cycles in 72 quality control samples (TSH concentrations from about 0.1 mIU/L to 18.0 mIU/L). TSH concentrations were recalibrated using a mathematical approach based on the principal component analysis (PCA).Results:Systematic differences were found between the most popular commercially available TSH immunoassays. TSH concentrations measured by the clinical laboratories were very closely correlated to those measured with the same method by reference laboratories after 2 months of storage at −80 °C. After recalibration using the PCA approach the variation of TSH values significantly decreased from a median pre-calibration value of 13.53% (10.79%–16.53%) to 9.63% (6.90%–13.21%) after recalibration.Conclusions:Our data suggest that EQA schemes are useful to improve harmonization among TSH immunoassays and also to produce some mathematical formulas, which can be used by clinicians to better compare TSH values measured with different methods.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University Hospital of Verona, P.le LA Scuro 10, 37134 – Verona, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Italy ; and Editor in Chief of Clinical Chemistry and Laboratory Medicine
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Yusof MM, Arifin A. Towards an evaluation framework for Laboratory Information Systems. J Infect Public Health 2016; 9:766-773. [PMID: 27665060 DOI: 10.1016/j.jiph.2016.08.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 07/20/2016] [Accepted: 08/24/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Laboratory testing and reporting are error-prone and redundant due to repeated, unnecessary requests and delayed or missed reactions to laboratory reports. Occurring errors may negatively affect the patient treatment process and clinical decision making. Evaluation on laboratory testing and Laboratory Information System (LIS) may explain the root cause to improve the testing process and enhance LIS in supporting the process. This paper discusses a new evaluation framework for LIS that encompasses the laboratory testing cycle and the socio-technical part of LIS. METHODOLOGY Literature review on discourses, dimensions and evaluation methods of laboratory testing and LIS. A critical appraisal of the Total Testing Process (TTP) and the human, organization, technology-fit factors (HOT-fit) evaluation frameworks was undertaken in order to identify error incident, its contributing factors and preventive action pertinent to laboratory testing process and LIS. RESULT A new evaluation framework for LIS using a comprehensive and socio-technical approach is outlined. Positive relationship between laboratory and clinical staff resulted in a smooth laboratory testing process, reduced errors and increased process efficiency whilst effective use of LIS streamlined the testing processes. CONCLUSION The TTP-LIS framework could serve as an assessment as well as a problem-solving tool for the laboratory testing process and system.
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Affiliation(s)
- Maryati M Yusof
- Centre for Software Technology & Management, Faculty of Information Science and Technology, Universiti Kebangsaan Malaysia, 43600 Bangi, Selangor, Malaysia.
| | - Azila Arifin
- Centre for Software Technology & Management, Faculty of Information Science and Technology, Universiti Kebangsaan Malaysia, 43600 Bangi, Selangor, Malaysia.
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Pelloso M, Basso D, Padoan A, Fogar P, Plebani M. Computer-based-limited and personalised education management maximise appropriateness of vitamin D, vitamin B12 and folate retesting. J Clin Pathol 2016; 69:777-83. [DOI: 10.1136/jclinpath-2015-203447] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 01/13/2016] [Indexed: 12/18/2022]
Abstract
AimTo identify the best management strategy for improving the appropriateness of vitamin D, vitamin B12 and folate retesting.MethodsThe study was conducted between 3 November 2012 and 8 June 2015, with inpatients and outpatients being considered separately. After an observational reference period (3 November 2012 to 14 September 2013), an information technology (IT)-based permissive strategy (16 September 2013 to 27 July 2014) followed by a limiting strategy was used to manage the demand for inpatient retesting. For outpatients, an educational strategy period (28 July 2014 to 16 December 2014) with direct contact between medical personnel and general practitioners (GPs) was followed by a post-educational period without any restriction. Data from a total of 66 496 patients for vitamin D, 14 618 for vitamin B12 and 14 445 for folate were retrieved from the laboratory IT system. The main outcomes measures were inappropriate vitamin D, vitamin B12 and folate retesting. The minimal retesting intervals were 90 (vitamin D) or 180 days (vitamin B12 and folate).ResultsIn the absence of a laboratory demand strategy, the frequency of inappropriate retesting for vitamin D, vitamin B12 and folate was 60%, 94% and 93%, respectively, for inpatients, and 27%, 87% and 87%, respectively, for outpatients. A limiting IT-based demand management strategy reduced inappropriate retesting for vitamin D (36%), but not for vitamin B12 and folate. The educational strategy was followed by a reduction in inappropriate retesting among outpatients (16% for vitamin D, 72% for vitamin B12 and folate).ConclusionsLaboratory demand management based on an IT-limiting management strategy or on education of the referring physicians appears helpful in maximising appropriate retesting.
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Plebani M. Harmonization in laboratory medicine: Requests, samples, measurements and reports. Crit Rev Clin Lab Sci 2015; 53:184-96. [DOI: 10.3109/10408363.2015.1116851] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Salivary cortisol and cortisone by LC–MS/MS: validation, reference intervals and diagnostic accuracy in Cushing's syndrome. Clin Chim Acta 2015; 451:247-51. [DOI: 10.1016/j.cca.2015.10.004] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 09/08/2015] [Accepted: 10/05/2015] [Indexed: 01/17/2023]
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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.
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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
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Abstract
Defensive medicine often involves the excessive ordering of diagnostic tests. Constantly aware of the risk of malpractice liability, physicians turn to diagnostic tests with the goal of reducing the likelihood of error. Findings reported in literature suggest that medical malpractice contributes significantly to the increased use of diagnostic testing and related costs. It has also been demonstrated that defensive testing not only increases costs but harms patients to a degree that depends on the risk incurred by the test itself, its false-positive and false-negative rates, the benefits and risks of available therapies, and the prior probability of disease. Several solutions have been proposed in the attempt to address this issue, but the physician's competence and training appear to be key factors, data from clinical trials showing that education and feedback for improving test-ordering tendencies have a prolonged effect. Particularly in the field of laboratory medicine, increasing attention is being paid to improving demand management in order to minimize inappropriate testing.
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Affiliation(s)
- Mario Plebani
- 1Department of Laboratory Medicine, University-Hospital, Padova, Azienda Ospedaliera di Padova Via Nicolo Giustiniani 2 Padova 35128, Italy
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Tate JR, Johnson R, Barth JH, Panteghini M. “Harmonization of laboratory testing — A global activity”. Clin Chim Acta 2014; 432:1-3. [DOI: 10.1016/j.cca.2014.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 02/07/2014] [Indexed: 11/27/2022]
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40
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Plebani M, Sciacovelli L, Aita A, Chiozza ML. Harmonization of pre-analytical quality indicators. Biochem Med (Zagreb) 2014; 24:105-13. [PMID: 24627719 PMCID: PMC3936970 DOI: 10.11613/bm.2014.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 11/28/2013] [Indexed: 11/08/2022] Open
Abstract
Quality indicators (QIs) measure the extent to which set targets are attained and provide a quantitative basis for achieving improvement in care and, in particular, laboratory services. A body of evidence collected in recent years has demonstrated that most errors fall outside the analytical phase, while the pre- and post-analytical steps have been found to be more vulnerable to the risk of error. However, the current lack of attention to extra-laboratory factors and related QIs prevent clinical laboratories from effectively improving total quality and reducing errors. Errors in the pre-analytical phase, which account for 50% to 75% of all laboratory errors, have long been included in the ‘identification and sample problems’ category. However, according to the International Standard for medical laboratory accreditation and a patient-centered view, some additional QIs are needed. In particular, there is a need to measure the appropriateness of all test request and request forms, as well as the quality of sample transportation. The QIs model developed by a working group of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) is a valuable starting point for promoting the harmonization of available QIs, but further efforts should be made to achieve a consensus on the road map for harmonization.
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Affiliation(s)
- Mario Plebani
- Department of Laboratory Medicine, University Hospital, Padova, Italy
| | - Laura Sciacovelli
- Department of Laboratory Medicine, University Hospital, Padova, Italy
| | - Ada Aita
- Department of Laboratory Medicine, University Hospital, Padova, Italy
| | - Maria Laura Chiozza
- Department for Quality and Accreditation, University Hospital, Padova, Italy
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