Anatomy of a value proposition for laboratory medicine

Cost-Effectiveness and Return on Investment Analysis of an In-house HemosIL Heparin-Induced Thrombocytopenia Antibody Assay at a Mid-Sized Institution

CONTEXT.—

Laboratories face the challenge of providing quality patient care while managing costs and turnaround times (TATs). To this end, we brought the heparin-induced thrombocytopenia (HIT) antibody test in-house with the goal of reducing costs and the time to diagnosis.

OBJECTIVES.—

To determine the cost-effectiveness and return on investment of our in-house HIT antibody test by comparing it to send-out assays with TATs of 2, 3, or 4 days.

DESIGN.—

We performed a retrospective chart review of all patients with a HIT antibody assay and analysis of laboratory financial records. Analysis included the percentage of patients receiving alternative treatment, cost of treatment, startup costs of bringing the test in-house, and average TAT of the in-house test.

RESULTS.—

We found significant reductions in the cost of treatment for patients and the overall cost to the health care system. The in-house assay became cost-effective at between 8 and 20 tests, with a return on investment of up to 298%.

CONCLUSIONS.—

Bringing the HIT antibody assay in-house becomes cost-effective at a very low test volume with excellent return on investment. This novel analysis can provide a framework for other laboratory medicine professionals to analyze the benefits of bringing this and other assays in-house.

Improved implementation of medical tests - barriers and opportunities

Applying the concept of a value proposition to medical testing is just one of the many ways to identify and monitor the value of tests. A key part of this concept focusses on processes that should take place after a test is introduced into routine local practice, namely test implementation. This process requires identification of the clinical pathway, the stakeholders and the benefits or disbenefits that accrue to those stakeholders. There are various barriers and challenges to test implementation. Implementation requires the process of clinical audit which involves measurement of outcomes external to the laboratory but this is not widely performed in laboratory medicine. A second key challenge is that implementation requires liaison with stakeholders outside of the laboratory including clinicians and other healthcare professional such as finance managers. Many laboratories are remote from clinical care and other stakeholders making such liaison difficult. The implementation process is based on data which again will be primarily on processes outside of the laboratory. However the recent enthusiasm for so-called real world data and new data mining techniques may represent opportunities that will facilitate better test implementation. A final barrier is that a range of new tools not currently in the education curriculum of the laboratory professional is required for implementation such as those of preparing a business case to support the introduction of a test and health economic analysis. The professional bodies in laboratory medicine could assist with education in these areas.

Molecular chlamydia and gonorrhoea point of care tests implemented into routine practice: Systematic review and value proposition development

BACKGROUND

Sexually Transmitted Infections, including Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT), continue to be a global health problem. Increased access to point-of-care-tests (POCTs) could help detect infection and lead to appropriate management of cases and contacts, reducing transmission and development of reproductive health sequelae. Yet diagnostics with good clinical effectiveness evidence can fail to be implemented into routine care. Here we assess values beyond clinical effectiveness for molecular CT/NG POCTs implemented across diverse routine practice settings.

METHODS

We conducted a systematic review of peer-reviewed primary research and conference abstract publications in Medline and Embase reporting on molecular CT/NG POCT implementation in routine clinical practice until 16th February 2021. Results were extracted into EndNote software and initially screened by title and abstract by one author according to the inclusion and exclusion criteria. Articles that met the criteria, or were unclear, were included for full-text assessment by all authors. Results were synthesised to assess the tests against guidance criteria and develop a CT/NG POCT value proposition for multiple stakeholders and settings.

FINDINGS

The systematic review search returned 440 articles; 28 were included overall. The Cepheid CT/NG GeneXpert was the only molecular CT/NG POCT implemented and evaluated in routine practice. It did not fulfil all test guidance criteria, however, studies of test implementation showed multiple values for test use across various healthcare settings and locations. Our value proposition highlights that the majority of values are setting-specific. Sexual health services and outreach services have the least overlap, with General Practice and other non-sexual health specialist services serving as a "bridge" between the two.

CONCLUSIONS

Those wishing to improve CT/NG diagnosis should be supported to identify the values most relevant to their settings and context, and prioritise implementation of tests that are most closely aligned with those values.

Who Conducts Health Economic Evaluations of Laboratory Tests? A Scoping Review

Background

Health economic evaluations (HEEs) are effectively used to inform decision making in healthcare. We sought to assess the level of involvement of laboratory professionals (LPs) in HEEs of laboratory tests.

Methods

A systematic literature search was conducted in Medline (2013 to November 28, 2018) for original articles reporting HEEs of medical laboratory tests. Eligible studies were characterized by indication, utilization, region, setting, study design, primary outcome measures, and sponsorship. Authors were classified based on stated affiliation as clinician, scientist, public health expert, or LP.

Results

In total, 140 HEEs were included in the study, of which 24 (17.1%) had contributions from LPs. Studies were primarily focused on infectious disease (n = 68), oncology (n = 23), and cardiovascular disease (n = 16). Cost-utility or cost-effectiveness analyses (n = 117) were the most frequent study types, with effectiveness measured mainly in terms of quality-adjusted life-years (n = 57) and detected cases (n = 41). Overall, 76% of HEEs followed a social or health system perspective, whereas 15% took a hospital viewpoint. Partial or full funding was received from public health organizations or industry in 39% and 16% of studies, respectively. The involvement of LPs was associated with test utilization, secondary care, analytic perspective, and an immediate time horizon (all P < 0.05). Quality of studies was found to be lower in HEEs coauthored by LPs.

Conclusion

Multidisciplinary collaboration is essential to understanding the complexity of clinical pathways. HEEs are used effectively to inform healthcare decision making. The involvement of LPs in HEEs is low. This implies that laboratory expertise is frequently not considered in decision processes.

Plasma PIK3CA Mutation Testing in Advanced Breast Cancer Patients for Personalized Medicine: A Value Proposition

BACKGROUND

Even though endocrine therapy is often initially successful in treating advanced breast cancer, most patients inevitably face disease progression. In advanced hormone receptor-positive (HR+) breast cancer, activation of the PI3K downstream pathway is a critical feature of the mechanism of endocrine resistance. A significant recent advance in treating HR+ advanced breast cancer has been the recent introduction of PI3K inhibitor (PI3Ki) for the treatment of patients with HR+, HER2-negative (HER2-) advanced or metastatic breast cancer that harbors PIK3CA mutations. A value proposition concept was applied to assess the potential benefits of cell-free tumor DNA (ctDNA) testing to identify patients who might respond to PI3Ki treatment.

CONTENT

By applying the framework of the value proposition to >35 publications, in addition to recommendations from professional organizations, it was evident that robust clinical evidence exists to support the role of ctDNA PIK3CA mutation evaluation in identifying patients with advanced breast cancer who could benefit from PI3Ki treatment.

SUMMARY

Detection of PIK3CA gene mutations in HR+HER2- advanced breast cancer patients allows for the identification of patients who might benefit from more effective personalized treatment with molecularly targeted drugs.

Where Is the Value of Laboratory Medicine and How Do You Unlock It?

BACKGROUND

The innovation pathway by which a newly discovered biomarker is developed into a medical test and used in routine clinical practice comprises a number of different processes split between 2 phases. The first follows on from biomarker discovery and involves the development of a robust analytical method, the accumulation of evidence to show its clinical and cost-effectiveness, and then adoption into clinical pathways. The second phase is one of implementation and sustainability, with active performance management to ensure that the test continues to deliver the benefits promised at the time of its adoption.

CONTENT

To date there has been much more emphasis on the first phase of discovery and accumulation of evidence to demonstrate effectiveness. Insufficient attention has been paid to the second phase of translating that evidence into routine practice, with little real-world evidence to demonstrate the benefits to all of the stakeholders involved in delivering and receiving care. Changes in healthcare that include a move away from activity-based costing to a more value-based approach require more attention be paid to what happens after a test is adopted, including an understanding of the clinical pathway, the stakeholders within that pathway, and the benefits and "disbenefits" that accrue to these stakeholders.

SUMMARY

The value proposition provides a guide for successful implementation of a test. Although it can address both adoption and implementation, it highlights that the requirements for test implementation are quite different to those of adoption, with an emphasis on real-world evidence and outcomes.

Dissemination and Implementation of Evidence-Based Dementia Care Using Embedded Pragmatic Trials

There are many nonpharmacologic interventions tested in randomized clinical trials that demonstrate significant benefits for people living with Alzheimer's disease (AD) and AD-related dementia, their care partners, or professional care providers. Nevertheless, with few exceptions, proven interventions have not been translated for delivery in real-world settings, such as home care, primary care, hospitals, community-based services, adult day services, assisted living, nursing homes, or other healthcare systems (HCSs). Using embedded pragmatic clinical trial (ePCT) methods is one approach that can facilitate dissemination and implementation (D&I) of dementia care interventions. The science of D&I can inform the integration of evidence-based dementia care in HCSs by offering theoretical frameworks that capture field complexities and guiding evaluation of implementation processes. Also, D&I science can suggest evidence-based strategies for implementing dementia care in HCSs. Although D&I considerations can inform each stage of dementia care intervention development, it is particularly critical when designing ePCTs. This article examines fundamental considerations for implementing dementia-specific interventions in HCSs and how best to prepare for successful dissemination upstream in the context of ePCTs, thereby illustrating the critical role of the D&I Core of the National Institute on Aging Imbedded Pragmatic Alzheimer's Disease and AD-Related Dementias Clinical Trials Collaboratory. The scientific premise of the D&I Core is that having the "end" in mind, upfront in the design and testing of dementia care programs, can lead to decision-making that optimizes the ultimate goal of wide-scale D&I of evidence-based dementia care programs in HCSs. J Am Geriatr Soc 68:S28-S36, 2020.

The Pursuit of Value in Laboratory Medicine - Progress and Challenges

The pressure on healthcare budgets including laboratory medicine is relentless and the focus on activities and costs remains the dominant funding model of laboratory medicine everywhere. The limitations of this model are well documented and for a decade or more laboratory professions worldwide have started looking at alternative models where the value of laboratory medicine and its impact on patient outcomes are the predominant driving force. There are multiple ways to determine the value of a medical test, particularly if one takes into consideration its impact upon the complete clinical pathway. Thus various approaches to value determination are being explored by a number of international organisations. These organisations will be reviewed below, including one which uses the concept of a value proposition that describes in detail how a test should be implemented by measuring its clinical, operational and economic impact. All approaches for determination of value require professional leadership. There is a need for research of varying types including that related to translating global evidence into local practice, a key challenge facing laboratory medicine and healthcare generally. Another challenge is to think and act beyond the silo of the laboratory to achieve greater collaboration with those colleagues more directly involved in patient care.

Evaluating diagnostic strategies for early detection of cancer: the CanTest framework

BACKGROUND

Novel diagnostic triage and testing strategies to support early detection of cancer could improve clinical outcomes. Most apparently promising diagnostic tests ultimately fail because of inadequate performance in real-world, low prevalence populations such as primary care or general community populations. They should therefore be systematically evaluated before implementation to determine whether they lead to earlier detection, are cost-effective, and improve patient safety and quality of care, while minimising over-investigation and over-diagnosis.

METHODS

We performed a systematic scoping review of frameworks for the evaluation of tests and diagnostic approaches.

RESULTS

We identified 16 frameworks: none addressed the entire continuum from test development to impact on diagnosis and patient outcomes in the intended population, nor the way in which tests may be used for triage purposes as part of a wider diagnostic strategy. Informed by these findings, we developed a new framework, the 'CanTest Framework', which proposes five iterative research phases forming a clear translational pathway from new test development to health system implementation and evaluation.

CONCLUSION

This framework is suitable for testing in low prevalence populations, where tests are often applied for triage testing and incorporated into a wider diagnostic strategy. It has relevance for a wide range of stakeholders including patients, policymakers, purchasers, healthcare providers and industry.

The value proposition for point-of-care testing in healthcare: HbA1c for monitoring in diabetes management as an exemplar

Point-of-care testing (POCT) is a key enabling technology for disruptive and transformative innovation in healthcare, allowing tests to be performed quickly and close to the patient. This results in faster clinical decision making and new, more efficient models of care, with clinical, process and economic benefits potentially accruing to all stakeholders. Recognised barriers to the adoption of new technology such as POCT include poor understanding of current practice and thus the unmet need, the challenges of process change, and reluctance to disinvest in redundant resources resulting from improved pathway efficiency. Major contributors to this problem include a background of funding, organisation and management of healthcare that fails to recognise the complexity of a multiple stakeholder health economy seeking to become more outcomes-based and value driven. We examine the concept of a structured value proposition as a generic tool to achieve better adoption of POCT using as an example, the evidence that is available for the rapid measurement of glycated haemoglobin (HbA1c) in the management of diabetes. We highlight the key components of the value proposition, identifying the impact of the test result on all stakeholders and the metrics which are required to define current practice (e.g. a laboratory-based HbA1c testing service), in order to develop the business case and the implementation plan required to demonstrate effective adoption of a POCT-based service. We conclude that the value proposition helps to identify the potential benefits to be gained from using POCT, and the stakeholders to whom they accrue.

Translational health economics: The key to accountable adoption of in vitro diagnostic technologies

Adoption of new technologies, including diagnostic tests, is often considered not to deliver the expected return on investment. The reasons for this poor link between expectation and outcome include lack of evidence, variation in use of the technology, and an inability of the health system to manage the balance between investment and disinvestment associated with the change in care pathway. The challenges lie in the complex nature of healthcare provision where the investment is likely to be made in the jurisdiction of one stakeholder while the benefits (as well as dis-benefits) accrue to the other stakeholders. A prime example is found in the field of laboratory medicine and the use of diagnostic tests. The current economic tools employed in healthcare are primarily used to make policy and strategic decisions, particularly across health systems, and in purchaser and provider domains. These tools primarily involve cost effectiveness and budget impact analyses, both of which have been applied in health technology assessment of diagnostic technologies. However, they lack the granularity to translate findings down to the financial management and operational decision making at the provider department level. We propose an approach to translational health economics based on information derived from service line management and time-driven activity-based costing, identifying the resource utilisation for each of the units involved in the delivery of a care pathway, before and after adoption of new technology. This will inform investment and disinvestment decisions, along with identifying where the benefits, and dis-benefits, can be achieved for all stakeholders.

Improving American Healthcare Through "Clinical Lab 2.0": A Project Santa Fe Report

Project Santa Fe was established both to provide thought leadership and to help develop the evidence base for the valuation of clinical laboratory services in the next era of American healthcare. The participants in Project Santa Fe represent major regional health systems that can operationalize laboratory-driven innovations and test their valuation in diverse regional marketplaces in the United States. We provide recommendations from the inaugural March 2016 meeting of Project Santa Fe. Specifically, in the transition from volume-based to value-based health care, clinical laboratories are called upon to provide programmatic leadership in reducing total cost of care through optimization of time-to-diagnosis and time-to-effective therapeutics, optimization of care coordination, and programmatic support of wellness care, screening, and monitoring. This call to action is more than working with industry stakeholders on the basis of our expertise; it is providing leadership in creating the programs that accomplish these objectives. In so doing, clinical laboratories can be effectors in identifying patients at risk for escalation in care, closing gaps in care, and optimizing outcomes of health care innovation. We also hope that, through such activities, the evidence base will be created for the new value propositions of integrated laboratory networks. In the very simplest sense, this effort to create “Clinical Lab 2.0” will establish the impact of laboratory diagnostics on the full 100% spend in American healthcare, not just the 2.5% spend attributed to in vitro diagnostics. In so doing, our aim is to empower regional and local laboratories to thrive under new models of payment in the next era of American health care delivery.

Critical appraisal in the practice of laboratory medicine

Critical appraisal is a key skill employed across the spectrum of laboratory medicine practice. It underpins the use of information that is relevant, of good quality and is meaningful. Relevance is answering the right question for the right patient at the right time, with quality ensuring provision of the right information. Meaningful is making the right decisions in order to deliver the right outcomes. Critical appraisal is about minimizing the risk of bias or 'departures from trueness' in all of the facets of laboratory medicine practice. It can be summarized in four steps: (i) a clear understanding and articulation of the problem being addressed - whether it be an analytical challenge, individual patient care or policymaking; (ii) verifying the methodological approach employed; (iii) assuring the reliability of the results and (iv) ensuring the applicability and implications of the results. Reference is made to a number of checklists that can be used to assist in the process of critical appraisal.