1
|
Devis L, Catry E, Honore PM, Mansour A, Lippi G, Mullier F, Closset M. Interventions to improve appropriateness of laboratory testing in the intensive care unit: a narrative review. Ann Intensive Care 2024; 14:9. [PMID: 38224401 PMCID: PMC10789714 DOI: 10.1186/s13613-024-01244-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/03/2024] [Indexed: 01/16/2024] Open
Abstract
Healthcare expenses are increasing, as is the utilization of laboratory resources. Despite this, between 20% and 40% of requested tests are deemed inappropriate. Improper use of laboratory resources leads to unwanted consequences such as hospital-acquired anemia, infections, increased costs, staff workload and patient stress and discomfort. The most unfavorable consequences result from unnecessary follow-up tests and treatments (overuse) and missed or delayed diagnoses (underuse). In this context, several interventions have been carried out to improve the appropriateness of laboratory testing. To date, there have been few published assessments of interventions specific to the intensive care unit. We reviewed the literature for interventions implemented in the ICU to improve the appropriateness of laboratory testing. We searched literature from 2008 to 2023 in PubMed, Embase, Scopus, and Google Scholar databases between April and June 2023. Five intervention categories were identified: education and guidance (E&G), audit and feedback, gatekeeping, computerized physician order entry (including reshaping of ordering panels), and multifaceted interventions (MFI). We included a sixth category exploring the potential role of artificial intelligence and machine learning (AI/ML)-based assisting tools in such interventions. E&G-based interventions and MFI are the most frequently used approaches. MFI is the most effective type of intervention, and shows the strongest persistence of effect over time. AI/ML-based tools may offer valuable assistance to the improvement of appropriate laboratory testing in the near future. Patient safety outcomes are not impaired by interventions to reduce inappropriate testing. The literature focuses mainly on reducing overuse of laboratory tests, with only one intervention mentioning underuse. We highlight an overall poor quality of methodological design and reporting and argue for standardization of intervention methods. Collaboration between clinicians and laboratory staff is key to improve appropriate laboratory utilization. This article offers practical guidance for optimizing the effectiveness of an intervention protocol designed to limit inappropriate use of laboratory resources.
Collapse
Affiliation(s)
- Luigi Devis
- Department of Laboratory Medicine, Biochemistry, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium
| | - Emilie Catry
- Department of Laboratory Medicine, Biochemistry, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium
- Institute for Experimental and Clinical Research (IREC), Pôle Mont Godinne (MONT), UCLouvain, Yvoir, Belgium
| | - Patrick M Honore
- Department of Intensive Care, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou University Hospital of Rennes, Rennes, France
- IRSET-INSERM-1085, Univ Rennes, Rennes, France
| | - Giuseppe Lippi
- Section of Clinical Biochemistry and School of Medicine, University Hospital of Verona, Verona, Italy
| | - François Mullier
- Department of Laboratory Medicine, Hematology, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Namur, Belgium
- Institute for Experimental and Clinical Research (IREC), Pôle Mont Godinne (MONT), UCLouvain, Yvoir, Belgium
| | - Mélanie Closset
- Department of Laboratory Medicine, Biochemistry, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium.
- Institute for Experimental and Clinical Research (IREC), Pôle Mont Godinne (MONT), UCLouvain, Yvoir, Belgium.
| |
Collapse
|
2
|
Cadamuro J. Disruption vs. evolution in laboratory medicine. Current challenges and possible strategies, making laboratories and the laboratory specialist profession fit for the future. Clin Chem Lab Med 2023; 61:558-566. [PMID: 36038391 DOI: 10.1515/cclm-2022-0620] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/01/2022] [Indexed: 01/06/2023]
Abstract
Since beginning of medical diagnostics, laboratory specialists have done an amazing job, continuously improving quality, spectrum and speed of laboratory tests, currently contributing to the majority of medical decision making. These improvements are mostly of an incremental evolutionary fashion, meaning improvements of current processes. Sometimes these evolutionary innovations are of a radical fashion, such as the invention of automated analyzers replacing manual testing or the implementation of mass spectrometry, leading to one big performance leap instead of several small ones. In few cases innovations may be of disruptive nature. In laboratory medicine this would be applicable to digitalization of medicine or the decoding of the human genetic material. Currently, laboratory medicine is again facing disruptive innovations or technologies, which need to be adapted to as soon as possible. One of the major disruptive technologies is the increasing availability and medical use of artificial intelligence. It is necessary to rethink the position of the laboratory specialist within healthcare settings and the added value he or she can provide to patient care. The future of the laboratory specialist profession is bright, as it the only medical profession comprising such vast experience in patient diagnostics. However, laboratory specialists need to develop strategies to provide this expertise, by adopting to the quickly evolving technologies and demands. This opinion paper summarizes some of the disruptive technologies as well as strategies to secure and/or improve the quality of diagnostic patient care and the laboratory specialist profession.
Collapse
Affiliation(s)
- Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria
| |
Collapse
|
3
|
Cadamuro J, Simundic AM, von Meyer A, Haschke-Becher E, Keppel MH, Oberkofler H, Felder TK, Mrazek C. Diagnostic Workup of Microcytic Anemia: An Evaluation of Underuse or Misuse of Laboratory Testing in a Hospital Setting Using the AlinIQ System. Arch Pathol Lab Med 2023; 147:117-124. [PMID: 35472855 DOI: 10.5858/arpa.2021-0283-oa] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2021] [Indexed: 12/31/2022]
Abstract
CONTEXT.— Underuse of laboratory testing has been previously investigated in preselected populations, such as documented malpractice claims. However, these numbers might not reflect real-life situations. OBJECTIVE.— To evaluate the underuse and misuse of laboratory follow-up testing in a real-life hospital patient population with microcytic anemia, using laboratory results ordered during routine patient care. DESIGN.— From all patients in whom a microcytic anemia was detected during routine diagnostics in 2018, all available laboratory data were collected and screened for appropriateness of diagnostic workup of iron deficiency and thalassemia. Subgroup analysis was performed for patient groups with mean corpuscular volume values 75 to 79 μm3 (group 1), 65 to 74 μm3 (group 2), and <65 μm3 (group 3). RESULTS.— A total of 2244 patients with microcytic anemia were identified. Follow-up testing for iron deficiency was not performed in 761 cases (34%). For inconclusive ferritin levels due to elevated C-reactive protein results (n = 336), reticulocyte hemoglobin content or soluble transferrin receptor levels were missing in 86 cases (26%). In patients with suspected thalassemia (n = 127), follow-up testing for hemoglobin variants was not performed in 70 cases (55%). Subgroup analysis showed that the frequency of underuse of iron status as well as thalassemia/hemoglobinopathy testing decreased from group 1 to group 3. When considering relevant preexisting anemia diagnoses, laboratory tests were underused in 904 cases (40.3%). CONCLUSIONS.— Because 40% (n = 904) of the patients with microcytic anemia were potentially not followed up correctly, laboratory specialists are advised to act by implementing demand management strategies in collaboration with clinicians to overcome underuse of laboratory tests and to improve patient safety.
Collapse
Affiliation(s)
- Janne Cadamuro
- From the Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria (Cadamuro, Haschke-Becher, Keppel, Oberkofler, Felder, Mrazek)
| | - Ana-Maria Simundic
- The Department of Medical Laboratory Diagnostics, Faculty of Pharmacy and Biochemistry, University Hospital Sveti Duh, University of Zagreb, Zagreb, Croatia (Simundic)
| | - Alexander von Meyer
- The Institute for Laboratory Medicine and Medical Microbiology, München Clinic, Munich, Germany (von Meyer)
| | - Elisabeth Haschke-Becher
- From the Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria (Cadamuro, Haschke-Becher, Keppel, Oberkofler, Felder, Mrazek)
| | - Martin H Keppel
- From the Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria (Cadamuro, Haschke-Becher, Keppel, Oberkofler, Felder, Mrazek)
| | - Hannes Oberkofler
- From the Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria (Cadamuro, Haschke-Becher, Keppel, Oberkofler, Felder, Mrazek)
| | - Thomas K Felder
- From the Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria (Cadamuro, Haschke-Becher, Keppel, Oberkofler, Felder, Mrazek)
| | - Cornelia Mrazek
- From the Department of Laboratory Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria (Cadamuro, Haschke-Becher, Keppel, Oberkofler, Felder, Mrazek)
| |
Collapse
|
4
|
Mrazek C, Haschke-Becher E, Felder TK, Keppel MH, Oberkofler H, Cadamuro J. Laboratory Demand Management Strategies-An Overview. Diagnostics (Basel) 2021; 11:1141. [PMID: 34201549 PMCID: PMC8305334 DOI: 10.3390/diagnostics11071141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 01/07/2023] Open
Abstract
Inappropriate laboratory test selection in the form of overutilization as well as underutilization frequently occurs despite available guidelines. There is broad approval among laboratory specialists as well as clinicians that demand management strategies are useful tools to avoid this issue. Most of these tools are based on automated algorithms or other types of machine learning. This review summarizes the available demand management strategies that may be adopted to local settings. We believe that artificial intelligence may help to further improve these available tools.
Collapse
Affiliation(s)
- Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, A-5020 Salzburg, Austria; (E.H.-B.); (T.K.F.); (M.H.K.); (H.O.); (J.C.)
| | | | | | | | | | | |
Collapse
|
5
|
Lang T. Minimum retesting intervals in practice: 10 years experience. ACTA ACUST UNITED AC 2020; 59:39-50. [DOI: 10.1515/cclm-2020-0660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/22/2020] [Indexed: 12/27/2022]
Abstract
Abstract
Background
Minimum retesting intervals (MRI) are a popular demand management solution for the identification and reduction of over-utilized tests. In 2011 Association of Clinical Biochemistry and Laboratory Medicines (ACB) published evidence-based recommendations for the use of MRI.
Aim
The aim of the paper was to review the use of MRI over the period since the introduction of these recommendations in 2011 to 2020 and compare it to previous published data between 2000-2010.
Methods
A multi-source literature search was performed to identify studies that reported the use of a MRI in the management or identification of inappropriate testing between the years prior to (2000–2010) and after implementation (2011–2020) of these recommendations.
Results
31 studies were identified which met the acceptance criteria (2000–2010 n=4, 2011–2020 n=27). Between 2000 and 2010 4.6% of tests (203,104/4,425,311) were identified as failing a defined MRI which rose to 11.8% of tests (2,691,591/22,777,288) in the 2011–2020 period. For those studies between 2011 and 2020 reporting predicted savings (n=20), 14.3% of tests (1,079,972/750,580) were cancelled, representing a total saving of 2.9 M Euros or 2.77 Euro/test. The most popular rejected test was Haemoglobin A1c which accounted for nearly a quarter of the total number of rejected tests. 13 out 27 studies used the ACB recommendations.
Conclusions
MRI are now an established, safe and sustainable demand management tool for the identification and management of inappropriate testing. Evidence based consensus recommendations have supported the adoption of this demand management tool into practice across multiple healthcare settings globally and harmonizing laboratory practice.
Collapse
Affiliation(s)
- Tim Lang
- Department of Clinical Biochemistry , University Hospital of North Durham , North Road , Durham , County Durham , DH1 5TW , UK
| |
Collapse
|