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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.
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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.
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Pati S, van den Akker M, Schellevis FFG, Sahoo KC, Burgers JS. Management of diabetes patients with comorbidity in primary care: a mixed-method study in Odisha, India. Fam Pract 2023; 40:714-721. [PMID: 36610706 DOI: 10.1093/fampra/cmac144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Diabetes patients with comorbidities need regular and comprehensive care for their disease management. Hence, it is essential to assess the primary care preparedness for managing diabetes patients and the perspectives of the diabetes patients on the care received at the primary care facilities. METHODS All 21 Urban Primary Health Centres (UPHCs) in Bhubaneswar city of Odisha, India, were assessed using the modified Primary Care Evaluation Tool and WHO Package of Essential Non-communicable disease interventions questionnaire. Additionally, 21 diabetes patients with comorbidities were interviewed in-depth to explore their perception of the care received at the primary care facilities. RESULTS All the UPHCs had provisions to meet the basic requirements for the management of diabetes and common comorbidities like hypertension. There were few provisions for chronic kidney illness, cardiovascular disease, mental health, and cancer. Diabetes patients felt that frequent change in primary care physicians at the primary care facilities affected their continuity of care. Easy accessibility, availability of free medicines, and provisions of basic laboratory tests at the facilities were felt to be necessary by the diabetes patients. CONCLUSION Our study highlights the existing gaps in India's healthcare system preparedness and the needs of diabetes patients with comorbidity. The government of India's Health and Wellness (HWC) scheme aims to deliver comprehensive healthcare to the population and provide holistic care at the primary care level for NCD patients. It is imperative that there is an early implementation of the various components of the HWC scheme to provide optimal care to diabetes patients.
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Affiliation(s)
- Sandipana Pati
- Department of Health and Family Welfare, Government of Odisha, Orissa State Institute of Health and Family Welfare, Bhubaneswar, India
| | - Marjan van den Akker
- Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Family Medicine, Goethe-Universität Frankfurt am Main Institut für Allgemeinmedizin, Frankfurt, Germany
- Katholieke Universiteit Leuven Academisch Centrum voor Huisartsgeneeskunde, Leuven, Belgium
- Department of General Practice & Elderly Care Medicine, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Department of General Practice & Elderly Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - F François G Schellevis
- Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Family Medicine, Goethe-Universität Frankfurt am Main Institut für Allgemeinmedizin, Frankfurt, Germany
- Katholieke Universiteit Leuven Academisch Centrum voor Huisartsgeneeskunde, Leuven, Belgium
- Department of General Practice & Elderly Care Medicine, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Department of General Practice & Elderly Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Krushna Chandra Sahoo
- Health Technology Assessment in India (HTAIn), ICMR-Regional Medical Research Centre, Bhubaneswar, India
| | - Jako S Burgers
- Department of Family Medicine, School CAPRI, Maastricht University, Maastricht, The Netherlands
- Dutch College of General Practitioners, Utrecht, The Netherlands
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Recsky C, Stowe M, Rush KL, MacPhee M, Blackburn L, Muniak A, Currie LM. Characterization of Safety Events Involving Technology in Primary and Community Care. Appl Clin Inform 2023; 14:1008-1017. [PMID: 38151041 PMCID: PMC10752655 DOI: 10.1055/s-0043-1777454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 10/10/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND The adoption of technology in health care settings is often touted as an opportunity to improve patient safety. While some adverse events can be reduced by health information technologies, technology has also been implicated in or attributed to safety events. To date, most studies on this topic have focused on acute care settings. OBJECTIVES To describe voluntarily reported safety events that involved health information technology in community and primary care settings in a large Canadian health care organization. METHODS Two years of safety events involving health information technology (2016-2018) were extracted from an online voluntary safety event reporting system. Events from primary and community care settings were categorized according to clinical setting, type of event, and level of harm. The Sittig and Singh sociotechnical system model was then used to identify the most prominent sociotechnical dimensions of each event. RESULTS Of 104 reported events, most (n = 85, 82%) indicated the event resulted in no harm. Public health had the highest number of reports (n = 45, 43%), whereas home health had the fewest (n = 7, 7%). Of the 182 sociotechnical concepts identified, many events (n = 61, 59%) mapped to more than one dimension. Personnel (n = 48, 46%), Workflow and Communication (n = 37, 36%), and Content (n = 30, 29%) were the most common. Personnel and Content together was the most common combination of dimensions. CONCLUSION Most reported events featured both technical and social dimensions, suggesting that the nature of these events is multifaceted. Leveraging existing safety event reporting systems to screen for safety events involving health information technology, and applying a sociotechnical analytic framework can aid health organizations in identifying, responding to, and learning from reported events.
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Affiliation(s)
- Chantelle Recsky
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Megan Stowe
- Regional Digital Solutions, Digital Health, Provincial Health Services Authority, Vancouver, Canada
| | - Kathy L. Rush
- School of Nursing, University of British Columbia Okanagan, Kelowna, Canada
| | - Maura MacPhee
- School of Nursing, University of British Columbia, Vancouver, Canada
| | | | - Allison Muniak
- Human Factors and Administrative Burdens, Health Quality BC, Vancouver, Canada
| | - Leanne M. Currie
- School of Nursing, University of British Columbia, Vancouver, Canada
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Rajan SS, Baldwin JL, Giardina TD, Singh H. Technology-Based Closed-Loop Tracking for Improving Communication and Follow-up of Pathology Results. J Patient Saf 2022; 18:e262-e266. [PMID: 32804871 DOI: 10.1097/pts.0000000000000759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Failure to follow-up on laboratory test results can lead to missed diagnoses, diagnostic delays, patient harm, and potential malpractice claims against providers. State-of-the-art tracking technologies such as the radio frequency identification (RFID) can potentially improve laboratory order processing and test result communication. We conducted a comparative evaluation of differences in completion rates for 5 testing process milestones and time to reach these process milestones, with and without RFID order tracking for skin biopsy orders. METHODS This observational study analyzed 48,515 orders from 20 dermatology providers, sent to 8 pathology laboratories in 2016 to 2017. Descriptive t tests and multiple Cox proportional hazard regressions were used to examine the differences in completion rates and times to the 5 testing process milestones, namely, (1) provider receipt of results, (2) provider review of results, (3) patient notification, (4) follow-up scheduling, and (5) order case closure, for orders processed with and without RFID order tracking. RESULTS Descriptive statistics illustrated that all 5 testing process milestone completion rates were statistically higher for RFID tracked orders compared with non-RFID tracked orders, and RFID tracked orders took 3 to 5 days lesser than non-RFID tracked orders to reach the 5 testing process milestones. Multiple cox proportional hazard regressions showed that the process milestones were achieved faster if orders were RFID tracked versus not (hazard ratios ranged from 1.3 to 4.9). CONCLUSIONS The RFID tracking technology considerably improved test result communication timeliness and reliability. Such technologies can be beneficial for laboratory order processing, and their effectiveness should be explored in other practice settings.
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Affiliation(s)
- Suja S Rajan
- From the Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center at Houston
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CLARKE LORCAN, ANDERSON MICHAEL, ANDERSON ROB, KLAUSEN MORTENBONDE, FORMAN REBECCA, KERNS JENNA, RABE ADRIAN, KRISTENSEN SØRENRUD, THEODORAKIS PAVLOS, VALDERAS JOSE, KLUGE HANS, MOSSIALOS ELIAS. Economic Aspects of Delivering Primary Care Services: An Evidence Synthesis to Inform Policy and Research Priorities. Milbank Q 2021; 99:974-1023. [PMID: 34472653 PMCID: PMC8718591 DOI: 10.1111/1468-0009.12536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Policy Points The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. While there is a large amount of literature on the economic aspects of delivering primary care services, there is a need for more comprehensive overviews of this evidence. In this article, we offer such an overview. Evidence suggests that there are several strategies involving coverage, financing, service delivery, and governance arrangements which can, if implemented, have positive economic impacts on the delivery of primary care services. These include arrangements such as worker task-shifting and telemedicine. The implementation of any such arrangements, based on positive economic evidence, should carefully account for potential impacts on overall health care access and quality. There are many opportunities for further research, with notable gaps in evidence on the impacts of increasing primary care funding or the overall supply of primary care services. CONTEXT The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. To strengthen primary health care, policymakers need guidance on how to allocate resources in a manner that maximizes its economic benefits. METHODS We collated and synthesized published systematic reviews of evidence on the economic aspects of different models of delivering primary care services. Building on previous efforts, we adapted existing taxonomies of primary care components to classify our results according to four categories: coverage, financing, service delivery, and governance. FINDINGS We identified and classified 109 reviews that met our inclusion criteria according to our taxonomy of primary care components: coverage, financing, service delivery, and governance arrangements. A significant body of evidence suggests that several specific primary care arrangements, such as health workers' task shifting and telemedicine, can have positive economic impacts (such as lower overall health care costs). Notably absent were reviews on the impact of increasing primary care funding or the overall supply of primary care services. CONCLUSIONS There is a great opportunity for further research to systematically examine the broader economic impacts of investing in primary care services. Despite progress over the last decade, significant evidence gaps on the economic implications of different models of primary care services remain, which could help inform the basis of future research efforts.
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Affiliation(s)
- LORCAN CLARKE
- London School of Economics and Political Science
- Trinity College Dublin
| | | | | | | | | | - JENNA KERNS
- London School of Economics and Political Science
| | | | | | | | | | - HANS KLUGE
- World Health Organization Regional Office for Europe (WHO/Europe)
| | - ELIAS MOSSIALOS
- London School of Economics and Political Science
- Imperial College London
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Deep into Laboratory: An Artificial Intelligence Approach to Recommend Laboratory Tests. Diagnostics (Basel) 2021; 11:diagnostics11060990. [PMID: 34072571 PMCID: PMC8227070 DOI: 10.3390/diagnostics11060990] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/19/2021] [Accepted: 05/27/2021] [Indexed: 01/16/2023] Open
Abstract
Laboratory tests are performed to make effective clinical decisions. However, inappropriate laboratory test ordering hampers patient care and increases financial burden for healthcare. An automated laboratory test recommendation system can provide rapid and appropriate test selection, potentially improving the workflow to help physicians spend more time treating patients. The main objective of this study was to develop a deep learning-based automated system to recommend appropriate laboratory tests. A retrospective data collection was performed at the National Health Insurance database between 1 January 2013, and 31 December 2013. We included all prescriptions that had at least one laboratory test. A total of 1,463,837 prescriptions from 530,050 unique patients was included in our study. Of these patients, 296,541 were women (55.95%), the range of age was between 1 and 107 years. The deep learning (DL) model achieved a higher area under the receiver operating characteristics curve (AUROC micro = 0.98, and AUROC macro = 0.94). The findings of this study show that the DL model can accurately and efficiently identify laboratory tests. This model can be integrated into existing workflows to reduce under- and over-utilization problems.
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Efficiency over thoroughness in laboratory testing decision making in primary care: findings from a realist review. BJGP Open 2021; 5:bjgpopen20X101146. [PMID: 33293413 PMCID: PMC8170611 DOI: 10.3399/bjgpopen20x101146] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/13/2020] [Indexed: 11/24/2022] Open
Abstract
Background Existing research demonstrates significant variation in test-ordering practice, and growth in the use of laboratory tests in primary care. Reviews of interventions designed to change test-ordering practice report heterogeneity in design and effectiveness. Improving understanding of clinicians’ decision making in relation to laboratory testing is an important means of understanding practice patterns and developing theory-informed interventions. Aim To develop explanations for the underlying causes of patterns of variation and increasing use of laboratory tests in primary care, and make recommendations for future research and intervention design. Design & setting Realist review of secondary data from primary care. Method Diverse evidence, including data from qualitative and quantitative studies, was gathered via systematic and iterative searching processes. Data were synthesised according to realist principles to develop explanations accounting for clinicians’ decision making in relation to laboratory tests. Results A total of 145 documents contributed data to the synthesis. Laboratory test ordering can fulfil many roles in primary care. Decisions about tests are incorporated into practice heuristics and tests are deployed as a tool to manage patient interactions. Ordering tests may be easier than not ordering tests in existing systems. Alongside high workloads and limited time to devote to decision making, there is a common perception that laboratory tests are relatively inconsequential interventions. Clinicians prioritise efficiency over thoroughness in decision making about laboratory tests. Conclusion Interventions to change test-ordering practice can be understood as aiming to preserve efficiency or encourage thoroughness in decision making. Intervention designs and evaluations should consider how testing decisions are made in real-world clinical practice.
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Laboratory test ordering in inpatient hospitals: a systematic review on the effects and features of clinical decision support systems. BMC Med Inform Decis Mak 2021; 21:20. [PMID: 33461548 PMCID: PMC7814592 DOI: 10.1186/s12911-020-01384-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/25/2020] [Indexed: 01/09/2023] Open
Abstract
Background Studies have revealed inappropriate laboratory testing as a source of waste. This review aimed at evaluating the effects and features of CDSSs on physicians' appropriate laboratory test ordering in inpatient hospitals. Method Medline through PubMed, SCOPUS, Web of Science, and Cochrane were queried without any time period restriction. Studies using CDSSs as an intervention to improve laboratory test ordering as the primary aim were included. The study populations in the included studies were laboratory tests, physicians ordering laboratory tests, or the patients for whom laboratory tests were ordered. The included papers were evaluated for their outcomes related to the effect of CDSSs which were categorized based on the outcomes related to tests, physician, and patients. The primary outcome measures were the number and cost of the ordered laboratory tests. The instrument from The National Heart Lung and Blood Institute (NIH) was used to assess the quality of the included studies. Moreover, we applied a checklist for assessing the quality and features of the CDSSs presented in the included studies. A narrative synthesis was used to describe and compare the designs and the results of included studies.
Result Sixteen studies met the inclusion criteria. Most studies were conducted based on a quasi-experimental design. The results showed improvement in laboratory test-related outcomes (e.g. proportion and cost of tests) and also physician-related outcomes (e.g. guideline adherence and orders cancellation). Patient-related outcomes (e.g. length of stay and mortality rate) were not well investigated in the included studies. In addition, the evidence about applying CDSS as a decision aid for interpreting laboratory results was rare. Conclusion CDSSs increase appropriate test ordering in hospitals through eliminating redundant test orders and enhancing evidence-based practice. Appropriate testing and cost saving were both affected by the CDSSs. However, the evidence is limited about the effects of laboratory test CDSSs on patient-related outcomes.
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Delvaux N, Piessens V, Burghgraeve TD, Mamouris P, Vaes B, Stichele RV, Cloetens H, Thomas J, Ramaekers D, Sutter AD, Aertgeerts B. Clinical decision support improves the appropriateness of laboratory test ordering in primary care without increasing diagnostic error: the ELMO cluster randomized trial. Implement Sci 2020; 15:100. [PMID: 33148311 PMCID: PMC7640389 DOI: 10.1186/s13012-020-01059-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/22/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Inappropriate laboratory test ordering poses an important burden for healthcare. Clinical decision support systems (CDSS) have been cited as promising tools to improve laboratory test ordering behavior. The objectives of this study were to evaluate the effects of an intervention that integrated a clinical decision support service into a computerized physician order entry (CPOE) on the appropriateness and volume of laboratory test ordering, and on diagnostic error in primary care. METHODS This study was a pragmatic, cluster randomized, open-label, controlled clinical trial. SETTING Two hundred eighty general practitioners (GPs) from 72 primary care practices in Belgium. PATIENTS Patients aged ≥ 18 years with a laboratory test order for at least one of 17 indications: cardiovascular disease management, hypertension, check-up, chronic kidney disease (CKD), thyroid disease, type 2 diabetes mellitus, fatigue, anemia, liver disease, gout, suspicion of acute coronary syndrome (ACS), suspicion of lung embolism, rheumatoid arthritis, sexually transmitted infections (STI), acute diarrhea, chronic diarrhea, and follow-up of medication. INTERVENTIONS The CDSS was integrated into a computerized physician order entry (CPOE) in the form of evidence-based order sets that suggested appropriate tests based on the indication provided by the general physician. MEASUREMENTS The primary outcome of the ELMO study was the proportion of appropriate tests over the total number of ordered tests and inappropriately not-requested tests. Secondary outcomes of the ELMO study included diagnostic error, test volume, and cascade activities. RESULTS CDSS increased the proportion of appropriate tests by 0.21 (95% CI 0.16-0.26, p < 0.0001) for all tests included in the study. GPs in the CDSS arm ordered 7 (7.15 (95% CI 3.37-10.93, p = 0.0002)) tests fewer per panel. CDSS did not increase diagnostic error. The absolute difference in proportions was a decrease of 0.66% (95% CI 1.4% decrease-0.05% increase) in possible diagnostic error. CONCLUSIONS A CDSS in the form of order sets, integrated within the CPOE improved appropriateness and decreased volume of laboratory test ordering without increasing diagnostic error. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02950142 , registered on October 25, 2016.
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Affiliation(s)
- Nicolas Delvaux
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33 Blok J PB 7001, B-3000, Leuven, Belgium.
| | - Veerle Piessens
- Department of Public Health and Primary Care, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Tine De Burghgraeve
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33 Blok J PB 7001, B-3000, Leuven, Belgium
| | - Pavlos Mamouris
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33 Blok J PB 7001, B-3000, Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33 Blok J PB 7001, B-3000, Leuven, Belgium
| | - Robert Vander Stichele
- Department of Basic and Applied Medical Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Hanne Cloetens
- Center for General Practice, University of Antwerp, Gouverneur Kinsbergen Centrum, Doornstraat 331, 2610, Wilrijk, Belgium
| | | | - Dirk Ramaekers
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33 Blok J PB 7001, B-3000, Leuven, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33 Blok J PB 7001, B-3000, Leuven, Belgium
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Church DL, Naugler C. Essential role of laboratory physicians in transformation of laboratory practice and management to a value-based patient-centric model. Crit Rev Clin Lab Sci 2020; 57:323-344. [PMID: 32180485 DOI: 10.1080/10408363.2020.1720591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The laboratory is a vital part of the continuum of patient care. In fact, there are few programs in the healthcare system that do not rely on ready access and availability of complex diagnostic laboratory services. The existing transactional model of laboratory "medical practice" will not be able to meet the needs of the healthcare system as it rapidly shifts toward value-based care and precision medicine, which demands that practice be based on total system indicators, clinical effectiveness, and patient outcomes. Laboratory "value" will no longer be focused primarily on internal testing quality and efficiencies but rather on the relative cost of diagnostic testing compared to direct improvement in clinical and system outcomes. The medical laboratory as a "business" focused on operational efficiency and cost-controls must transform to become an essential clinical service that is a tightly integrated equal partner in direct patient care. We would argue that this paradigm shift would not be necessary if laboratory services had remained a "patient-centric" medical practice throughout the last few decades. This review is focused on the essential role of laboratory physicians in transforming laboratory practice and management to a value-based patient-centric model. Value-based practice is necessary not only to meet the challenges of the new precision medicine world order but also to bring about sustainable healthcare service delivery.
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Affiliation(s)
- Deirdre L Church
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher Naugler
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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Educational intervention to optimise serum immunoglobulin test use in Irish primary care: an interrupted time series with segmented regression analysis. Br J Gen Pract 2020; 70:e146-e154. [PMID: 31594771 DOI: 10.3399/bjgp19x706085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/24/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Implementation science experts recommend that theory-based strategies, developed in collaboration with healthcare professionals, have greater chance of success. AIM This study evaluated the impact of a theory-based strategy for optimising the use of serum immunoglobulin testing in primary care. DESIGN AND SETTING An interrupted time series with segmented regression analysis in the Cork-Kerry region, Ireland. An intervention was devised comprising a guideline and educational messages-based strategy targeting previously identified GP concerns relevant to testing for serum immunoglobulins. METHOD Interrupted time series with segmented regression analysis was conducted to evaluate the intervention, using routine laboratory data from January 2012 to October 2016. Data were organised into fortnightly segments (96 time points pre-intervention and 26 post-intervention) and analysed using incidence rate ratios with their corresponding 95% confidence intervals. RESULTS In the most parsimonious model, the change in trend before and after the introduction of the intervention was statistically significant. In the 1-year period following the implementation of the strategy, test orders were falling at a rate of 0.42% per fortnight (P<0.001), with an absolute reduction of 0.59% per fortnight, corresponding to a reduction of 14.5% over the 12-month study period. CONCLUSION The authors' tailored guideline combined with educational messages reduced serum immunoglobulin test ordering in primary care over a 1-year period. Given the rarity of the conditions for which the test is utilised and the fact that the researchers had only population-level data, further investigation is required to examine the clinical implications of this change in test-ordering patterns.
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Raymond L, Paré G, Maillet É. Enabling Laboratory Medicine in Primary Care Through IT Systems Use. DATA BASE FOR ADVANCES IN INFORMATION SYSTEMS 2020. [DOI: 10.1145/3380799.3380806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Important problems remain regarding the efficiency and quality of laboratory testing in primary care. In view of this, a significant function of electronic medical record (EMR) systems is to enable the practice of laboratory medicine by primary care physicians. The present study aims to deepen our understanding of the nature and extent of physicians' use of EMR and other laboratory information exchange systems for patient management and care within the laboratory testing process. We conducted a survey of 684 Canadian family physicians. Results indicate that physicians use 84 percent of the laboratory functionalities available in their EMR system. The two most important impacts are the ability to gain time in the post-analytical phase and to take faster action in this same phase as they follow-up on their patients' test results. Physicians who perceive to benefit most from their EMR use are those who make the most extensive use of their system. Extended use of an EMR system allows primary care physicians to better ascertain and monitor the health status of their patients, verify their diagnosis assumptions, and, if their system includes a clinical decision support module, apply evidence-based practices in laboratory medicine.
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Affiliation(s)
- Louis Raymond
- Université du Québec à Trois-Rivières, Trois-Rivières, PQ, Canada
| | - Guy Paré
- HEC Montréal, Montréal, PQ, Canada
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Murphy DR, Satterly T, Rogith D, Sittig DF, Singh H. Barriers and facilitators impacting reliability of the electronic health record-facilitated total testing process. Int J Med Inform 2019; 127:102-108. [PMID: 31128821 DOI: 10.1016/j.ijmedinf.2019.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/15/2019] [Accepted: 04/05/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Despite ongoing efforts to improve reliability of the total testing process (TTP), breakdowns continue to occur resulting in diagnostic delays and suboptimal patient outcomes. We performed an exploratory study to identify factors that impact TTP reliability in electronic health record (EHR)-enabled care. MATERIALS AND METHODS We interviewed experts at three large EHR-enabled health care organizations and identified all TTP steps performed from clinician test ordering to result communication to patients. Findings from all sites were combined to develop a detailed process map of known TTP activities. We additionally asked experts about factors that positively or negatively impacted TTP reliability at each step. We describe the specific TTP steps identified and associated barriers and facilitators to TTP reliability. RESULTS We interviewed 39 experts involved in or overseeing the TTP. Most TTP activities identified were similar across sites, but we found significant differences with test order transmission to diagnostic services and relay of results back to clinicians and patients. Twenty-five unique barriers were identified related to technology and EHR usability issues, time and resource constraints, suboptimal clinic workflows, patient-related factors, information access limitations, and insufficient clinician training. Twenty-four unique facilitators were identified related to personnel training, workflow optimization and standardization, helpful EHR features, and improved electronic communication between clinics and diagnostic services. DISCUSSION Barriers related to EHR usability and with communication between clinicians and diagnostic services increase TTP vulnerability and should be targeted by future efforts to improve process reliability. Several facilitators identified in the study could inform future strategies and solutions to improve TTP reliability.
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Affiliation(s)
- Daniel R Murphy
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States; Department of Medicine, Baylor College of Medicine, Houston, TX, United States.
| | - Tyler Satterly
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States; Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Deevakar Rogith
- The University of Texas Health Science Center at Houston's School of Biomedical Informatics, Houston, TX, United States
| | - Dean F Sittig
- The University of Texas Health Science Center at Houston's School of Biomedical Informatics, Houston, TX, United States; The UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, TX, United States
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States; Department of Medicine, Baylor College of Medicine, Houston, TX, United States
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