Laboratory testing under managed care dominance in the USA

Managing transferability of laboratory data

Considerable attention has been focused on definition and enhancement of the analytical quality in laboratory testing over the past decades. Advances in laboratory technology and computer informatics have allowed a major sense of confidence with the analytical phase and more efforts should now be focused on extra-analytical areas of improvement, that should further strengthen the link between cost effectiveness and clinical outcome. Deduction and implementation of common reference intervals, to be possibly shared by a regional network of clinical laboratories, appear so far a crucial step to increase efficiency and harmonization. With the experience gained from External Quality Control exercises and with the consensus of several contributory laboratories, this process is underway in Italy. Quality performances resulting from widespread implementation of common reference intervals and longitudinal comparison of patient's data, will allow clinical laboratories to accomplish with a major transferability, amplifying health benefits and meeting increasing health systems demand.

The national health system: future possibilities for the clinical laboratory

BACKGROUND

The heavy burden of the costs of medical care has brought changes in the public health policy. The changes are partly related to the health management factors, but several cultural, social and environmental factors have also had a significant impact on healthcare. The role of the laboratory is now considered amidst changes that have occurred in the American health model (free-trader) and in the European-Canadian model (universalistic). Moreover, costs and clinical decision-making in laboratories in Italy have also changed in response to the new focus on the pre- and post-analytical phases of the testing process.

METHODS

In the present study, we used the Laboratory Information System (LIS) to evaluate whether the time involved in stages in the turnaround time (TAT) (admission, performance of tests, validation and decision-making for treatment) were reduced following improvements made to the laboratory organization and management of the pre-analytical and post-analytical phases. In particular, an analysis was made of laboratory testing for myocardial markers in patients with acute coronary syndrome.

RESULTS

TAT for myocardial markers in an emergency setting was reduced by 30% following changes made in the laboratory organization and in the management of the pre-analytical and post-analytical phases of the testing process.

CONCLUSIONS

Thanks to changes in healthcare service/system in Italy, laboratory services will now play a crucial role in cultural and socioeconomic changes, particularly where testing processes and techniques are concerned.

Yield and Cost of Individual Common Diagnostic Tests in New Primary Care Outpatients in Japan

Background:Appropriate diagnostic testing involves considerations of cost-effectiveness. We examined the cost-effectiveness of individual tests in a panel of tests defined by the Japan Society of Clinical Pathology.

Methods: We studied 540 new, symptomatic primary care outpatients with a set of 30 common diagnostic tests [the Essential Laboratory Tests (2); ELT(2) panel] for clinical evaluation and identification of occult disease. A useful result (UR) of testing was defined as a finding that contributed to a change in a physician’s diagnosis or decision-making relating to a “tentative initial diagnosis” obtained from history and physical examination alone.

Results: The ELT(2) panel testing yielded 398 URs and uncovered 261 occult diseases among 540 patients. In total, 1592 tests contributed to either UR-generation or discovery of occult disease. The cost per effective test (cost required per test that contributed to either definition of effectiveness) ranged from ¥108 (∼US$0.92) for total cholesterol to ¥6200 (∼$52.50) for chest x-ray. Contribution rates and the cost per effective test varied among disease categories. We restructured panel components considering the effectiveness of each test. Subsets of the ELT(2) would have improved cost-effectiveness and achieved cost savings in five of eight disease categories.

Conclusions: Assembly of tests based on cost-effectiveness can improve clinical efficiency and decrease total cost of panel testing for selected patient groups.

Office laboratory procedures, office economics, parenting and parent education, and urinary tract infection

We once again review four areas of interest to office-based pediatricians: office laboratory procedures, office economics, parenting and patient education, and urinary tract infections. Sean Elliott reviews the current status of the Clinical Laboratories Improvement Amendments (CLIA) and their continuing impact on physician office laboratories. Eve Shapiro reviews office economics, this year focusing on managed care, the physician workforce, practice management, and health care financing for the uninsured. Anna Binkiewicz provides an update on parenting and parent education, with recent reports on nutrition and childhood immunizations. Richard Wahl again reviews recent research on urinary tract infection, discussing voiding physiology, dysfunctional voiding patterns, acute urinary retention, urine collection techniques, diagnosis in young infants, and antibiotic prophylaxis.