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Podolsky E, Hudek N, McCudden C, Presseau J, Yanikomeroglu S, Brouwers M, Brehaut JC. Choosing which in-hospital laboratory tests to target for intervention: a scoping review. Clin Chem Lab Med 2023; 61:388-401. [PMID: 36410390 PMCID: PMC9876731 DOI: 10.1515/cclm-2022-0910] [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: 09/12/2022] [Accepted: 11/03/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Some laboratory testing practices may be of low value, leading to wasted resources and potential patient harm. Our scoping review investigated factors and processes that developers report using to inform decisions about what tests to target for practice improvement. METHODS We searched Medline on May 30th, 2019 and June 28th, 2021 and included guidelines, recommendation statements, or empirical studies related to test ordering practices. Studies were included if they were conducted in a tertiary care setting, reported making a choice about a specific test requiring intervention, and reported at least one factor informing that choice. We extracted descriptive details, tests chosen, processes used to make the choice, and factors guiding test choice. RESULTS From 114 eligible studies, we identified 30 factors related to test choice including clinical value, cost, prevalence of test, quality of test, and actionability of test results. We identified nine different processes used to inform decisions regarding where to spend intervention resources. CONCLUSIONS Intervention developers face difficult choices when deciding where to put scarce resources intended to improve test utilization. Factors and processes identified here can be used to inform a framework to help intervention developers make choices relevant to improving testing practices.
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Affiliation(s)
- Eyal Podolsky
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Natasha Hudek
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Christopher McCudden
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Biochemistry, Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Eastern Ontario Regional Laboratory Association, Ottawa, ON, Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sezgi Yanikomeroglu
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Melissa Brouwers
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jamie C. Brehaut
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
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Yoshida B, Nguyen A, Formanek B, Alam M, Wang JC, Buser Z. Hypoalbuminemia and Elevated CRP are Risk Factors for Deep Infections and Urinary Tract Infections After Lumbar Spine Surgery in a Large Retrospective Patient Population. Global Spine J 2023; 13:33-44. [PMID: 33517797 PMCID: PMC9837497 DOI: 10.1177/2192568221990647] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
STUDY DESIGN Retrospective cross-sectional study. OBJECTIVES To determine if pre-operative albumin and CRP can predict post-operative infections after lumbar surgery. METHODS Patients who underwent an anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), or lumbar discectomy were identified using a patient record database (PearlDiver) and were included in this retrospective study. Patients were stratified by Charlson Comorbidity Index (CCI) scores and pre-operative albumin and CRP status. Post-operative complications included deep infections and urinary tract infections within 3 months of the surgery and revisions within 1 year of the surgery. RESULTS 74,280 patients were included in this study. 21,903 had pre-operative albumin or CRP lab values. 7,191 (33%), 12,183 (56%), and 2,529 (12%) patients underwent an ALIF, PLIF, and a lumbar discectomy, respectively. 16,191 did not have any complication (74%). The most common complication was UTI (16%). Among all patients, hypoalbuminemia was a significant risk factor for deep infection and UTI after ALIF, deep infection, UTI, and surgical revision after PLIF, and deep infection after lumbar discectomy. Elevated CRP was a significant risk factor for deep infection after ALIF, UTI after PLIF, and deep infection after lumbar discectomy in patients with a CCI ≤ 3. CONCLUSIONS Pre-operative hypoalbuminemia and elevated CRP were significant risk factors for deep infection, UTI, and/or revision, after ALIF, PLIT, and/or lumbar discectomy. Future studies with a larger population of patients with low albumin and high CRP values are needed to further elaborate on the current findings.
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Affiliation(s)
- Brandon Yoshida
- Department of Orthopaedic Surgery, Keck
School of Medicine of the University of Southern California, Los Angels, CA,
USA
| | - Ailene Nguyen
- Department of Orthopaedic Surgery, Keck
School of Medicine of the University of Southern California, Los Angels, CA,
USA
| | - Blake Formanek
- Department of Orthopaedic Surgery, Keck
School of Medicine of the University of Southern California, Los Angels, CA,
USA
| | - Milad Alam
- Department of Orthopaedic Surgery, Keck
School of Medicine of the University of Southern California, Los Angels, CA,
USA
| | - Jeffrey C. Wang
- Department of Orthopaedic Surgery, Keck
School of Medicine of the University of Southern California, Los Angels, CA,
USA
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck
School of Medicine of the University of Southern California, Los Angels, CA,
USA,Zorica Buser, PhD, Department of Orthopaedic
Surgery, Keck School of Medicine, University of Southern California, 1450 San
Pablo St., HC4-5400A, Los Angels, CA 90033, USA.
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Hematologic Risk Assessment. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00010-1] [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] Open
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Karim HMR, Singha SK, Neema PK, Baruah TD, Ray R, Mohanty D, Siddiqui MS, Nanda R, Bodhey NK. Information technology-based joint preoperative assessment, risk stratification and its impact on patient management, perioperative outcome, and cost. Discoveries (Craiova) 2021; 9:e130. [PMID: 34849397 PMCID: PMC8627278 DOI: 10.15190/d.2021.9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 04/23/2021] [Accepted: 05/08/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Despite negative recommendations, routine preoperative testing practice is nearly universal. Our aim is to bring the healthcare providers on one platform by using information-technology based preanaesthetic assessment and evaluate the routine preoperative testing’s impact on patient outcome and cost.
Methods: A prospective, non-randomised study was conducted in a teaching hospital during January 2019-August 2020. A locally developed software and cloud-computing were used as a tool to modify preanaesthesia evaluation. The number of investigations ordered, time taken, cost incurred, were compared with the routine practice. Further data were matched as per surgical invasiveness and the patient's physical status. Appropriate tests compared intergroup differences and p-value <0.05 was considered significant.
Results: Data from 114 patients (58 in routine and 56 in patient and surgery specific) were analysed. Patient and surgery specific investigation led to a reduction in the investigations by 80-90%, hospital visit by 50%, and the total cost by 80%, without increasing the day of surgery cancellation or complications.
Conclusion: Information technology-based joint preoperative assessment and risk stratification are feasible through locally developed software with minimal cost. It helps in applying patient and surgery specific investigation, reducing the number of tests, hospital visit, and cost, without adversely affecting the perioperative outcome. The application of the modified method will help in cost-effective, yet quality and safe perioperative healthcare delivery. It will also benefit the public from both service and economic perspective.
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Affiliation(s)
| | - Subrata Kumar Singha
- Department of Anaesthesiology, India Institute of Medical Sciences, Raipur, India
| | - Praveen Kumar Neema
- Department of Anaesthesiology, India Institute of Medical Sciences, Raipur, India
| | - Tridip Dutta Baruah
- Department of General Surgery, India Institute of Medical Sciences, Raipur, India
| | - Rubik Ray
- Department of General Surgery, India Institute of Medical Sciences, Raipur, India
| | - Debajyoti Mohanty
- Department of General Surgery, India Institute of Medical Sciences, Raipur, India
| | - Md Sabah Siddiqui
- Department of General Medicine, India Institute of Medical Sciences, Raipur, India
| | - Rachita Nanda
- Department of Clinical Biochemistry, India Institute of Medical Sciences, Raipur, India
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Siddaiah H, Patil S, Shelvan A, Ehrhardt KP, Stark CW, Ulicny K, Ridgell S, Howe A, Cornett EM, Urman RD, Kaye AD. Preoperative laboratory testing: Implications of "Choosing Wisely" guidelines. Best Pract Res Clin Anaesthesiol 2020; 34:303-314. [PMID: 32711836 DOI: 10.1016/j.bpa.2020.04.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/07/2020] [Indexed: 01/15/2023]
Abstract
Preoperative laboratory testing is often necessary and can be invaluable for diagnosis, assessment, and treatment. However, performing routine laboratory tests for patients who are considered otherwise healthy is not usually beneficial and is costly. It is estimated that $18 billion (U.S.) is spent annually on preoperative testing, although how much is wasteful remains unknown. Ideally, a targeted and comprehensive patient history and physical exam should largely determine whether preprocedure laboratory studies should be obtained. Healthcare providers, primarily anesthesiologists, should remain cost-conscious when ordering specific laboratory or imaging tests prior to surgery based on available literature. We review the overall evidence and key points from the Choosing Wisely guidelines, the identification of potential wasteful practices, possible harms of testing, and key clinical findings associated with preoperative laboratory testing.
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Affiliation(s)
- Harish Siddaiah
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA.
| | - Shilpadevi Patil
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA.
| | | | - Kenneth Philip Ehrhardt
- Department of Anesthesiology, LSU Health New Orleans, 1542 Tulane Ave, Room 659, New Orleans, LA, 70112, USA.
| | - Cain W Stark
- Medical College of Wisconsin, 8701 West Watertown Plank Road, Wauwatosa, WI, 53226, USA.
| | - Kenneth Ulicny
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Sasha Ridgell
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Austin Howe
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSU Health Shreveport, 1501 Kings Highway, Shreveport LA, 71103, USA.
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Lippi G, Salvagno GL, Lampus S, Danese E, Gelati M, Bovo C, Montagnana M, Simundic AM. Impact of blood cell counts and volumes on glucose concentration in uncentrifuged serum and lithium-heparin blood tubes. Clin Chem Lab Med 2019; 56:2125-2131. [PMID: 29935113 DOI: 10.1515/cclm-2018-0523] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 05/30/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although it is known that glucose concentration exhibits a time-dependent decay in uncentrifuged serum and lithium-heparin blood tubes, no evidence exists on how this variation may depend on blood cell counts (CBC) and volumes. METHODS Venous blood was drawn from 30 non fasting healthy volunteers into three serum and three lithium-heparin tubes. One serum and lithium-heparin tubes were centrifuged within 15 min after collection and glucose was measured with a hexokinase assay. The second and third serum and lithium-heparin tubes were maintained at room temperature for 1 and 2 h after the first tubes were centrifuged. These other tubes were then centrifuged and glucose was measured. CBC was performed in the first lithium-heparin tube, before centrifugation. RESULTS The mean decrease of glucose was higher in lithium-heparin plasma than in serum (0.33 vs. 0.24 mmol/L/h; p<0.001). Glucose concentration decreased by 7% and 5% per hour in lithium-heparin plasma and serum, respectively. In univariate analysis, the absolute decrease of glucose concentration was associated with sex (higher in men than in women), red blood cell (RBC) count, hematocrit, white blood cell (WBC) count, neutrophils and monocytes in both lithium-heparin plasma and serum. In multivariate analysis, the decrease of glucose concentration remained independently associated with RBC, WBC, neutrophils and monocytes in both sample matrices. No significant association was found with platelet number and erythrocyte or platelet volume. CONCLUSIONS Glucose concentration decrease in uncentrifuged lithium-heparin and serum tubes depends on the baseline number of RBC, WBC, neutrophils and monocytes within the tubes.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | - Gian Luca Salvagno
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | - Simona Lampus
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | - Elisa Danese
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | - Matteo Gelati
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | - Chiara Bovo
- Medical Direction, University Hospital of Verona, Verona, Italy
| | - Martina Montagnana
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | - Ana-Maria Simundic
- Department of Medical Laboratory Diagnostics, University Hospital Sveti Duh, Zagreb, Croatia
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Raiten J, Spelde A, Gutsche J. Preoperative Cardiac Stress Testing- A Thing of the Past? J Cardiothorac Vasc Anesth 2018; 33:933-934. [PMID: 30292387 DOI: 10.1053/j.jvca.2018.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Jesse Raiten
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Audrey Spelde
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
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