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Fernandes CJ, Yee HK, Fishman FG. The Limited Utility of Routine Pathologic Examination of Ganglion Cyst Excision From the Hand and Digits. Hand (N Y) 2024:15589447241231292. [PMID: 38379165 DOI: 10.1177/15589447241231292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
BACKGROUND It is routine practice at many institutions to send surgically excised ganglion cysts for pathologic analysis. This adds significant cost to the procedure with questionable benefit. The purpose of this study was to determine the necessity of routine pathologic examination of ganglion cysts excised from the hand. METHODS We conducted a retrospective review of 443 patients who underwent ganglion excision from the hand with routine pathologic examination between 2012 and 2022. The final pathologic diagnosis was compared with the treating surgeon's clinical diagnosis, and the rates of concordant, discrepant, and discordant diagnoses were identified. Discrepant diagnoses were defined as differing clinical and pathologic diagnoses that did not change clinical management. Discordant diagnoses were defined as differing clinical and pathologic diagnoses that altered the treatment plan. RESULTS The prevalence of a concordant diagnosis was 96.2% (426 of 443; 95% confidence interval, 94.4%-98.0%). The prevalence of a discrepant diagnosis was 3.8% (17 of 443; 95% confidence interval, 2.1%-5.6%), and the prevalence of a discordant diagnosis was 0. The odds ratio was 0.04 for a discrepant diagnosis and 0 for a discordant diagnosis. CONCLUSIONS Our study suggests abandoning routine pathologic analysis in patients undergoing ganglion cyst excision from the hand will not compromise quality of care when the surgeon is able to make a confident diagnosis. Discrepant diagnoses were rare and discordant diagnoses that did not occur. We recommend pathologic evaluation only when there is uncertainty in the clinical diagnosis.
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Affiliation(s)
- Carlton J Fernandes
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Heather K Yee
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Felicity G Fishman
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL, USA
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Liu D, Grisdela P, Zhang D, Dyer G, Blazar P, Earp B. Utility of Routine Pathologic Examination for Fasciectomy for Dupuytren Contracture. J Hand Surg Am 2023; 48:1273.e1-1273.e5. [PMID: 35933252 DOI: 10.1016/j.jhsa.2022.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 03/03/2022] [Accepted: 04/13/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The objective of this study was to examine the routine pathologic examination of surgical specimens obtained during fasciectomy for Dupuytren contracture. METHODS A total of 376 consecutive patients who underwent surgical limited fasciectomy with the excised tissue sent for histopathologic evaluation were identified. Patients were excluded for miscoded procedures, cases where no tissue was sent for pathologic review, and excisions of nodules only. Repeat surgeries in the same patient during the study period were excluded. The rates of concordant, discrepant, and discordant diagnoses were reported. Discrepant diagnoses were defined as different clinical diagnosis and pathologic diagnosis that did not change clinical management. Discordant diagnoses were defined as a different clinical diagnosis and a pathologic diagnosis that altered the treatment plan. The reference standard for final clinical decision-making was the pathologic diagnosis. RESULTS The prevalence of concordant diagnoses was 97.1% (365 of 376), of discrepant diagnoses was 2.9% (11 of 376), and there were no discordant diagnoses. Of 376 patients, 43 underwent previous surgical fasciectomy before the study surgery, and pathologic examination was obtained in 10 of these patients. All 10 patients had concordant diagnoses. CONCLUSIONS Our results suggest that routine pathologic examination did not alter the future treatment plan for patients who underwent limited fasciectomy. Discrepant diagnoses were encountered infrequently, and rarely in the setting of revision fasciectomy. Discordant diagnoses did not occur. Given the cost associated with pathologic evaluation, this raises the question of whether routine pathologic evaluation is necessary for Dupuytren surgery, where the capability of the treating surgeon to make a clinical diagnosis accurately may render confirmatory pathologic assessment redundant. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.
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Affiliation(s)
- David Liu
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Philip Grisdela
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - George Dyer
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Philip Blazar
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Brandon Earp
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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Meidani Z, Mousavi GA, Kheirkhah D, Benar N, Maleki MR, Sharifi M, Farrokhian A. Going beyond audit and feedback: towards behaviour-based interventions to change physician laboratory test ordering behaviour. J R Coll Physicians Edinb 2019. [PMID: 29537404 DOI: 10.4997/jrcpe.2017.407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Studies indicate there are a variety of contributing factors affecting physician test ordering behaviour. Identifying these behaviours allows development of behaviour-based interventions. Methods Through a pilot study, the list of contributing factors in laboratory tests ordering, and the most ordered tests, were identified, and given to 50 medical students, interns, residents and paediatricians in questionnaire form. The results showed routine tests and peer or supervisor pressure as the most influential factors affecting physician ordering behaviour. An audit and feedback mechanism was selected as an appropriate intervention to improve physician ordering behaviour. The intervention was carried out at two intervals over a three-month period. Findings There was a large reduction in the number of laboratory tests ordered; from 908 before intervention to 389 and 361 after first and second intervention, respectively. There was a significant relationship between audit and feedback and the meaningful reduction of 7 out of 15 laboratory tests including complete blood count (p = 0.002), erythrocyte sedimentation rate (p = 0.01), C-reactive protein (p = 0.01), venous blood gas (p = 0.016), urine analysis (p = 0.005), blood culture (p = 0.045) and stool examination (p = 0.001). Conclusion The audit and feedback intervention, even in short duration, affects physician ordering behaviour. It should be designed in terms of behaviour-based intervention and diagnosis of the contributing factors in physicians' behaviour. Further studies are required to substantiate the effectiveness of such behaviour-based intervention strategies in changing physician behaviour.
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Affiliation(s)
- Z Meidani
- D Kheirkhah, Infectious Diseases Research Centre, Kashan University of Medical Sciences, Kashan, Iran.
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Cadamuro J, Gaksch M, Wiedemann H, Lippi G, von Meyer A, Pertersmann A, Auer S, Mrazek C, Kipman U, Felder TK, Oberkofler H, Haschke-Becher E. Are laboratory tests always needed? Frequency and causes of laboratory overuse in a hospital setting. Clin Biochem 2018; 54:85-91. [PMID: 29409798 DOI: 10.1016/j.clinbiochem.2018.01.024] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/20/2018] [Accepted: 01/30/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Inappropriate utilization of laboratory resources is an increasing concern especially in high-throughput facilities. Until now, no reliable information has been published addressing to which extent laboratory results are actually used for clinical decision-making. Therefore, we aimed to close this gap using a novel retrospective approach including a survey of clinicians and nurses. METHODS We retrospectively evaluated the number of re-orders for potassium (K), lactate dehydrogenase (LD), aspartate-aminotransferase (AST), activated partial thromboplastin-time (APTT) and prothrombin-time/INR (PT/INR), after the initial order had to be cancelled due to preanalytical non-conformities. We analyzed subgroups regarding time to re-order, ward and sample priority (urgent vs. routine). Subsequently, we surveyed clinicians and nurses, asking for their estimate of the amount of failed re-orders as well as for possible reasons. RESULTS From initially cancelled tests, only ~20% of K, LD, AST and ~30% of APTT and PT/INR tests were re-ordered within 24 h. 70% of the investigated clinical chemistry and 60% of coagulation tests were re-ordered one week after cancellation or not at all. Survey participants quite accurately estimated these numbers. Routine laboratory panels, short stay of out-patients, obsolete test results and avoiding additional phlebotomies were the main reasons for not re-ordering cancelled tests. CONCLUSIONS Overall, 60-70% of test results in the investigated assays ordered in a high throughput laboratory are potentially inappropriate or of doubtful clinically importance. Although clinicians and nurses are aware of this situation, it is the duty of laboratory specialists to overcome overutilization in close collaboration with all involved healthcare workers.
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Affiliation(s)
- Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria.
| | - Martin Gaksch
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Helmut Wiedemann
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Alexander von Meyer
- Institute of Laboratory Medicine, Kliniken Nordoberpfalz AG, Klinikum St. Marien, Amberg, Weiden, Germany
| | - Astrid Pertersmann
- Institute of Clinical Chemistry and Laboratory Medicine, University of Greifswald, Greifswald, Germany
| | - Simon Auer
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Thomas K Felder
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Hannes Oberkofler
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
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Vrijenhoek T, Kraaijeveld K, Elferink M, de Ligt J, Kranendonk E, Santen G, Nijman IJ, Butler D, Claes G, Costessi A, Dorlijn W, van Eyndhoven W, Halley DJJ, van den Hout MCGN, van Hove S, Johansson LF, Jongbloed JDH, Kamps R, Kockx CEM, de Koning B, Kriek M, Lekanne Dit Deprez R, Lunstroo H, Mannens M, Mook OR, Nelen M, Ploem C, Rijnen M, Saris JJ, Sinke R, Sistermans E, van Slegtenhorst M, Sleutels F, van der Stoep N, van Tienhoven M, Vermaat M, Vogel M, Waisfisz Q, Marjan Weiss J, van den Wijngaard A, van Workum W, Ijntema H, van der Zwaag B, van IJcken WFJ, den Dunnen J, Veltman JA, Hennekam R, Cuppen E. Next-generation sequencing-based genome diagnostics across clinical genetics centers: implementation choices and their effects. Eur J Hum Genet 2015; 23:1142-50. [PMID: 25626705 PMCID: PMC4538197 DOI: 10.1038/ejhg.2014.279] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 11/26/2014] [Accepted: 11/28/2014] [Indexed: 12/30/2022] Open
Abstract
Implementation of next-generation DNA sequencing (NGS) technology into routine diagnostic genome care requires strategic choices. Instead of theoretical discussions on the consequences of such choices, we compared NGS-based diagnostic practices in eight clinical genetic centers in the Netherlands, based on genetic testing of nine pre-selected patients with cardiomyopathy. We highlight critical implementation choices, including the specific contributions of laboratory and medical specialists, bioinformaticians and researchers to diagnostic genome care, and how these affect interpretation and reporting of variants. Reported pathogenic mutations were consistent for all but one patient. Of the two centers that were inconsistent in their diagnosis, one reported to have found 'no causal variant', thereby underdiagnosing this patient. The other provided an alternative diagnosis, identifying another variant as causal than the other centers. Ethical and legal analysis showed that informed consent procedures in all centers were generally adequate for diagnostic NGS applications that target a limited set of genes, but not for exome- and genome-based diagnosis. We propose changes to further improve and align these procedures, taking into account the blurring boundary between diagnostics and research, and specific counseling options for exome- and genome-based diagnostics. We conclude that alternative diagnoses may infer a certain level of 'greediness' to come to a positive diagnosis in interpreting sequencing results. Moreover, there is an increasing interdependence of clinic, diagnostics and research departments for comprehensive diagnostic genome care. Therefore, we invite clinical geneticists, physicians, researchers, bioinformatics experts and patients to reconsider their role and position in future diagnostic genome care.
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Affiliation(s)
- Terry Vrijenhoek
- Department of Medical Genetics, Centre for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ken Kraaijeveld
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin Elferink
- Department of Medical Genetics, Centre for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joep de Ligt
- Department of Human Genetics, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Elcke Kranendonk
- Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Gijs Santen
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Isaac J Nijman
- Department of Medical Genetics, Centre for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Godelieve Claes
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Wim Dorlijn
- Agilent Technologies Netherlands B.V., Amstelveen, The Netherlands
| | | | - Dicky J J Halley
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Lennart F Johansson
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan D H Jongbloed
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rick Kamps
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Christel E M Kockx
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bart de Koning
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marjolein Kriek
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Ronald Lekanne Dit Deprez
- Department of Human Genetics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marcel Mannens
- Department of Human Genetics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Olaf R Mook
- Department of Human Genetics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel Nelen
- Department of Human Genetics, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Corrette Ploem
- Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Marco Rijnen
- Life Technologies Europe B.V., Bleiswijk, The Netherlands
| | - Jasper J Saris
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Richard Sinke
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik Sistermans
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Frank Sleutels
- Center for Biomics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nienke van der Stoep
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Martijn Vermaat
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje Vogel
- Department of Medical Genetics, Centre for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Quinten Waisfisz
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - Janneke Marjan Weiss
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - Arthur van den Wijngaard
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Helger Ijntema
- Department of Human Genetics, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Bert van der Zwaag
- Department of Medical Genetics, Centre for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Johan den Dunnen
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Joris A Veltman
- Department of Human Genetics, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Raoul Hennekam
- 1] Department of Human Genetics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands [2] Department of Pediatrics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Edwin Cuppen
- Department of Medical Genetics, Centre for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Vossen MHE, den Broeder AA, Hendriks-Roelofs F, van der Heijde DMFM, Reijnierse M. Improvement in deployment of MRI of the sacroiliac joints in patients suspected for spondyloarthritis using a targeted intervention: a case study. Rheumatology (Oxford) 2013; 52:933-8. [PMID: 23335636 DOI: 10.1093/rheumatology/kes405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess characteristics of deployment of MRI of the SI joints (MR-SI) in patients with suspected axial spondyloarthritis (SpA) before and after a targeted intervention. METHODS In a retrospective chart review study, all MR-SI performed in the period 1 April 2004 to 31 December 2010 were collected. Inclusion criteria were complete patient data and MR-SI ordered by a rheumatologist for suspicion of axial SpA. MR-SI reports were graded as normal, suspected sacroiliitis or sacroiliitis. In April 2007 an intervention was made to improve deployment. Rheumatologists were provided with data on ordering behaviour, patient characteristics and MRI outcomes. An introduction on the effect of pretest chance on positive and negative predictive value was given; the burden for patients and costs was illustrated. An alternative behavioural strategy was offered in the form of a simple diagnostic algorithm. Percentages of MRIs and positive MRI for sacroiliitis were compared before and after intervention. RESULTS From April 2004 to April 2007, 198 MR-SIs were performed, of which 166 (83.9%) were normal, 5 (2.5%) were suspicious and 27 (13.6%) were positive. After the intervention, patients displayed significantly more SpA features. More optimal patient selection resulted in 79 MR-SI requests, a decrease of 60.1%. Fifty-seven (72.2%) reports were normal, 0 were suspicious and 22 (27.8%) were positive. CONCLUSION A simple, one-time, five-step feedback intervention resulted in a 60% reduction in MR-SI requests with a doubling of the percentage of MR-SI positive for sacroiliitis. This approach may benefit future research in areas with diagnostic uncertainty and suboptimal testing.
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Affiliation(s)
- Maria H E Vossen
- Department of Radiology, C2-S, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
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Abstract
Clinical laboratories have an important role in improving patient care. The past decades have seen enormous changes with unpredictable improvements in analytical performance, range of tests and capacity to manage large volumes of work. At the same time, there has been a dramatic fall in the rate of laboratory errors. However, there is now a growing awareness that the testing process includes the time before samples reach the laboratory and after reports have been printed and that these areas need to be included in the quality assessment of the total testing process. Laboratory quality should include a focus on patient safety and clinical effectiveness. Services should be patient-centred, timely, efficient and equitable, and finally, should be moulded to ensure optimal outcomes. There is a need to define quality indicators that will ensure there is appropriate choice and selection of tests, use of the appropriate assay standardization and the correct interpretation of the assay results at the appropriate time. These are the areas in which a quality laboratory can, and should, now involve itself.
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Affiliation(s)
- Julian H Barth
- Clinical Biochemistry, Leeds General Infirmary, Leeds LS1 3EX, UK.
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Windak A, Gryglewska B, Tomasik T, Narkiewicz K, Yaphe J, Grodzicki T. The competence of primary care doctors in the investigation of patients with elevated blood pressure: results of a cross-sectional study using clinical vignettes. J Eval Clin Pract 2010; 16:784-9. [PMID: 20557416 DOI: 10.1111/j.1365-2753.2009.01194.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Specific laboratory tests are required to ensure adequate management of patients with hypertension, according to internationally accepted guidelines. There is wide variation in doctor test ordering behaviour. Many factors are known to affect this. Little is known about the interaction between doctor, patient and practice characteristics. The current study was designed to explore this. METHODS A series of eight case vignettes was designed to examine test ordering behaviour among primary care doctors in Poland. The cases differed with regard to the level of blood pressure and the presence or absence of other cardiovascular risk factors, including diabetes. Doctors stated their choices of laboratory investigations needed in these cases. Their responses were compared with recommendations in the 2003 European Society of Hypertension/European Society of Cardiology hypertension guidelines. Associations between the correct responses and patient, doctor and practice characteristics were tested. RESULTS One hundred and twenty-five out of 192 invited doctors (65%) participated in the study. They ordered a mean of 4.9 laboratory tests per case. This represents 47.9% of the tests recommended by current guidelines. Older doctors working in smaller practices and private settings ordered fewer laboratory tests. Specialization in family medicine was associated with greater compliance with guidelines. Grade 2 hypertension and the presence of other risk factors of cardiovascular disease were associated with ordering more tests but the presence of diabetes did not improve compliance with guidelines. CONCLUSIONS Further educational efforts are needed to promote rational test ordering for hypertensive patients by Polish primary health care doctors.
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Affiliation(s)
- Adam Windak
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Cracow, Poland.
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Guitton TG, van Leerdam RH, Ring D. Necessity of routine pathological examination after surgical excision of wrist ganglions. J Hand Surg Am 2010; 35:905-8. [PMID: 20478665 DOI: 10.1016/j.jhsa.2010.03.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Revised: 03/08/2010] [Accepted: 03/10/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE The value of routine pathological evaluation of ganglion cysts is questionable considering that the pretest odds of a wrist lesion being a ganglion cyst are usually high based on physical examination and surgical findings alone. This study evaluates the necessity of routine pathological examination of specimens derived from surgical removal of wrist ganglion cysts. METHODS We identified 429 consecutive adult patients who underwent surgical excision of a wrist ganglion with routine pathological examination of the specimen between 1997 and 2008. The rates of concordant, discrepant, and discordant diagnoses were reported with 95% confidence intervals. The odds of a discrepant or discordant diagnosis were calculated. RESULTS The prevalence of a concordant diagnosis was 98.6% (424 of 429; 95% confidence interval, 97.3% to 99.6%). The prevalence of a discrepant diagnosis was 1.4% (5 of 429; 95% confidence interval, 0.38% to 2.7%), and the prevalence of a discordant diagnosis was zero. The odds ratio was 0.012 for a discrepant diagnosis and zero for a discordant diagnosis. CONCLUSIONS This study suggests that, in patients with the clinical diagnosis of wrist ganglion cyst, quality of care would not be compromised by abandoning the practice of routinely submitting surgical specimens for pathological examination after excision of the ganglion cyst. Discrepant diagnoses are encountered infrequently and discordant diagnoses did not occur. We recommend pathological examination only when the clear gelatinous fluid typical of a ganglion cyst is not encountered at surgery.
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Affiliation(s)
- Thierry G Guitton
- Orthopaedic Hand and Upper Extremity Service, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
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10
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Guthrie B. Why do general practitioners take blood? A cross-sectional study of use of blood tests in UK general practice. Eur J Gen Pract 2009. [DOI: 10.3109/13814780109094332] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Shahangian S, Snyder SR. Laboratory medicine quality indicators: a review of the literature. Am J Clin Pathol 2009; 131:418-31. [PMID: 19228647 DOI: 10.1309/ajcpjf8ji4zldque] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We summarize information on quality indicators related to laboratory testing from published literature and Internet sources to assess current gaps with respect to stages of the laboratory testing process, the Institute of Medicine (IOM) health care domains, and quality measure evaluation criteria. Our search strategy used various general and specific terms for clinical conditions and laboratory procedures. References related to a potential quality indicator associated with laboratory testing and an IOM health care domain were included. With the exception of disease- and condition-related indicators originating from clinical guidelines, the laboratory medicine quality indicators reviewed did not satisfy minimum standard evaluation criteria for quality or performance measures (ie, importance, scientific acceptability, and feasibility) and demonstrated a need across the total laboratory testing process for consistently specified, useful, and evidence-based, laboratory-related quality and performance measures that are important to health outcomes and meaningful to health care stakeholders for which laboratories can be held accountable.
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12
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El entusiasmo por las pruebas diagnósticas: efectos en la salud y formas de control. Informe SESPAS 2008. GACETA SANITARIA 2008; 22 Suppl 1:216-22. [DOI: 10.1016/s0213-9111(08)76095-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Poley MJ, Edelenbos KI, Mosseveld M, van Wijk MAM, de Bakker DH, van der Lei J, Rutten-van Mölken MPMH. Cost consequences of implementing an electronic decision support system for ordering laboratory tests in primary care: evidence from a controlled prospective study in the Netherlands. Clin Chem 2006; 53:213-9. [PMID: 17185371 DOI: 10.1373/clinchem.2006.073908] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The economic consequences of interventions to promote rational, evidence-based use of laboratory tests by physicians are not yet fully understood. We evaluated the cost consequences of a computer-based, guideline-driven decision-support system (CDSS) for ordering blood tests in primary care. METHODS We installed the CDSS in 118 practices [159 general practitioners (GPs)] throughout The Netherlands and calculated the costs of the intervention in this group. During a period of 6 months before and 6 months after installation of the CDSS, the test-ordering behavior of 87 (109 GPs) of these 118 study practices was studied and the results were compared with those of a nonhistorical control group that did not receive the CDSS. In addition the costs of laboratory requests were calculated for both groups. RESULTS Total intervention costs, comprising development costs and installation costs, amounted to 79,000 euro (670 euro per practice). Whereas the introduction of the CDSS did not affect the number of order forms submitted to the laboratories, it did reduce the number of blood tests per order form. As a result, the CDSS yielded mean savings on the costs of laboratory requests of 847 euro per practice per 6 months. CONCLUSIONS This study demonstrates that providing electronic decision support for ordering blood tests in primary care represents an economically promising concept. Savings on laboratory costs are achievable and not offset by disproportionally high intervention costs.
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Affiliation(s)
- Marten J Poley
- Institute for Medical Technology Assessment (iMTA), Erasmus MC, Rotterdam, The Netherlands.
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Bindels R, Hasman A, van Wersch JWJ, Talmon J, Winkens RAG. Evaluation of an automated test ordering and feedback system for general practitioners in daily practice. Int J Med Inform 2004; 73:705-12. [PMID: 15325327 DOI: 10.1016/j.ijmedinf.2004.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2004] [Revised: 06/08/2004] [Accepted: 06/09/2004] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the use of an automated test ordering and feedback system (named GRIF) in daily practice. The system produces recommendations to general practitioners (GPs) to improve the application of accepted practice guidelines for test ordering. METHODS A randomised controlled trial with balanced block design was carried out in general practices in two regions of the Netherlands from August 2000 to July 2001. We implemented the GRIF system on the workstations at the offices of the participating GPs. The GPs (n=11) were asked to use GRIF during patient consultation instead of filling in the paper request form. The system displayed critical comments about their non-adherence to the guidelines as apparent from the request forms. RESULTS The median time of producing the comments plus the response time of the GP was 13s. Of the 2780 presented recommendations, 4.3% were accepted. Advice of the GRIF system that presents a concrete test to request in a particular situation is adhered to most frequently. Finally, there seems to be a decrease of accepted comments over the trial period. CONCLUSION Computerised recommendations should contain, if possible, suggestions for alternative tests to improve the application of these recommendations. Furthermore, creative solutions must be developed to avoid that GPs get used to the recommendations of critiquing systems and to stimulate a better adherence to these recommendations.
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Affiliation(s)
- Rianne Bindels
- Department of Medical Informatics, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
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Severens JL. Value for money of changing healthcare services? Economic evaluation of quality improvement. Qual Saf Health Care 2003; 12:366-71. [PMID: 14532369 PMCID: PMC1743758 DOI: 10.1136/qhc.12.5.366] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
There are many instances of perceived or real inefficiencies in health service delivery. Both healthcare providers and policy makers need to know the impact and cost of applying strategies to change the behaviour of individuals or organisations. Quality improvement or implementation research is concerned with evaluating the methods of behavioural change. Addressing inefficiencies in healthcare services raises a series of issues, beginning with how inefficiency itself should be defined. The basic concepts of cost analysis and economic evaluations are explained and a model for working through the economic issues of quality improvement is discussed. This model combines the costs and benefits of corrected inefficiency with the costs and degree of behavioural change achieved by a quality improvement method in the policy maker's locality. It shows why it may not always be cost effective for policy makers to address suboptimal behaviour. Both the interpretation of quality improvement research findings and their local application need careful consideration. The limited availability of applicable quality improvement research may make it difficult to provide robust advice on the value for money of many behavioural quality improvement strategies.
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Affiliation(s)
- J L Severens
- University of Maastricht, Department of Health, Organisation, Policy and Economics, Maastricht, The Netherlands.
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Rao GG, Crook M, Tillyer ML. Pathology tests: is the time for demand management ripe at last? J Clin Pathol 2003; 56:243-8. [PMID: 12663633 PMCID: PMC1769923 DOI: 10.1136/jcp.56.4.243] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2002] [Indexed: 11/04/2022]
Abstract
With the ever increasing demands for pathology testing within the National Health Service there is a need to manage the demand for these tests. This review discusses strategies for the demand management of requests made by clinicians in the disciplines of biochemistry, haematology, and microbiology. The various approaches that have been used to manage demand will be described, along with specific clinical strategies for demand management.
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Affiliation(s)
- G Gopal Rao
- Department of Microbiology, University Hospital Lewisham, London SE13 6LH, UK.
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Bindels R, Hasman A, van Wersch JWJ, Pop P, Winkens RAG. The reliability of assessing the appropriateness of requested diagnostic tests. Med Decis Making 2003; 23:31-7. [PMID: 12583453 DOI: 10.1177/0272989x02239647] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite a poor reliability, peer assessment is the traditional method to assess the appropriateness of health care activities. This article describes the reliability of the human assessment of the appropriateness of diagnostic tests requests. The authors used a random selection of 1217 tests from 253 request forms submitted by general practitioners in the Maastricht region of The Netherlands. Three reviewers independently assessed the appropriateness of each requested test. Interrater kappa values ranged from 0.33 to 0.42, and kappa values of intrarater agreement ranged from 0.48 to 0.68. The joint reliability coefficient of the 3 reviewers was 0.66. This reliability is sufficient to review test ordering over a series of cases but is not sufficient to make case-by-case assessments. Sixteen reviewers are needed to obtain a joint reliability of 0.95. The authors conclude that there is substantial variation in assessment concerning what is an appropriately requested diagnostic test and that this feedback method is not reliable enough to make a case-by-case assessment. Computer support maybe beneficial to support and make the process of peer review more uniform.
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Affiliation(s)
- Rianne Bindels
- Department of Medical Informatics, University of Mastricht, The Netherlands.
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Isouard G. A quality management intervention to improve clinical laboratory use in acute myocardial infarction. Med J Aust 1999. [DOI: 10.5694/j.1326-5377.1999.tb126856.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Godfrey Isouard
- Division of Public HealthUniversity of Western SydneyMacarthurNSW
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