La gestión de la demanda de las pruebas: un reto en el nuevo modelo de medicina de laboratorio

Introducción

En las últimas décadas está evolucionando el posicionamiento de la Medicina de Laboratorio en el proceso médico asistencial de atención al paciente y también el modelo de laboratorio; de un modelo tradicional, con solo intervención, a un modelo líder, que además de intervenir condiciona la decisión clínica. La mejora en tecnología y automatización ha permitido también al profesional de laboratorio centrarse en la primera y última fase del ciclo de laboratorio, la solicitud de pruebas, y la acción tras su resultado, las etapas con más errores, y donde principalmente se debe actuar para conseguir una mejora en la calidad asistencial del paciente.

Contenido

Se muestra el diseño y la implantación de intervenciones de gestión de la demanda de pruebas de laboratorio, logrando el diagnóstico de la enfermedad oculta, y mejorando la adherencia a las guías clínicas y la seguridad del paciente.

Resumen

Se expondrán los puntos clave en el proceso de gestión de la demanda, tanto de exceso como de defecto.

Perspectivas

El objetivo de la revisión es lograr que el profesional del laboratorio se involucre en el diseño e implantación de intervenciones de gestión de la demanda y en la creación de ese nuevo modelo de Laboratorio Líder.

Managing laboratory test ordering: a challenge in the new laboratory medicine model

Introduction

The role of Laboratory Medicine in patient care has evolved in the last decades. The same has occurred to the laboratory model, which has evolved from a traditional model where the laboratory is merely involved in clinical decision-making to a leading model where the laboratory is not only involved but also determines decision-making. The advent of new technologies and automation of processes have enabled laboratory professionals to focus on the first and last phase of the analytical process namely, test ordering and decision-making based on laboratory results. These phases are more error-prone than the analytical phase, and where action must be taken to improve the quality of patient care.

Content

We share our experience in the design and establishment of laboratory test demand management interventions that facilitated diagnosis of occult disease, improved adherence to clinical guidelines, and optimized patient safety.

Summary

A description is provided of key points in the management of laboratory test over/underutilization.

Outlook

The objective of this review is to promote the involvement of laboratory professionals in the design and implementation of demand management interventions and in the development of the new Leader Laboratory model.

The clinical laboratory: a decision maker hub

OBJECTIVES

We aimed to share a new laboratory model based on laboratory knowledge, meaningful use of information technology, and partnership with clinicians, to lead the appropriate use of laboratory testing and clinical decision making in the diagnosis of as-yet-undiagnosed disease. More specifically, we evaluate the role of eight different opportunistic interventions to diagnose certain asymptomatic disorders, by means of the automatic registration of appropriate laboratory testing according to different scenarios.

METHODS

This is a retrospective longitudinal study to evaluate the impact of laboratory interventions on the diagnosis of different diseases and on patient care, including data from January 2012 to September 2020.

RESULTS

Overall, the above strategies have so far identified 2063 patients with clinically relevant as-yet-undiagnosed disorders who would have otherwise remained occult, such as for instance, primary hyperparathyroidism, diabetes, and hypomagnesemia.

CONCLUSIONS

We are facing a new laboratory model, a leading laboratory rather than a passive traditional laboratory, not just to intervene in clinical decision-making, but to make the clinical decision, through the identification of patients with occult disease.

Decision support system through automatic algorithms and electronic request in diagnosis of anaemia for primary care patients

Introduction

An appropriate management of anaemia laboratory tests is crucial for a correct diagnosis and treatment. A non-sequential “shotgun” approach (where every anaemia related test is ordered) causes workload and cost increases and could be potentially harmful. We have implemented a Decision Support System through our laboratory information system (LIMS) based on reflexive algorithms and automatic generation of interpretative reports specifically in diagnosis of anaemia for primary care patients.

Materials and methods

When a request contained an “Anaemia Suspicion Study” profile, more than twenty automatic reflexive rules were activated in our LIMS based upon laboratory results. These rules normally involved the addition of reflexive tests. A final report was automatically generated for each interpretation which was always reviewed for their validity by two staff pathologists. We measured the impact of this system in the ordering of most common anaemia related tests and if a proper treatment was established based on the interpretive report.

Results

From all the studies performed, only 12% were positive being “iron deficiency” and “anaemia of chronic disease” the most frequent causes, 62% and 17%, respectively. Proper treatment was established in 88% of these anaemic patients. Total iron, transferrin, ferritin, folate and vitamin B12 demand decreased substantially after implementation representing a cost reduction of 40% only for these five tests.

Conclusions

Our system has easily improved patient outcomes, advising on individual clinical cases. We have also noticeably reduced the number of over-requested tests and laboratory costs.

Initial study of anaemia profile for primary care centres with automated laboratory algorithms reduces the demand for ferritin, iron, transferrin, vitamin B12 and folate tests

AIM

To evaluate the influence of an algorithm designed to incorporate reflex testing according to haemogram results for analytical tests ordered to investigate anaemia.

METHODS

In 2020, a new request for 'initial study of anaemia' was created in three primary care pilot centres for suspected anaemia or new anaemias. A haemogram was ordered and the remainder of the tests were created in a reflex manner according to an algorithm integrated in the laboratory information system that also generates a comment that is completed and validated by a haematologist. The demand for tests was evaluated over three time periods.

RESULTS

Of 396 requests, anaemia was detected in 80 (20.2%), with 26 microcytic anaemias (6.57%), 20 iron deficiency anaemias, 41 (10.3%) normocytic anaemias and 13 macrocytic anaemias (3.28%); 4 with folate deficiency; and 1 haemolytic anaemia. No haematological diseases were detected. Twenty-four (6.06%) cases exhibited microcytosis/hypochromia without anaemia, 12 of which exhibited iron deficiency. Four young women exhibiting within-limit haemoglobin levels had iron deficiency. There were 56 (14.1%) cases of macrocytosis without anaemia.With the new profile of 'initial study of anaemia', the demand for tests was reduced and was significantly lower than in the remainder of primary centres for iron, transferrin, ferritin, vitamin B₁₂ and folate.

CONCLUSIONS

A new profile of 'initial study of anaemia' in the request form with algorithms integrated in the laboratory information system enabled submission of orders and decreased the demand for unnecessary iron, transferrin, ferritin, vitamin B₁₂ and folate tests.

[Effectiveness of an intervention to improve demand management of laboratory tests related to anaemia in primary care]

OBJECTIVE

To evaluate the appropriateness oflaboratory test requests for the diagnosis and monitoring of anaemia in Primary Care. As a secondary objective, a decrease in variability was sought byunifying the test profile performed.

MATERIAL AND METHODS

A decision algorithm based on scientific evidence for test requests related to anaemia in Primary Care was implemented, so that the profile of tests performed is conditioned by haemoglobin results and mean corpuscular volume. A multidisciplinary laboratory-Primary Care team was created for the design, execution and evaluation of the results obtained. In addition, there was computer support for the development and inclusion of the rules in the laboratory and Primary Care computer systems.

RESULTS

Through the directed algorithm, the necessary tests for the diagnosis and follow-up of anaemia were performed sequentially, even so this meant an average monthly decrease in the number of tests of 70% for folic acid, 66% for vitamin B₁₂, 92% for transferrin, 43% foriron and 42% for ferritin. It was also possible to unify the profile of tests performed, regardless of the centre of origin.

CONCLUSIONS

Better use of the biochemical tests related to anaemia was achieved, since only the necessary tests for the patient were performed. Variability is reduced by unifying the request profile in all centres.

Alopecia and Iron Deficiency: An Interventional Pilot Study in Primary Care to Improve the Request of Ferritin

BACKGROUND

The aim was to study the demographic and laboratory pattern of primary care patients with alopecia undergoing laboratory testing, more specifically, the request of hemoglobin and ferritin and values showing anemia and iron deficiency, and to evaluate the effects of an intervention involving automatic ferritin registration and measurement when not requested.

METHODS

Retrospective and prospective observational cross-sectional studies were conducted, as well as an intervention to automatically register and measure ferritin when not requested by the general practitioner.

RESULTS

There were 343 and 1032 primary care laboratory requests prompted by alopecia in the retrospective and prospective studies. Hemoglobin was requested in almost every patient and ferritin in 88%. 5% of the cohort had anemia, and 25% had iron deficiency. The intervention registered and measured that 123 ferritin and 24 iron deficiencies were detected in patients with alopecia, all women, at a cost of 10.6€.

CONCLUSION

Primary care patients with alopecia and laboratory tests request were mainly young female. Our intervention added ferritin when not requested, detecting iron deficiency in 27.9% of women, potentially avoiding the adverse effects of iron deficiency on hair loss.

Less is more: Two automated interventions to increase vitamin B12 measurement when long-term proton pump inhibitor and decrease redundant testing

INTRODUCTION

To test the efficacy of two interventions to promote the measurement of serum vitamin B₁₂ (s- vitamin B₁₂) in patients with long-term proton pump inhibitor (PPI) use and to decrease inadequate s-vitamin B₁₂ measurement by implementing a minimum retest interval.

MATERIAL AND METHODS

The Laboratory Information System (LIS) automatically registered s-vitamin B₁₂ when not ordered by General Practitioners to all requests patients with long term (>3years) PPI treatment, and with no s-vitamin B₁₂ testing in the previous year. Through the second intervention, the LIS reported the previous s-vitamin B₁₂ result through an explanatory comment in the report, when the test had been requested in the previous three months. We calculated the new diagnoses of vitamin deficiency (s-vitamin B₁₂ < 200 pg/mL), examined the number of tests needed to detect a new case and investigated the economic cost of each one identified by the intervention. Additionally, we counted the s-vitamin B₁₂ that were requested but not measured, and calculated the savings in reagent.

RESULTS

The strategy added 548 s-vitamin B₁₂ and identified 47 new cases of vitamin B₁₂ deficit. The number of added s-vitamin B₁₂ needed to identify a new case by means of the intervention was 12. The total intervention reagent cost was 1446€, with a cost of 30.7€ per new case. The second intervention avoided unnecessary measurement of 611 tests, with 1613€ savings.

CONCLUSIONS

Through the two automated interventions we improved the diagnosis of vitamin B₁₂ deficiency, and decreased inadequate redundant s-vitamin B₁₂ measurement, cutting unnecessary laboratory costs.

Computer-assisted interventions in the clinical laboratory process improve the diagnosis and treatment of severe vitamin B12 deficiency

Background:

Severe vitamin B12 deficiency can result in serious complications if undiagnosed or untreated. Our aim was to test the efficacy of interventions in the laboratory process to improve the detection and the treatment of severe vitamin B12 deficiency.

Methods:

Quasi-experimental investigation with a retrospective 7-year pre-intervention period and 29-month post-intervention follow-up in a university hospital. Two interventions were designed to improve the detection and treatment of subjects with vitamin B12 deficiency: the laboratory information system (LIS) automatically added seru vitamin B12 (s-vitamin B12) based on certain conditions; and created a comment in the report and scheduled an appointment with the general practitioner (GP). We calculated the number of new diagnoses of severe vitamin deficiency (s-vitamin B12 <73.8 pmol/L) and the proportion of identified patients that were correctly treated in the pre- and post-intervention periods. We compared the number of tests needed to detect a new case when ordered by GPs vs. added by the strategy. Finally, we investigated the economic cost of each new case.

Results:

The strategy added 699 s-vitamin B12 and detected 66 new cases of severe vitamin deficiency. The number of tests needed to identify a new case when s-vitamin B12 was ordered by GPs was 187, as opposed to 10 when added through the intervention (p<0.001). The intervention reagent cost was €26.7 per new case. In the post-intervention cohort, 88% of patients were correctly treated, as opposed to 52% in the pre-intervention (p<0.001).

Conclusions:

Interventions in the clinical laboratory process improved the diagnosis and treatment of severe vitamin B12 deficiency.

Glycated hemoglobin: A powerful tool not used enough in primary care

BACKGROUND

Glycated haemoglobin (HbA1c) is one of the most useful and relevant laboratory tests currently available. The aim of the actual research was to study the variability and appropriateness in the request of HbA1c in primary care, and differences between regions, to assess if there would be an opportunity to improve the request.

METHODS

A cross-sectional study was conducted enrolling clinical Spanish laboratories. The number of HbA1c requested in 2014 by all general practitioners was reported by each participant. Test-utilization rate was expressed as tests per 1000 inhabitants. The index of variability was calculated, as the top decile divided by the bottom decile. HbA1c per 1000 inhabitants was compared between the different regions. To investigate whether HbA1c was appropriately requested to manage patients with diabetes, the real request was compared to the theoretically ideal number, according to prevalence of known diabetes mellitus in Spain and guideline recommendations.

RESULTS

A total of 110 laboratories participated in the study, corresponding to a catchment area of 27 798 262 inhabitants (59.8% of the Spanish population) from 15 different autonomous communities (AACCs). 2 655 547 HbA1c were requested, a median of 93.9 (interquartile range (IQR): 33.4) per 1000 inhabitants. The variability index was 1.97. The HbA1c/1000 inhabitants was significantly different among the AACCs, ranging from 73.4 to 126.3. A total of 4 336 529 additional HbA1c would have been necessary to manage patients with diabetes according to guidelines, and 3 861 769 for diagnosis in asymptomatic patients.

CONCLUSIONS

There was a high variability and significant differences between Spanish AACCs. Also a significant under-request of HbA1c was observed in Primary Care in Spain.

Urinary albumin: a risk marker under-requested in primary care in Spain

Background

To study the inter-practice regional variation in the request of urinary albumin by general practitioners and compare to guideline recommendations.

Methods

A cross-sectional study enrolled laboratories from different Spanish autonomous communities. Laboratories were invited to report the number of urinary albumin requested by general practitioners during 2012 and 2014. Urinary albumin requested per 1000 inhabitants and the index of variability (90th centile/10th centile) was calculated, and compared between autonomous communities and time periods. To investigate potential inappropriate requesting in the management of diabetes and arterial hypertension, the actual number of requests was compared to the theoretical, based on prevalence and guideline recommendations.

Results

Urinary albumin requested per 1000 inhabitants was similar for years 2012 and 2014 (78.2 (60.1) to 85.4 (55.4); P = 0.235), as was the variability index (4.6 for both). There were significant differences between autonomous communities, with the indicator ranging from 46.0 (33.1) to 125.8 (64.3) ( P < 0.05). The theoretical cut-off ratios of urinary albumin per 1000 inhabitants to manage patients with diabetes and arterial hypertension were, respectively, 78 and 159; no laboratory reached both values.

Conclusions

Requesting of urinary albumin showed a significant regional variability in primary care in Spain, and was insufficient to correctly monitor patients with diabetes and arterial hypertension.

Primary care requests for anaemia chemistry tests in Spain: potential iron, transferrin and folate over-requesting

Aim

To study the regional variability of requests for anaemia chemistry tests in primary care in Spain and the associated economic costs of potential over-requesting.

Methods

Requests for anaemia tests were examined in a cross-sectional study. Clinical laboratories from different autonomous communities (AACCs) were invited to report on primary care anaemia chemistry tests requested during 2014. Demand for iron, ferritin, vitamin B12 and folate tests per 1000 inhabitants and the ratios of the folate/vitamin B12 and transferrin/ferritin requests were compared between AACCs. We also calculated reagent costs and the number of iron, transferrin and folate tests and the economic saving if every AACC had obtained the results achieved by the AACC with best practice.

Results

110 laboratories participated (59.8% of the Spanish population). More than 12 million tests were requested, resulting in reagent costs exceeding €16.5 million. The serum iron test was the most often requested, and the ferritin test was the most costly (over €7 million). Close to €4.5 million could potentially have been saved if iron, transferrin and folate had been appropriately requested (€6 million when extrapolated to the whole Spanish population).

Conclusions

The demand for and expenditure on anaemia chemistry tests in primary care in Spain is high, with significant regional differences between different AACCs.

Temporal and regional variability in the request of vitamin D from general practitioners in Spain

Background:

Our main goal is to study the inter-practice regional variability and the temporal evolution in the request of 25-hydroxyvitamin D (25[OH]D) by general practitioners (GPs) in Spain.

Methods:

Clinical laboratories in different autonomic communities (AACCs) were invited to report the number of 25(OH)D test requested by GPs during 2012 and 2014. The number of 25(OH)D requested per 1000 inhabitants and the index of variability were calculated, and compared between regions and time periods. We calculated the number of tests that could have been potentially saved in regions where 25(OH)D could be requested from primary care without restrictions taking into account the request in those where it is restricted, and the potential economical savings.

Results:

Seventy-six laboratories participated in the 2012 edition, and 110 in 2014, corresponding to 17,679,195 and 27,798,262 inhabitants (59.8% Spanish population). The number of 25(OH)D requested per 1000 inhabitants increased from 1.1 in 2012 to 3.4 in 2014 (p<0.001). The variability index also increased from 51.7 to 68. There was a significantly variability among the different AACCs, ranging from 0.94 to 21.24 (p=0.002). 173,885 tests could have been not measured from primary care in regions without ordering restrictions, resulting in potential 886,813.5€ savings.

Conclusions:

There was a high variability in the request of 25(OH)D by GPs in Spain, which significantly increased in a 2 year period. The demand was higher in areas where the request of 25(OH)D was not restricted in primary care, with potential savings if the request would approach to regions with ordering restrictions.

The role of European Federation of Clinical Chemistry and Laboratory Medicine Working Group for Preanalytical Phase in standardization and harmonization of the preanalytical phase in Europe

Patient safety is a leading challenge in healthcare and from the laboratory perspective it is now well established that preanalytical errors are the major contributor to the overall rate of diagnostic and therapeutic errors. To address this, the European Federation of Clinical Chemistry and Laboratory Medicine Working Group for Preanalytical Phase (EFLM WG-PRE) was established to lead in standardization and harmonization of preanalytical policies and practices at a European level. One of the key activities of the WG-PRE is the organization of the biennial EFLM-BD conference on the preanalytical phase to provide a forum for National Societies (NS) to discuss their issues. Since 2012, a year after the first Preanalytical phase conference, there has been a rapid growth in the number of NS with a working group engaged in preanalytical phase activities and there are now at least 19 countries that have one. As a result of discussions with NS at the third conference held in March 2015 five key areas were identified as requiring harmonisation. These were test ordering, sample transport and storage, patient preparation, sampling procedures and management of unsuitable specimens. The article below summarises the work that has and will be done in these areas. The goal of this initiative is to ensure the EFLM WG-PRE produces work that meets the needs of the European laboratory medicine community. Progress made in the identified areas will be updated at the next preanalytical phase conference and show that we have produced guidance that has enhanced standardisation in the preanalytical phase and improved patient safety throughout Europe.

Larger differences in utilization of rarely requested tests in primary care in Spain

INTRODUCTION

The study was performed to compare and analyze the inter-departmental variability in the request of rarely requested laboratory tests in primary care, as opposed to other more common and highly requested tests.

MATERIALS AND METHODS

Data from production statistics for the year 2012 from 76 Spanish laboratories was used. The number of antinuclear antibodies, antistreptolysin O, creatinine, cyclic citrullinated peptide antibodies, deaminated peptide gliadine IgA antibodies, glucose, protein electrophoresis, rheumatoid factor, transglutaminase IgA antibodies, urinalysis and uric acid tests requested was collected. The number of test requests per 1000 inhabitants was calculated. In order to explore the variability the coefficient of quartile dispersion was calculated.

RESULTS

The smallest variation was seen for creatinine, glucose, uric acid and urinalysis; the most requested tests. The tests that were least requested showed the greatest variability.

CONCLUSION

Our study shows through a very simplified approach, in a population close to twenty million inhabitants, how in primary care, the variability in the request of laboratory tests is inversely proportional to the request rate.