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

Perspectives of primary care providers regarding multicancer early detection panels

OBJECTIVE

Multicancer early detection panels have recently become available to patients with healthcare provider prescriptions and available funds. These tests utilize circulating tumor DNA (ctDNA) to screen more than 50 cancers using a single blood sample. However, perspectives and data on how the deployment of these tests may impact the practices of primary care providers in terms of implementation, interpretation, documentation, and costs are limited. This study aimed to assess the perspectives of primary care providers regarding the integration of multicancer early detection panels into clinical practice.

METHODS

We used a survey to assess the opinions and perspectives of primary care providers, including physicians, nurse practitioners, and physician assistants, across a multistate, tertiary healthcare system. We used a single form consisting of novel questions on familiarity with multi-cancer early detection panels, cost, healthcare equity, documentation, medicolegal, and other concerns. The subgroup analysis was consistent with stratification based on familiarity with ctDNA-based tests and their roles in clinical practice.

RESULTS

Most respondents were unfamiliar with multicancer early detection panels and had not used ctDNA-based tests. Most primary care providers suggested that they would reorder multicancer early detection panel testing at 1- to 5-year intervals and prefer subspecialists for both ordering multicancer early detection panels as well as interpreting their results. Relative concerns differed between physicians and nonphysicians.

CONCLUSION

The integration of multicancer early detection panels into primary care practice requires careful planning and consideration for the management of increased clinical load, interpretation of results, and cost management.

Clinicians' and laboratory medicine specialists' views on laboratory demand management: a survey in nine European countries

BACKGROUND

Laboratory tests are an essential aspect of current medical practice and their use has grown exponentially. Several studies however have demonstrated inappropriate use of laboratory testing. This inappropriateness can lead to delayed or wrong diagnosis, negatively impacting patient safety and an increase in health care expenditure. The aim of the present small-scale survey was to obtain information on the current status of demand management in European laboratories, as well as the opinions of laboratory and clinical professionals in this regard.

METHODS

Two surveys were developed, one for laboratory specialists and one for clinicians, covering information on current use, knowledge and opinions on the possible impact of different demand management strategies on patient outcome and health care costs. Additionally, we asked for the current state and willingness on collaboration of laboratory specialists and clinicians.

RESULTS

One hundred and fifty responses, 72 laboratory specialists and 78 clinicians, from nine countries were received. Developing local ordering protocols/profiles in collaboration with clinicians was the most used strategy (80.3% of laboratories). Of clinicians, 85.6% considered measures to ensure appropriate use of tests necessary and 100% were interested in advice/information about their indication. Of the laboratory specialists 97.2% were either already participating or willing to participate in multidisciplinary groups on the appropriateness of test demand as were 60.3% of clinicians, and 85.9% of clinicians were interested in attending activities about laboratory test demand management.

CONCLUSIONS

The results of our survey show that tools to improve the appropriate use of laboratory tests are already regularly used today. Laboratory medicine specialists as well as clinicians are willing to undertake additional shared activities aimed at improving patient-centered laboratory diagnostic workup.

Explaining variations in test ordering in primary care: protocol for a realist review

INTRODUCTION

Studies have demonstrated the existence of significant variation in test-ordering patterns in both primary and secondary care, for a wide variety of tests and across many health systems. Inconsistent practice could be explained by differing degrees of underuse and overuse of tests for diagnosis or monitoring. Underuse of appropriate tests may result in delayed or missed diagnoses; overuse may be an early step that can trigger a cascade of unnecessary intervention, as well as being a source of harm in itself.

METHODS AND ANALYSIS

This realist review will seek to improve our understanding of how and why variation in laboratory test ordering comes about. A realist review is a theory-driven systematic review informed by a realist philosophy of science, seeking to produce useful theory that explains observed outcomes, in terms of relationships between important contexts and generative mechanisms.An initial explanatory theory will be developed in consultation with a stakeholder group and this 'programme theory' will be tested and refined against available secondary evidence, gathered via an iterative and purposive search process. This data will be analysed and synthesised according to realist principles, to produce a refined 'programme theory', explaining the contexts in which primary care doctors fail to order 'necessary' tests and/or order 'unnecessary' tests, and the mechanisms underlying these decisions.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. A complete and transparent report will be produced in line with the RAMESES standards. The theory developed will be used to inform recommendations for the development of interventions designed to minimise 'inappropriate' testing. Our dissemination strategy will be informed by our stakeholders. A variety of outputs will be tailored to ensure relevance to policy-makers, primary care and pathology practitioners, and patients.

PROSPERO REGISTRATION NUMBER

CRD42018091986.

Effectiveness of Practices to Support Appropriate Laboratory Test Utilization: A Laboratory Medicine Best Practices Systematic Review and Meta-Analysis

Objectives

To evaluate the effectiveness of practices used to support appropriate clinical laboratory test utilization.

Methods

This review followed the Centers for Disease Control and Prevention (CDC) Laboratory Medicine Best Practices A6 cycle method. Eligible studies assessed one of the following practices for effect on outcomes relating to over- or underutilization: computerized provider order entry (CPOE), clinical decision support systems/tools (CDSS/CDST), education, feedback, test review, reflex testing, laboratory test utilization (LTU) teams, and any combination of these practices. Eligible outcomes included intermediate, systems outcomes (eg, number of tests ordered/performed and cost of tests), as well as patient-related outcomes (eg, length of hospital stay, readmission rates, morbidity, and mortality).

Results

Eighty-three studies met inclusion criteria. Fifty-one of these studies could be meta-analyzed. Strength of evidence ratings for each practice ranged from high to insufficient.

Conclusion

Practice recommendations are made for CPOE (specifically, modifications to existing CPOE), reflex testing, and combined practices. No recommendation for or against could be made for CDSS/CDST, education, feedback, test review, and LTU. Findings from this review serve to inform guidance for future studies.

Laboratory Tests Ordering Pattern by Medical Residents From a Brazilian University Hospital

OBJECTIVES

The adequacy of laboratory test orders by medical residents is a longstanding issue. The aim of this study is to analyze the number, types, and pattern of repetition of tests ordered by medical residents.

METHODS

We studied all tests ordered over a 1-year period for inpatients of an internal medicine ward in a university hospital. Types, results, and repetition pattern of tests were analyzed in relation to patients' diagnoses.

RESULTS

We evaluated 117,666 tests, requested for 1,024 inpatients. The mean number of tests was 9.5 per day. The test repetition pattern was similar, regardless of patients' diagnoses, previous test results, or duration of stay. The probability of an abnormal result after a sequence of three normal tests was lower than 25%, regardless of the diagnosis.

CONCLUSIONS

Number of tests and repetition were both high, imposing costs, discomfort, and risks to patients, thus warranting further investigation.

A review of the economic tools for assessing new medical devices

Whereas the economic evaluation of pharmaceuticals is an established practice within international health technology assessment (HTA) and is often produced with the support of comprehensive methodological guidance, the equivalent procedure for medical devices is less developed. Medical devices, including diagnostic products, are a rapidly growing market in healthcare, with over 10,000 medical technology patent applications filed in Europe in 2012-nearly double the number filed for pharmaceuticals. This increase in the market place, in combination with the limited, or constricting, budgets that healthcare decision makers face, has led to a greater level of examination with respect to the economic evaluation of medical devices. However, methodological questions that arise due to the unique characteristics of medical devices have yet to be addressed fully. This review of journal publications and HTA guidance identified these characteristics and the challenges they may subsequently pose from an economic evaluation perspective. These unique features of devices can be grouped into four categories: (1) data quality issues; (2) learning curve; (3) measuring long-term outcomes from diagnostic devices; and (4) wider impact from organisational change. We review the current evaluation toolbox available to researchers and explore potential future approaches to improve the economic evaluation of medical devices.

Costs associated with implementation of computer-assisted clinical decision support system for antenatal and delivery care: case study of Kassena-Nankana district of northern Ghana

OBJECTIVE

This study analyzed cost of implementing computer-assisted Clinical Decision Support System (CDSS) in selected health care centres in Ghana.

METHODS

A descriptive cross sectional study was conducted in the Kassena-Nankana district (KND). CDSS was deployed in selected health centres in KND as an intervention to manage patients attending antenatal clinics and the labour ward. The CDSS users were mainly nurses who were trained. Activities and associated costs involved in the implementation of CDSS (pre-intervention and intervention) were collected for the period between 2009-2013 from the provider perspective. The ingredients approach was used for the cost analysis. Costs were grouped into personnel, trainings, overheads (recurrent costs) and equipment costs (capital cost). We calculated cost without annualizing capital cost to represent financial cost and cost with annualizing capital costs to represent economic cost.

RESULTS

Twenty-two trained CDSS users (at least 2 users per health centre) participated in the study. Between April 2012 and March 2013, users managed 5,595 antenatal clients and 872 labour clients using the CDSS. We observed a decrease in the proportion of complications during delivery (pre-intervention 10.74% versus post-intervention 9.64%) and a reduction in the number of maternal deaths (pre-intervention 4 deaths versus post-intervention 1 death). The overall financial cost of CDSS implementation was US$23,316, approximately US$1,060 per CDSS user trained. Of the total cost of implementation, 48% (US$11,272) was pre-intervention cost and intervention cost was 52% (US$12,044). Equipment costs accounted for the largest proportion of financial cost: 34% (US$7,917). When economic cost was considered, total cost of implementation was US$17,128-lower than the financial cost by 26.5%.

CONCLUSIONS

The study provides useful information in the implementation of CDSS at health facilities to enhance health workers' adherence to practice guidelines and taking accurate decisions to improve maternal health care.

Temporal growth and geographic variation in the use of laboratory tests by NHS general practices: using routine data to identify research priorities

BACKGROUND

Laboratory tests are extensively used for diagnosis and monitoring in UK primary care. Test usage by GPs, and associated costs, have grown substantially in recent years.

AIM

This study aimed to quantify temporal growth and geographic variation in utilisation of laboratory tests.

DESIGN AND SETTING

Retrospective cohort study using data from general practices in the UK.

METHOD

Data from the General Practice Research Database, including patient demographics, clinical details, and laboratory test results, were used to estimate rates of change in utilisation between 2005 and 2009, and identify tests with greatest inter-regional variation, by fitting random-effects Poisson regression models. The study also investigated indications for test requests, using diagnoses and symptoms recorded in the 2 weeks before each test.

RESULTS

Around 660 000 tests were recorded in 230 000 person-years of follow-up. Test use increased by 24.2%, from 23 872 to 29 644 tests per 10 000 person-years, between 2005 and 2009. Tests with the largest increases were faecal occult blood (121%) and C-reactive protein (86%). There was substantial geographic variation in test utilisation; GPs in some regions requested tests such as plasma viscosity and cardiac enzymes at a rate more than three times the national average.

CONCLUSION

Increases in the use of laboratory tests have substantial resource implications. Rapid increases in particular tests may be supported by evidence-based guidelines, but these are often vague about who should be tested, how often, and for how long. Substantial regional variation in test use may reflect uncertainty about diagnostic accuracy and appropriate indications for the laboratory test. There is a need for further research on the diagnostic accuracy, therapeutic impact, and effect on patient health outcomes of the most rapidly increasing and geographically variable tests.

Optimizing personalized bone marrow testing using an evidence-based, interdisciplinary team approach

OBJECTIVES

To address the overuse of testing that complicates patient care, diminishes quality, and increases costs by implementing the diagnostic management team, a multidisciplinary system for the development and deployment of diagnostic testing guidelines for hematologic malignancies.

METHODS

The team created evidence-based standard ordering protocols (SOPs) for cytogenetic and molecular testing that were applied by pathologists to bone marrow biopsy specimens on adult patients. Testing on 780 biopsy specimens performed during the six months before SOP implementation was compared with 1,806 biopsy specimens performed during the subsequent 12 months.

RESULTS

After implementation, there were significant decreases in tests discordant with SOPs, omitted tests, and the estimated cost of testing to payers. The fraction of positive tests increased. Clinicians reported acceptance of the new procedures and perceived time savings.

CONCLUSIONS

This process is a model for optimizing complex and personalized diagnostic testing.

Measuring value for money: a scoping review on economic evaluation of health information systems

Objective

To explore how key components of economic evaluations have been included in evaluations of health information systems (HIS), to determine the state of knowledge on value for money for HIS, and provide guidance for future evaluations.

Materials and methods

We searched databases, previously collected papers, and references for relevant papers published from January 2000 to June 2012. For selection, papers had to: be a primary study; involve a computerized system for health information processing, decision support, or management reporting; and include an economic evaluation. Data on study design and economic evaluation methods were extracted and analyzed.

Results

Forty-two papers were selected and 33 were deemed high quality (scores ≥8/10) for further analysis. These included 12 economic analyses, five input cost analyses, and 16 cost-related outcome analyses. For HIS types, there were seven primary care electronic medical records, six computerized provider order entry systems, five medication management systems, five immunization information systems, four institutional information systems, three disease management systems, two clinical documentation systems, and one health information exchange network. In terms of value for money, 23 papers reported positive findings, eight were inconclusive, and two were negative.

Conclusions

We found a wide range of economic evaluation papers that were based on different assumptions, methods, and metrics. There is some evidence of value for money in selected healthcare organizations and HIS types. However, caution is needed when generalizing these findings. Better reporting of economic evaluation studies is needed to compare findings and build on the existing evidence base we identified.

Managing laboratory test ordering through test frequency filtering

Modern computer systems allow limits to be set on the periods allowed for repetitive testing. We investigated a computerised system for managing potentially overtly frequent laboratory testing, calculating the financial savings obtained.

In consultation with hospital physicians, tests were selected for which ‘spare periods’ (periods during which tests are barred) might be set to control repetitive testing. The tests were selected and spare periods determined based on known analyte variations in health and disease, variety of tissues or cells giving rise to analytes, clinical conditions and rate of change determining analyte levels, frequency with which doctors need information about the analytes and the logistical needs of the clinic.

The operation and acceptance of the system was explored with 23 analytes. Frequency filtering was subsequently introduced for 44 tests, each with their own spare periods. The proportion of tests barred was 0.56%, the most frequent of these being for total cholesterol, uric acid and HDL-cholesterol. The financial savings were 0.33% of the costs of all testing, with HbA

Managing laboratory testing through computerised limits to prevent overtly frequent testing is feasible. The savings were relatively low, but sustaining the system takes little effort, giving little reason not to apply it. The findings will serve as a basis for improving the system and may guide others in introducing similar systems.

Demand management and test request rationalization

Demand for laboratory testing is increasing disproportionately to medical activity, and the tests involved are becoming increasingly complex. When this phenomenon is seen in parallel with declining teaching of laboratory medicine in the medical curriculum, a need emerges to manage demand to avoid unnecessary expenditure and improve the use of laboratory services: 'the right test in the right patient at the right time.' Various methods have been tried to manage demand, with success depending on the medical context, type of health service and preintervention situation. Because many factors contribute to demand, and the different settings in which these exist, it is not realistic to meta-analyse the studies and we are limited to trying to identify trends in results in particular situations. The studies suggest that education combined with facilitating interventions, such as feedback, prompts and changes to laboratory request forms are the most successful. From the perspective of a whole health service, it is important that results are not exaggerated by assessing benefits in terms of total rather than marginal cost. It would be desirable, although difficult, to include the impact on downstream clinical activity caused or avoided by the interventions. Advances in information and web technology may make the elusive goal of achieving substantial demand control more achievable.

Impact of electronic medical record on physician practice in office settings: a systematic review

BACKGROUND

Increased investments are being made for electronic medical records (EMRs) in Canada. There is a need to learn from earlier EMR studies on their impact on physician practice in office settings. To address this need, we conducted a systematic review to examine the impact of EMRs in the physician office, factors that influenced their success, and the lessons learned.

RESULTS

For this review we included publications cited in Medline and CINAHL between 2000 and 2009 on physician office EMRs. Studies were included if they evaluated the impact of EMR on physician practice in office settings. The Clinical Adoption Framework provided a conceptual scheme to make sense of the findings and allow for future comparison/alignment to other Canadian eHealth initiatives.In the final selection, we included 27 controlled and 16 descriptive studies. We examined six areas: prescribing support, disease management, clinical documentation, work practice, preventive care, and patient-physician interaction. Overall, 22/43 studies (51.2%) and 50/109 individual measures (45.9%) showed positive impacts, 18.6% studies and 18.3% measures had negative impacts, while the remaining had no effect. Forty-eight distinct factors were identified that influenced EMR success. Several lessons learned were repeated across studies: (a) having robust EMR features that support clinical use; (b) redesigning EMR-supported work practices for optimal fit; (c) demonstrating value for money; (d) having realistic expectations on implementation; and (e) engaging patients in the process.

CONCLUSIONS

Currently there is limited positive EMR impact in the physician office. To improve EMR success one needs to draw on the lessons from previous studies such as those in this review.

Managing the pre- and post-analytical phases of the total testing process

For many years, the clinical laboratory's focus on analytical quality has resulted in an error rate of 4-5 sigma, which surpasses most other areas in healthcare. However, greater appreciation of the prevalence of errors in the pre- and post-analytical phases and their potential for patient harm has led to increasing requirements for laboratories to take greater responsibility for activities outside their immediate control. Accreditation bodies such as the Joint Commission International (JCI) and the College of American Pathologists (CAP) now require clear and effective procedures for patient/sample identification and communication of critical results. There are a variety of free on-line resources available to aid in managing the extra-analytical phase and the recent publication of quality indicators and proposed performance levels by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) working group on laboratory errors and patient safety provides particularly useful benchmarking data. Managing the extra-laboratory phase of the total testing cycle is the next challenge for laboratory medicine. By building on its existing quality management expertise, quantitative scientific background and familiarity with information technology, the clinical laboratory is well suited to play a greater role in reducing errors and improving patient safety outside the confines of the laboratory.

Clinical quality indicators in laboratory medicine

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.

The use of count data models in biomedical informatics evaluation research

OBJECTIVES

Studies on the impact and value of health information technology (HIT) have often focused on outcome measures that are counts of such things as hospital admissions or the number of laboratory tests per patient. These measures with their highly skewed distributions (high frequency of 0s and 1s) are more appropriately analyzed with count data models than the much more frequently used variations of ordinary least squares (OLS). Use of a statistical procedure that does not properly fit the distribution of the data can result in significant findings being overlooked. The objective of this paper is to encourage greater use of count data models by demonstrating their utility with an example based on the authors' current work.

TARGET AUDIENCE

Researchers conducting impact and outcome studies related to HIT.

SCOPE

We review and discuss count data models and illustrate their value in comparison to OLS using an example from a study of the impact of an electronic health record (EHR) on laboratory test orders. The best count data model reveals significant relationships that OLS does not detect. We conclude that comprehensive model checking is highly recommended to identify the most appropriate analytic model when the dependent variable being examined contains count data. This strategy can lead to more valid and precise findings in HIT evaluation studies.

Assessing the cost of electronic health records: a review of cost indicators

We systematically reviewed PubMed and EBSCO business, looking for cost indicators of electronic health record (EHR) implementations and their associated benefit indicators. We provide a set of the most common cost and benefit (CB) indicators used in the EHR literature, as well as an overall estimate of the CB related to EHR implementation. Overall, CB evaluation of EHR implementation showed a rapid capital-recovering process. On average, the annual benefits were 76.5% of the first-year costs and 308.6% of the annual costs. However, the initial investments were not recovered in a few studied implementations. Distinctions in reporting fixed and variable costs are suggested.

Effectiveness of electronic guideline-based implementation systems in ambulatory care settings - a systematic review

Background

Electronic guideline-based decision support systems have been suggested to successfully deliver the knowledge embedded in clinical practice guidelines. A number of studies have already shown positive findings for decision support systems such as drug-dosing systems and computer-generated reminder systems for preventive care services.

Methods

A systematic literature search (1990 to December 2008) of the English literature indexed in the Medline database, Embase, the Cochrane Central Register of Controlled Trials, and CRD (DARE, HTA and NHS EED databases) was conducted to identify evaluation studies of electronic multi-step guideline implementation systems in ambulatory care settings. Important inclusion criterions were the multidimensionality of the guideline (the guideline needed to consist of several aspects or steps) and real-time interaction with the system during consultation. Clinical decision support systems such as one-time reminders for preventive care for which positive findings were shown in earlier reviews were excluded. Two comparisons were considered: electronic multidimensional guidelines versus usual care (comparison one) and electronic multidimensional guidelines versus other guideline implementation methods (comparison two).

Results

Twenty-seven publications were selected for analysis in this systematic review. Most designs were cluster randomized controlled trials investigating process outcomes more than patient outcomes. With success defined as at least 50% of the outcome variables being significant, none of the studies were successful in improving patient outcomes. Only seven of seventeen studies that investigated process outcomes showed improvements in process of care variables compared with the usual care group (comparison one). No incremental effect of the electronic implementation over the distribution of paper versions of the guideline was found, neither for the patient outcomes nor for the process outcomes (comparison two).

Conclusions

There is little evidence at the moment for the effectiveness of an increasingly used and commercialised instrument such as electronic multidimensional guidelines. After more than a decade of development of numerous electronic systems, research on the most effective implementation strategy for this kind of guideline-based decision support systems is still lacking. This conclusion implies a considerable risk towards inappropriate investments in ineffective implementation interventions and in suboptimal care.

Laboratory medicine quality indicators: a review of the literature

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.

Improving the appropriateness of laboratory submissions for urinalysis from general practice

BACKGROUND

Urine is the most common microbiology laboratory specimen. Submissions increase annually by 5-10%, and many specimens may be unnecessary.

OBJECTIVES

To assess the impact of guidance, implemented by interactive workshops and reinforced with modified request forms, on specimen submission.

METHODS

This was a prospective randomized controlled study with modified Zelen design. The study population comprised five primary care trusts (PCTs) in Gloucestershire/County Durham/Darlington, containing 82 general practices in six geographical clusters. The six clusters were randomly assigned to urine workshop covering submission in the elderly, adults and children or a control workshop. Within these groups, half the practices were randomized to receive modified laboratory forms emphasizing the workshop messages. Practices were not aware of the study.

RESULTS

Workshops lead to a 12% reduction in urine submissions from 16- to 64-year olds, which persisted for the 15 months but had no effect on bacteriuria rate. Workshops had no significant effect in the elderly or children. Modified forms were not associated with any reduction in submissions but were associated with an 11% reduction in detection of significant bacteriuria in 16- to 64-year olds.

CONCLUSIONS

The 12% decrease in urine submissions from 16- to 64-year olds, attained with workshops, may help counter relentlessly rising test submissions. Modified forms are currently not worth pursuing. When educational workshops are used across PCTs to change practice, the change in test submission is smaller than attained in educational initiatives involving volunteers. Workshops may be more effective if they also discuss urine submissions from asymptomatic patients and are directed at high testing practices and care homes.

Health care costs associated with changing clinics and "walk-in" deliveries: evidence supporting a regionalized health information network

OBJECTIVE

The objective of the study was to describe the prevalence of changing clinics and "walk-in" deliveries and estimate associated health care costs.

STUDY DESIGN

This was a retrospective review at an urban teaching hospital over a 6 month period. Principal outcome measures were availability of laboratory data at delivery and the number, type, and costs of duplicated tests for patients receiving various amounts of prenatal care (PNC) at our site. The prevalence of changing clinics, walk-in deliveries, and availability of records in our hospital was applied to the Los Angeles County Medicaid population to calculate the estimated cost of repeated prenatal laboratory studies.

RESULTS

Of the 1120 patients delivered by our service, 50% received all PNC at our site, 27% transferred PNC to our site, and 23% of patients were walk-ins for delivery only. Medical records were unavailable in 26% of cases, requiring prenatal laboratory studies repeated. Costs varied by amount of PNC on site (range, $107.00-201.00).

CONCLUSION

Changing clinics and walk-in deliveries are associated with significant health care costs because of redundant laboratory services and personnel costs associated with reviewing and exchanging medical records.

[Administrative and reporting tasks of family physicians in Europe. Comparison with the Hungarian system]

Administrative tasks are continuously increasing in the different health systems worldwide and also in the primary care. The administrative and reporting tasks of family physicians in Hungary are regulated by laws and rules. The aim of the study was to compare the recent Hungarian administrative tasks to those of other European countries in the primary care. Family physicians from 22 countries of the European General Practice Research Network were asked to fill a questionnaire regarding their countries. The results of their answers were presented and analyzed. Doctors are paid by capitation or fee for services, sometimes by the combination of both. They are obliged to prepare reports which depend on the respective countries, contain identification data of patients, diagnoses to be set up, and treatments. Administrative duties and the national characteristics of drug-prescriptions, referral systems to specialist or hospital were also analyzed. Conclusions were made in comparison with the European and Hungarian regulations. Reports needed by the Hungarian authorities are more complex and detailed, with many overlaps. The reasons why data are needed are often not clear and do not fit for the purpose. The time available for medical treatment is decreased by administrative duties making the gate-keeper function ineffective. There is no time for real prevention. Without official (governmental) version of primary care softwares, family physicians use too many softwares with different quality, which are not compatible with each other. It is suggested to check and modify the data obliged in reporting systems. Only data relevant in epidemiological or economical points of view should be reported with more focus to personal protection of privacy rights.

Time for guidelines in diagnostic imaging?

The increasing costs of health care in a modern developed country consume a high percentage of its economy's resources. In 2006, total spending for this sector in the UK represented 9.4% of the gross domestic product. This was substantially greater than 2001, when 7.1% of the gross domestic product was devoted to health (Griffin, 2007). The growth in expenditure is in part a result of the health requirements of an ageing population with inherent chronic medical conditions. Coupled with this, however, is the everemerging new and costly medical technologies that are available to diagnose and treat disease and the public expectation that health authorities will fund the provision of these services.

Laboratory medicine: challenges and opportunities

Technologic innovations have substantially improved the productivity of clinical laboratories, but the services provided by clinical laboratories are increasingly becoming commoditized. We reflect on how current developments may affect the future of laboratory medicine and how to deal with these changes. We argue that to be prepared for the future, clinical laboratories should enhance efficiency and reduce costs by forming alliances and networks; consolidating, integrating, or outsourcing; and more importantly, create additional value by providing knowledge services related to in vitro diagnostics.