1
|
Lou A, Thoni A, Shandi N, Yang Z, Nassar BA, Elnenaei M. Effective stewardship strategies to enhance appropriateness of refer-out test requests in a Canadian tertiary centre laboratory. Clin Biochem 2024; 129:110777. [PMID: 38857837 DOI: 10.1016/j.clinbiochem.2024.110777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/17/2024] [Accepted: 06/04/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVES Specialized testing conducted in reference laboratories is costly and often not optimally directed. Since 2016, our institution has worked to ensure the appropriateness of refer-out (RO) tests. We examine the impact of utilization initiatives on the patterns of requests and completed tests. DESIGN AND METHODS In 2016, 81 RO tests were selected for a more rigorous approval process. Physicians not pre-approved for testing received a prompt to consult with laboratory subject matter experts (SMEs) for further detail. After review, SMEs provided responses, approving or rejecting requests based on clinical relevance. Stewardship activities also included: repatriating tests locally, preferring Canadian over foreign institutions, unbundling tests, distributing educational memos, and introducing staged testing. We collected data on the number of requested (NoR) and number of completed (NoC) tests in 2015, before the implementation of the new vetting procedures, and for the post-implementation phase from 2016-2022. RESULTS For 62 targeted RO tests (including trace metals, vitamins, antibodies, and endocrine-related tests), there was a 33% reduction in NoR and a 51% reduction in NoC in 2022 compared to 2015. The total savings for the study period based on NoC was $807,736. The NoC rate for Neuronal antibody tests decreased to 48.6% in 2022, with cost savings of $17,123, and an additional $50,000 saved by changing the testing site. Insourcing apolipoprotein B and fecal calprotectin tests resulted in cost savings of $3,380 and $3,371, respectively, in 2022. CONCLUSIONS Automated messaging followed by a formal review of RO test requests is an effective utilization strategy that prevents redundant or clinically unjustified testing. This approach leads to significant economic savings and is expected to improve the efficiency of patient care.
Collapse
Affiliation(s)
- Amy Lou
- Division of Clinical Chemistry, Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Andrea Thoni
- Division of Clinical Chemistry, Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Nafisa Shandi
- Division of Clinical Chemistry, Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Zhifeng Yang
- Division of Clinical Chemistry, Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bassam A Nassar
- Division of Clinical Chemistry, Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Manal Elnenaei
- Division of Clinical Chemistry, Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| |
Collapse
|
2
|
Gounden V, Banerjee M, Amundsen EK, Serdar MA, Suárez Sánchez CI, Strain C, Kinniburgh D, Zhao Z. Linking Laboratory Testing to Clinical Outcomes: Bridging the Gap through Outcome-Based Studies in Laboratory Medicine. Clin Chem 2023; 69:1317-1321. [PMID: 37688514 DOI: 10.1093/clinchem/hvad132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023]
Affiliation(s)
- Verena Gounden
- Department of Chemical Pathology, Inkosi Albert Luthuli Central Hospital, National Health Laboratory Service and University of KwaZulu Natal, Durban, South Africa
| | - Mithu Banerjee
- Department of Biochemistry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Erik Koldberg Amundsen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
- Department of Life Sciences and Health, Oslo Metropolitan University, Oslo, Norway
| | - Muhittin A Serdar
- Department of Medical Biochemistry, Acibadem University, Istanbul, Turkey
| | | | - Colleen Strain
- Scientific Leadership and Education, Core Diagnostics, Scientific and Medical Affairs, Abbott, Canada
| | - David Kinniburgh
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zhen Zhao
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
| |
Collapse
|
3
|
Ahmed HAS, Al-Faris NA, Sharp JW, Abduljaber IO, Ghaida SSA. Managing Resource Utilization Cost of Laboratory Tests for Patients on Chemotherapy in Johns Hopkins Aramco Healthcare. GLOBAL JOURNAL ON QUALITY AND SAFETY IN HEALTHCARE 2023; 6:111-116. [PMID: 38404459 PMCID: PMC10887474 DOI: 10.36401/jqsh-23-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/16/2023] [Accepted: 08/08/2023] [Indexed: 02/27/2024]
Abstract
Introduction Laboratory testing is a fundamental diagnostic and prognostic tool to ensure the quality of healthcare, treatment, and responses. This study aimed to evaluate the cost of laboratory tests performed for patients undergoing chemotherapy treatment in the oncology treatment center at Johns Hopkins Aramco Healthcare in Saudi Arabia. Additionally, we aimed to reduce the cost of unnecessary laboratory tests in a 1-year period. Methods This was a quality improvement study with a quasi-experimental design using DMAIC methodology. The intervention strategy involved educating staff about adhering to the British Columbia Cancer Agency (BCCA) guidelines when ordering laboratory tests for chemotherapy patients, then integrating those guidelines into the electronic health record system. Data were collected for 200 randomly selected cases with 10 different chemotherapy protocols before and after the intervention. A paired t test was used to analyze differences in mean cost for all laboratory tests and unnecessary testing before and after the intervention. Results A significant cost reduction was achieved for unnecessary laboratory tests (77%, p < 0.01) when following the BCCA guidelines. In addition, the mean cost of all laboratory tests (including necessary and unnecessary) was significantly reduced by 45.5% (p = 0.023). Conclusion Lean thinking in clinical practice, realized by integrating a standardized laboratory test guided by BCCA guidelines into the electronic health record, significantly reduced financial costs within 1 year, thereby enhancing efficient resource utilization in the organization. This quality improvement project may serve to increase awareness of further efforts to improve resource utilization for other oncology treatment protocols.
Collapse
Affiliation(s)
- Huda Al-Sayed Ahmed
- Department of Quality & Patient Safety, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Nafeesa A Al-Faris
- Division of Oncology, Department of Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabi
| | - Joshua W Sharp
- Division of Oncology, Department of Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabi
| | - Issam O Abduljaber
- Division of Oncology, Department of Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabi
| | - Salam S Abou Ghaida
- Division of Oncology, Department of Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabi
| |
Collapse
|
4
|
Schiavinato A. Mapping the current state of the medical specialties in laboratory medicine in Italy. J Clin Pathol 2023; 76:281-284. [PMID: 35840321 DOI: 10.1136/jcp-2022-208431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/04/2022] [Indexed: 11/04/2022]
Abstract
Laboratory medicine is the single highest volume medical activity and it plays an increasingly essential role in the modern healthcare systems. In vitro diagnostic tests are now used in virtually every aspect of the patient care, including disease prevention, diagnosis, disease monitoring as well as personalised medicine. Nevertheless, the profession of laboratory medicine differs between countries in many respects, such as specialist training (medical or scientific), fields of interest, responsibilities and professional organisation. Many attempts have been made to quantify the role of laboratory medicine in patient outcomes, but the precise figures are still not clear. Moreover, the relative contribution of medical specialists in laboratory medicine is not well known and somehow controversial. To start exploring these aspects, we studied the current state of the two medical specialties that make up the majority of laboratory medicine in Italy: clinical pathology and medical microbiology. Our analysis revealed that both specialties suffer from a low attractivity among postgraduate physicians, and suggest that a restructuring of the training programme and professional reorganisation should be considered.
Collapse
Affiliation(s)
- Alvise Schiavinato
- Department of Pediatrics and Adolescent Medicine, University of Cologne, Cologne, Germany
- Department of Laboratory Medicine, University Hospital of Udine, Udine, Italy
| |
Collapse
|
5
|
Olver P, Bohn MK, Adeli K. Central role of laboratory medicine in public health and patient care. Clin Chem Lab Med 2023; 61:666-673. [PMID: 36436024 DOI: 10.1515/cclm-2022-1075] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/18/2022] [Indexed: 11/28/2022]
Abstract
Clinical laboratories play a vital role in the healthcare system. Objective medical data provided by clinical laboratories supports approximately 60-70% of clinical decisions, however, evidence supporting this claim is poorly documented and laboratories still lack visibility, despite their indisputable impact on patient care and public health. The International Federation for Clinical Chemistry and Laboratory Medicine (IFCC) Task Force on Outcome Studies in Laboratory Medicine (TF-OSLM) was recently developed to support directed research evaluating the role of laboratory medicine on clinical outcomes. Establishing and documenting this evidence is key to enhance visibility of the field in the eye of the public and other healthcare professionals together with optimizing patient outcomes and health care system operations. In this review, we discuss four areas that exemplify the contribution of laboratory medicine directly to patient care. This includes high-sensitivity cardiac troponin (hs-cTn) and N-terminal pro-B-type natriuretic peptide/B-type natriuretic peptides (NT-proBNP/BNP) for the diagnosis and prognosis of myocardial infarction and heart failure, respectively, and procalcitonin for the management of sepsis and antibiotic stewardship. Emerging markers of traumatic brain injury and the role of laboratory medicine in the fight against the COVID-19 pandemic are discussed along with an introduction to plans of IFCC TF-OSLM.
Collapse
Affiliation(s)
- Pyper Olver
- CALIPER Program, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mary Kathryn Bohn
- CALIPER Program, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Khosrow Adeli
- CALIPER Program, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
6
|
Miller WG, Myers G, Cobbaert CM, Young IS, Theodorsson E, Wielgosz RI, Westwood S, Maniguet S, Gillery P. Overcoming challenges regarding reference materials and regulations that influence global standardization of medical laboratory testing results. Clin Chem Lab Med 2022; 61:48-54. [PMID: 36239374 DOI: 10.1515/cclm-2022-0943] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Standardized results for laboratory tests are particularly important when their interpretation depends on fixed medical practice guidelines or common reference intervals. The medical laboratory community has developed a roadmap for an infrastructure to achieve standardized test results described in the International Organization for Standardization standard 17511:2020 In vitro diagnostic medical devices - Requirements for establishing metrological traceability of values assigned to calibrators, trueness control materials and human samples. Among the challenges to implementing metrological traceability are the availability of fit-for-purpose matrix-based certified reference materials (CRMs) and requirements for regulatory review that differ among countries. A workshop in December 2021 focused on these two challenges and developed recommendations for improved practices. DISCUSSION The participants agreed that prioritization of measurands for standardization should be based on their impact on medical decisions in a clinical pathway. Ensuring that matrix-based CRMs are globally available for more measurands will enable fit-for-purpose calibration hierarchies for more laboratory tests. Regulation of laboratory tests is important to ensure safety and effectiveness for the populations served. Because regulations are country or region specific, manufacturers must submit recalibration changes intended to standardize results for regulatory review to all areas in which a measuring system is marketed. RECOMMENDATIONS A standardization initiative requires collaboration and planning among all interested stakeholders. Global collaboration should be further developed for prioritization of measurands for standardization, and for coordinating the production and supply of CRMs worldwide. More uniform regulatory submission requirements are desirable when recalibration is implemented to achieve internationally standardized results.
Collapse
Affiliation(s)
- W Greg Miller
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Christa M Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ian S Young
- Centre for Public Health, Queens University Belfast, Belfast, Northern Ireland
| | - Elvar Theodorsson
- Department of Biomedical and Clinical Science, Clinical Chemistry, Linköping University, Linköping, Sweden
| | - Robert I Wielgosz
- Bureau International des Poids et Mesures (BIPM), Sèvres Cedex, France
| | - Steven Westwood
- Bureau International des Poids et Mesures (BIPM), Sèvres Cedex, France
| | | | - Philippe Gillery
- Laboratory of Biochemistry-Pharmacology-Toxicology, University Hospital of Reims, Reims, France
| |
Collapse
|
7
|
VanSpronsen AD, Villatoro V, Zychla L, Wang Y, Turley E, Ohinmaa A, Yuan Y. A New List for Choosing Wisely Canada From the "Hidden Profession" of Medical Laboratory Science. Am J Clin Pathol 2022; 157:40-46. [PMID: 34302336 DOI: 10.1093/ajcp/aqab094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 04/30/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Choosing Wisely Canada (CWC) publishes practices that may contribute to medical overuse and patient harm. Many practices concern laboratory testing, but the recommendations are often written for the test-ordering professionals. Our objective was to develop a list for CWC reflecting the scope of practice of nonpathologist medical laboratory professionals (MLPs). METHODS We used a national survey, a convention session, and a panel of MLPs from across Canada to generate content for the CWC list. We used a modified Delphi process to identify the most important items and scoping reviews to gather evidence supporting each item. RESULTS We identified 95 potential CWC list items. After 2 Delphi rounds, there was little movement in the top items. Scoping reviews revealed varying degrees of evidentiary support, which influenced the composition of the final list of 7 CWC items submitted. Three of the final recommendations address ways MLPs preserve the status quo with respect to overutilization of laboratory tests by other health care professionals. The remaining recommendations prompt MLPs to exert clinical judgment in specific scenarios, particularly where they can impact blood collection volumes. CONCLUSIONS This work brings a more nuanced and comprehensive understanding of the relationships among MLPs, patient safety, and resource waste.
Collapse
Affiliation(s)
| | | | - Laura Zychla
- Canadian Society for Medical Laboratory Science, Hamilton, Canada
| | | | | | | | - Yan Yuan
- University of Alberta, Edmonton, Canada
| |
Collapse
|
8
|
Signorini SG, Brugnoni D, Levaggi R, Garrafa E. Less is more: an ecological and economic point of view on appropriate use of lab testing for COVID-19 patients. Bioanalysis 2021; 13:1781-1783. [PMID: 34355575 PMCID: PMC8438925 DOI: 10.4155/bio-2021-0064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/22/2021] [Indexed: 02/03/2023] Open
Affiliation(s)
| | - Duilio Brugnoni
- Department of Laboratory Diagnostics, ASST Spedali Civili, Brescia, Italy
| | - Rosella Levaggi
- Department of Economics & Management, University of Brescia, Brescia, Italy
| | - Emirena Garrafa
- Department of Laboratory Diagnostics, ASST Spedali Civili, Brescia, Italy
- Department of Clinical & Experimental Sciences, University of Brescia, Brescia, Italy
| |
Collapse
|
9
|
Sun C, Wang D, Xu H, Yang G, Yan X, Liu H. A method for measuring the experimental resolution of laboratory assays (clinical biochemical, blood count, immunological, and qPCR) to evaluate analytical performance. J Clin Lab Anal 2021; 35:e24087. [PMID: 34724262 PMCID: PMC8649380 DOI: 10.1002/jcla.24087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/02/2021] [Accepted: 10/22/2021] [Indexed: 11/11/2022] Open
Abstract
Background The measurement method for experimental resolution and related data to evaluate analytical performance is poorly explored in clinical research. We established a method to measure the experimental resolution of clinical tests, including biochemical tests, automatic hematology analyzer methods, immunoassays, chemical experiments, and qPCR, to evaluate their analytical performance. Methods Serially diluted samples in equal proportions were measured, and correlation analysis was performed between the relative concentration and the measured value. Results were accepted for p ≤ 0.01 of the correlation coefficient. The minimum concentration gradient (eg, 10%) was defined as the experimental resolution. For this method, the smaller the value, the higher the experimental resolution and the better the analytical performance. Results The experimental resolution of the most common biochemical indices reached 10%, with some even reaching 1%. The results of most counting experiments showed experimental resolution up to 10%, whereas the experimental resolution of the classical chemical assays reached 1%. Unexpectedly, the experimental resolution of more sensitive assays, such as immunoassays was only 25% when using the manual method and 10% for qPCR. Conclusion This study established a method for measuring the experimental resolution of laboratory assays and provides a new index for evaluating the reliability of methods in clinical laboratories.
Collapse
Affiliation(s)
- Chenxi Sun
- College of Medical Laboratory, Dalian Medical University, Dalian, China
| | - Dongxia Wang
- College of Medical Laboratory, Dalian Medical University, Dalian, China
| | - Henggui Xu
- College of Medical Laboratory, Dalian Medical University, Dalian, China
| | - Guang Yang
- College of Medical Laboratory, Dalian Medical University, Dalian, China
| | - Xiaomei Yan
- College of Medical Laboratory, Dalian Medical University, Dalian, China
| | - Hui Liu
- College of Medical Laboratory, Dalian Medical University, Dalian, China
| |
Collapse
|
10
|
Chantraine F, Van Calsteren K, Devlieger R, Gruson D, Keirsbilck JV, Dubon Garcia A, Vandeweyer K, Gucciardo L. Enhancing the value of the sFlt-1/PlGF ratio for the prediction of preeclampsia: Cost analysis from the Belgian healthcare payers' perspective. Pregnancy Hypertens 2021; 26:31-37. [PMID: 34482271 DOI: 10.1016/j.preghy.2021.08.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 07/28/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the economic impact of introducing the soluble fms-like tyrosine kinase (sFlt-1) to placental growth factor (PlGF) ratio test into clinical practice in Belgium for the prediction of preeclampsia (PE). STUDY DESIGN We developed a one-year time-horizon decision tree model to evaluate the short-term costs associated with the introduction of the sFlt-1/PlGF test for guiding the management of women with suspected PE from the Belgian public healthcare payers' perspective. The model estimated the costs associated with the diagnosis and management of PE in pregnant women managed in either a test scenario, in which the sFlt-1/PlGF test is used in addition to current clinical practice, or a no test scenario, in which clinical decisions are based on current practice alone. Test characteristics were derived from PROGNOSIS, a non-interventional study in women presenting with clinical suspicion of PE. Unit costs were obtained from Belgian-specific sources. The main model outcome was the total cost per patient. RESULTS Introduction of the sFlt-1/PlGF ratio test is expected to result in a cost saving of €712 per patient compared with the no test scenario. These savings are generated mainly due to a reduction in unnecessary hospitalizations. CONCLUSIONS The sFlt-1/PlGF test is projected to result in substantial cost savings for the Belgian public healthcare payers through reduction of unnecessary hospitalization of women with clinical suspicion of PE that ultimately do not develop the condition. The test also has the potential to ensure that women at high risk of developing PE are identified and appropriately managed.
Collapse
Affiliation(s)
- Frederic Chantraine
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Liège, CHR Citadelle, Liège, Belgium.
| | - Kristel Van Calsteren
- Department of Obstetrics and Gynaecology, University Hospitals, KULeuven, Leuven, Belgium.
| | - Roland Devlieger
- Department of Obstetrics and Gynaecology, University Hospitals, KULeuven, Leuven, Belgium.
| | - Damien Gruson
- Department of Laboratory Medicine, Division of Clinical Biochemistry, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium.
| | | | | | | | - Leonardo Gucciardo
- Department of Obstetrics and Prenatal Medicine, UZ Brussel University Hospital, VUB, Brussels, Belgium.
| |
Collapse
|
11
|
Lubin IM. Bringing the clinical laboratory into the strategy to advance diagnostic excellence. Diagnosis (Berl) 2021; 8:281-294. [PMID: 33554526 PMCID: PMC8255320 DOI: 10.1515/dx-2020-0119] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/16/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Clinical laboratory testing provides essential data for making medical diagnoses. Generating accurate and timely test results clearly communicated to the treating clinician, and ultimately the patient, is a critical component that supports diagnostic excellence. On the other hand, failure to achieve this can lead to diagnostic errors that manifest in missed, delayed and wrong diagnoses. CONTENT Innovations that support diagnostic excellence address: 1) test utilization, 2) leveraging clinical and laboratory data, 3) promoting the use of credible information resources, 4) enhancing communication among laboratory professionals, health care providers and the patient, and 5) advancing the use of diagnostic management teams. Integrating evidence-based laboratory and patient-care quality management approaches may provide a strategy to support diagnostic excellence. Professional societies, government agencies, and healthcare systems are actively engaged in efforts to advance diagnostic excellence. Leveraging clinical laboratory capabilities within a healthcare system can measurably improve the diagnostic process and reduce diagnostic errors. SUMMARY An expanded quality management approach that builds on existing processes and measures can promote diagnostic excellence and provide a pathway to transition innovative concepts to practice. OUTLOOK There are increasing opportunities for clinical laboratory professionals and organizations to be part of a strategy to improve diagnoses.
Collapse
Affiliation(s)
- Ira M. Lubin
- Division of Laboratory Systems, Centers for Disease Control and Prevention, 1600 Clifton Rd., NE Mail Stop V24-3, GA 30329, Atlanta, GA, USA
| |
Collapse
|
12
|
Doi D, do Vale RR, Monteiro JMC, Plens GCM, Ferreira Junior M, Fonseca LAM, Perazzio SF, Besen BAMP, Lichtenstein A, Taniguchi LU, Sumita NM, Corá AP, Eisencraft AP, Duarte AJDS. Perception of usefulness of laboratory tests ordering by internal medicine residents in ambulatory setting: A single-center prospective cohort study. PLoS One 2021; 16:e0250769. [PMID: 33974629 PMCID: PMC8112663 DOI: 10.1371/journal.pone.0250769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 04/13/2021] [Indexed: 11/29/2022] Open
Abstract
The demand for high value health care uncovered a steady trend in laboratory tests ordering and inappropriate testing practices. Residents' training in laboratory ordering practice provides an opportunity for quality improvement. We collected information on demographics, the main reason for the appointment, preexisting medical conditions and presence of co-morbidities from first-visit patients to the internal medicine outpatient service of our university general hospital. We also collected information on all laboratory tests ordered by the attending medical residents. At a follow-up visit, we recorded residents' subjective perception on the usefulness of each ordered laboratory test for the purposes of diagnosis, prognosis, treatment or screening. We observed that 17.3% of all ordered tests had no perceived utility by the attending resident. Tests were usually ordered to exclude differential diagnoses (26.7%) and to help prognosis estimation (19.1%). Age and co-morbidity influenced the chosen category to legitimate usefulness of tests ordering. This study suggests that clinical objectives (diagnosis, prognosis, treatment or prevention) as well as personalization to age and previous health conditions should be considered before test ordering to allow a more appropriate laboratory tests ordering, but further studies are necessary to examine this framework beyond this medical training scenario.
Collapse
Affiliation(s)
- Dimitria Doi
- Central Laboratory Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Romulo Ribeiro do Vale
- Department of Internal Medicine, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Jean Michell Correia Monteiro
- Department of Internal Medicine, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Glauco Cabral Marinho Plens
- Department of Internal Medicine, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Mario Ferreira Junior
- Department of Internal Medicine, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luiz Augusto Marcondes Fonseca
- Department of Internal Medicine, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Bruno Adler Maccagnan Pinheiro Besen
- Medical ICU, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Arnaldo Lichtenstein
- Department of Internal Medicine, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Leandro Utino Taniguchi
- Medical ICU, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Nairo Massakazu Sumita
- Central Laboratory Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Aline Pivetta Corá
- Central Laboratory Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Adriana Pasmanik Eisencraft
- Emergency Department, Children’s Institute, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alberto José da Silva Duarte
- Central Laboratory Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| |
Collapse
|
13
|
Hicks AJ, Carwardine ZL, Hallworth MJ, Kilpatrick ES. Using clinical guidelines to assess the potential value of laboratory medicine in clinical decision-making. Biochem Med (Zagreb) 2020; 31:010703. [PMID: 33380890 PMCID: PMC7745157 DOI: 10.11613/bm.2021.010703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/23/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction It is often quoted that 70% of clinical decisions are based on laboratory results, but the evidence to substantiate this claim is lacking. Since clinical guidelines aim to document best-practice decision making for specific disease conditions, inclusion of any laboratory test means that the best available evidence is recommending clinicians use it. Cardiovascular disease (CVD) is the world’s most common cause of mortality, so this study reviewed all CVD guidelines published by five national/international authorities to determine what proportion of them recommended laboratory testing. Materials and methods Five leading CVD guidelines were examined, namely the European Society of Cardiology (ESC), the UK National Institute for Health and Clinical Excellence (NICE), the American College of Cardiology (ACC), the Australian Heart Foundation (AHF) and the Cardiac Society of Australia and New Zealand (CSANZ). Results A total of 101 guidelines were reviewed. Of the 33 individual ESC guidelines relating to CVD, 24/33 made a direct reference to the use of clinical laboratory tests in either diagnosis or follow-up treatment. The same applied to 15/20 of NICE guidelines, 24/32 from the ACC and 15/16 from the AHF/CSANZ. Renal function and blood count testing were the most recommended (39 and 26 times), with lipid, troponin and natriuretic peptide measurement advocated 25, 19 and 19 times respectively. Conclusions This study has shown that laboratory testing is advocated by between 73% and 94% of individual CVD guideline recommendations from five national/international authorities. This provides an index to assess the potential value of laboratory medicine to healthcare.
Collapse
Affiliation(s)
- Allan J Hicks
- School of Medical Science, Griffith University, Southport, Australia
| | | | - Mike J Hallworth
- Clinical Biochemistry, Royal Shrewsbury Hospital, Shrewsbury, UK
| | - Eric S Kilpatrick
- Department of Clinical Biochemistry, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| |
Collapse
|
14
|
Ong SK, Donovan GT, Ndefru N, Song S, Leang C, Sek S, Noble M, Perrone LA. Strengthening the clinical laboratory workforce in Cambodia: a case study of a mixed-method in-service training program to improve laboratory quality management system oversight. HUMAN RESOURCES FOR HEALTH 2020; 18:84. [PMID: 33148269 PMCID: PMC7610006 DOI: 10.1186/s12960-020-00521-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/08/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Laboratory diagnostic testing service delivery and compliance with international standards for laboratory quality are directly influenced by laboratory workforce competency. Many hospital laboratories in constrained resource settings such as Cambodia struggle to cope with the training needs of laboratory professionals in an environment of competing healthcare development priorities. Resource-limited countries need an adaptable and effective approach to provide laboratory professionals with job-specific quality oversight training to ensure the accuracy, timeliness, and reliability of diagnostic services. CASE PRESENTATION Here, we describe the results of an in-service training and mentoring program conducted with the Cambodia Ministry of Health at 12 tertiary-level hospital laboratories to drive improvements in laboratory quality management systems toward ISO 15189 accreditation, which demonstrated significant progress between baseline and outcome audits in a concurrent study. This case study describes the program, and evaluates how the four primary activities, including actionable gap assessments and planning, centralized and in situ training curriculum, in-person mentoring, and remote tele-mentoring via video communication technologies, contributed towards quality improvement in the participating laboratories. We evaluated participant responses to Likert scale and free response questions from program and training evaluation surveys, and we used thematic analysis to develop a model of best practices within the program's four primary activities to inform future training approaches. Of these activities, participants agreed most highly that in-person visits and planning based on gap assessments contributed to their learning and ability to improve laboratory operations. Tele-mentoring was rated lowest by participants, who were critical of excessive group dialogue and distraction during web-conferencing; however, feedback suggests both in-person and remote mentoring contribute to continuing education, accountability to action, and peer collaboration and problem solving to improve workforce efforts toward improved quality management systems. CONCLUSIONS We recommend here a package of in-service training activities for laboratory quality management system improvement initiatives in resource constrained settings that includes needs-based curricula and personalized action plans for participants; interactive and on-site training workshops; and in-person mentoring, complemented with well managed and regular tele-mentoring that focuses on knowledge retention, accountability to goals, and collaborative problem solving. Our model presents an adaptable approach to human resource development for quality improvement in medical laboratories.
Collapse
Affiliation(s)
- Siew Kim Ong
- International Training and Education Center for Health (I-TECH) Cambodia, Phnom Penh, Cambodia
| | - Grant T. Donovan
- Department of Global Health, Schools of Public Health and Medicine, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA USA
| | - Nayah Ndefru
- Department of Global Health, Schools of Public Health and Medicine, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA USA
| | - Sophanna Song
- International Training and Education Center for Health (I-TECH) Cambodia, Phnom Penh, Cambodia
| | - Chhayheng Leang
- International Training and Education Center for Health (I-TECH) Cambodia, Phnom Penh, Cambodia
| | - Sophat Sek
- International Training and Education Center for Health (I-TECH) Cambodia, Phnom Penh, Cambodia
| | - Michael Noble
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC Canada
| | - Lucy A. Perrone
- Department of Global Health, Schools of Public Health and Medicine, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA USA
- Department of Laboratory Medicine, School of Medicine, University of Washington, Seattle, WA USA
| |
Collapse
|
15
|
Nagler M. Translating Laboratory Tests into Clinical Practice: A Conceptual Framework. Hamostaseologie 2020; 40:420-429. [DOI: 10.1055/a-1227-8008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractThe use of laboratory biomarkers in clinical practice is rapidly increasing. Laboratory tests are, however, rarely evaluated adequately before implementation, and the utility of many tests is essentially unclear. An important reason for this knowledge gap is that a comprehensive and generally accepted methodological framework supporting evaluation studies is essentially lacking. Researchers, clinicians, and decision-makers are often not aware of the methodological tools available and face problems with the appraisal of a test's utility. With the present article, I aim to summarize current concepts and methodological tools and propose a framework for a phased approach that could be used in future evaluation projects. Future research will refine this suggested framework by identifying problems in current evaluation projects, specifying methodological criteria for all phases, as well as developing advanced methodological tools.
Collapse
Affiliation(s)
- Michael Nagler
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
16
|
Karnutsch D, Occhipinti F, Tumiatti D, Mueller T. Evaluation of the Impact of Changing Quality Control Rules and Frequency on the Risk Management Index: Results from the Clinical Routine of a Medical Laboratory. Lab Med 2020; 52:211-218. [PMID: 32926146 DOI: 10.1093/labmed/lmaa064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The consideration of the principles of risk management in the analytical process is a current trend. The aim of this study was to evaluate whether the risk management index (RMI) for various laboratory parameters can be influenced by interventions that change the internal quality control (IQC) strategy. METHODS We selected 10 laboratory parameters associated with cardiovascular disease for the study (myoglobin, N-terminal fragment of the pro B-type natriuretic polypeptide, cardiac troponin T, creatinine kinase, lactate dehydrogenase, glucose, triglycerides, total cholesterol, and low-density lipoprotein and high-density lipoprotein cholesterol). The study-specific interventions included changing the IQC rules and changing the IQC schedule. This was a one-armed intervention study in which changes in the RMI, a measure of patient harm risk, was recorded over time. RESULTS Before the intervention, the mean RMI was 1.022 (95% confidence interval [CI], 0.269-1.776). After the intervention, the mean RMI was 0.934 (95% CI, 0.088-1.956). The RMI values before and after the intervention were not significantly different (P =.89). CONCLUSION The study-specific interventions did not lead to an improvement of the RMI in the clinical routines of a medical laboratory. There is a great need to further explore this subject area with interventional studies to clarify how the risk of unintended patient harm can be measurably improved.
Collapse
Affiliation(s)
- Daniela Karnutsch
- Department of Clinical Pathology, Hospital of Bolzano, Bolzano, Italy
| | | | - Daniel Tumiatti
- Department of Clinical Pathology, Hospital of Bolzano, Bolzano, Italy
| | - Thomas Mueller
- Department of Clinical Pathology, Hospital of Bolzano, Bolzano, Italy
| |
Collapse
|
17
|
Giusepi I, John AS, Jülicher P. Who Conducts Health Economic Evaluations of Laboratory Tests? A Scoping Review. J Appl Lab Med 2020; 5:954-966. [DOI: 10.1093/jalm/jfaa107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/21/2020] [Indexed: 12/23/2022]
Abstract
AbstractBackgroundHealth economic evaluations (HEEs) are effectively used to inform decision making in healthcare. We sought to assess the level of involvement of laboratory professionals (LPs) in HEEs of laboratory tests.MethodsA systematic literature search was conducted in Medline (2013 to November 28, 2018) for original articles reporting HEEs of medical laboratory tests. Eligible studies were characterized by indication, utilization, region, setting, study design, primary outcome measures, and sponsorship. Authors were classified based on stated affiliation as clinician, scientist, public health expert, or LP.ResultsIn total, 140 HEEs were included in the study, of which 24 (17.1%) had contributions from LPs. Studies were primarily focused on infectious disease (n = 68), oncology (n = 23), and cardiovascular disease (n = 16). Cost-utility or cost-effectiveness analyses (n = 117) were the most frequent study types, with effectiveness measured mainly in terms of quality-adjusted life-years (n = 57) and detected cases (n = 41). Overall, 76% of HEEs followed a social or health system perspective, whereas 15% took a hospital viewpoint. Partial or full funding was received from public health organizations or industry in 39% and 16% of studies, respectively. The involvement of LPs was associated with test utilization, secondary care, analytic perspective, and an immediate time horizon (all P < 0.05). Quality of studies was found to be lower in HEEs coauthored by LPs.ConclusionMultidisciplinary collaboration is essential to understanding the complexity of clinical pathways. HEEs are used effectively to inform healthcare decision making. The involvement of LPs in HEEs is low. This implies that laboratory expertise is frequently not considered in decision processes.
Collapse
Affiliation(s)
- Isabella Giusepi
- Health Economics and Outcomes Research, Abbott Diagnostics, Wiesbaden, Germany
| | | | - Paul Jülicher
- Health Economics and Outcomes Research, Abbott Diagnostics, Wiesbaden, Germany
| |
Collapse
|
18
|
John AS. Determining value – Do laboratory professionals need to learn more about the ‘dismal science’? Ann Clin Biochem 2020; 57:337-338. [DOI: 10.1177/0004563220946073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
19
|
Paquette P, Higgins J, Danino MA, Harris P, Lamontagne M, Gagnon DH. Effects of a preoperative neuromobilization program offered to individuals with carpal tunnel syndrome awaiting carpal tunnel decompression surgery: A pilot randomized controlled study. JOURNAL OF HAND THERAPY : OFFICIAL JOURNAL OF THE AMERICAN SOCIETY OF HAND THERAPISTS 2020. [PMID: 32151500 DOI: 10.1016/b978-0-12-815499-1.00003-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
STUDY DESIGN Pilot randomized controlled trial with parallel groups. INTRODUCTION Engaging individuals with carpal tunnel syndrome (CTS) awaiting carpal tunnel decompression surgery in a preoperative rehabilitation program may mitigate pain and sensorimotor impairments, enhance functional abilities before surgery, and improve postoperative outcomes. PURPOSE OF THE STUDY To assess the feasibility and the efficacy of a novel preoperative neuromobilization exercise program (NEP). METHODS Thirty individuals with CTS were randomly allocated into a four-week home-based neuromobilization exercise group or a standard care group while awaiting surgery. Outcome measures included feasibility (ie, recruitment, attrition, adherence, satisfaction, and safety) and efficacy metrics (ie, median nerve integrity and neurodynamics, tip pinch grip, pain, and upper limb functional abilities) collected before (ie, at the baseline and about four weeks later) and four weeks after surgery. RESULTS Thirty individuals with CTS were recruited (recruitment rate = 11.8%) and 25 completed the study (attrition rate = 16.7%). Adherence (94%) and satisfaction with the program (eg, enjoy the exercises and likeliness to repeat the NEP (≥4.2/5) were high and no serious adverse event was reported. NEP-related immediate pre- and post-surgery beneficial effects on pain interference were documented (P = .05, η2 = .10), whereas an overall increased neurodynamics (P = .04, η2 = .11) and decreased pain severity (P = .01, η2 = .21) were observed. DISCUSSION Engaging in the proposed NEP has limited beneficial effect as a stand-alone intervention on pre- and post-surgery outcomes for individuals with CTS. Expanding the program's content and attribute by adding other components including desensitization maneuvers and novel therapies promoting corticospinal plasticity is recommended. CONCLUSION A preoperative NEP completed by individuals with CTS awaiting surgery is feasible, acceptable, and safe. However, given the limited beneficial effectsof the program, revision of its content and attributes is recommended before proceeding to large-scale trials.
Collapse
Affiliation(s)
- Philippe Paquette
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Institut universitaire sur la réadaptation en déficience physique de Montréal, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montreal, Canada; School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Johanne Higgins
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Institut universitaire sur la réadaptation en déficience physique de Montréal, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montreal, Canada; School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Michel Alain Danino
- Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Patrick Harris
- Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Martin Lamontagne
- Department of Physical Medicine and Rehabilitation, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Dany H Gagnon
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Institut universitaire sur la réadaptation en déficience physique de Montréal, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montreal, Canada; School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Canada.
| |
Collapse
|
20
|
Abstract
The pressure on healthcare budgets including laboratory medicine is relentless and the focus on activities and costs remains the dominant funding model of laboratory medicine everywhere. The limitations of this model are well documented and for a decade or more laboratory professions worldwide have started looking at alternative models where the value of laboratory medicine and its impact on patient outcomes are the predominant driving force. There are multiple ways to determine the value of a medical test, particularly if one takes into consideration its impact upon the complete clinical pathway. Thus various approaches to value determination are being explored by a number of international organisations. These organisations will be reviewed below, including one which uses the concept of a value proposition that describes in detail how a test should be implemented by measuring its clinical, operational and economic impact. All approaches for determination of value require professional leadership. There is a need for research of varying types including that related to translating global evidence into local practice, a key challenge facing laboratory medicine and healthcare generally. Another challenge is to think and act beyond the silo of the laboratory to achieve greater collaboration with those colleagues more directly involved in patient care.
Collapse
|
21
|
Jovičić S, Siodmiak J, Watson ID. Quality evaluation of smartphone applications for laboratory medicine. Clin Chem Lab Med 2019; 57:388-397. [PMID: 30496130 DOI: 10.1515/cclm-2018-0710] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 11/07/2018] [Indexed: 02/06/2023]
Abstract
Background Many of the mobile applications (apps) used for delivering health interventions involve laboratory medicine data. This survey was conducted to search the online market for health apps that manage laboratory medicine data. The aim was to review them and perform a quality evaluation. Methods Apps search criteria were "Lab results blood work", "Lab results", and "Health apps". After the stepwise exclusion process, 52 selected apps were downloaded and analyzed. For review and content analysis of the apps, a multidimensional tool for classifying and rating the quality of mobile health apps - Mobile App Rating Scale (MARS), was used. Results Selected apps were classified into five categories according to their intended use by patients or physicians, and the type of data engaged. Spearman's correlation analysis found significant correlations between MARS individual scoring items, as with the subjective quality and number of technical aspects. Kruskal-Wallis analysis showed a significant difference in the number of technical aspects employed, MARS engagement and informational quality score items, total score, and subjective quality. The lowest values for all of these items were in the category of apps designed for patients, and the post hoc test showed that the difference was statistically significant between this and the values in all other categories. Conclusions Apps designed for patients, are of the poorest quality, considering the total quality of the content and information they provide, estimated using the MARS tool. This estimation needs to be validated for laboratory medicine apps, and eventually modified after consideration of specific quality benchmarks.
Collapse
Affiliation(s)
- Snežana Jovičić
- Center for Medical Biochemistry, Clinical Center of Serbia, Višegradska 26, 11000 Belgrade, Serbia, Phone/Fax: +381 11 361 56 31
- Department for Medical Biochemistry, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia, E-mail:
| | - Joanna Siodmiak
- Department for Laboratory Medicine, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Ian D Watson
- c/o European Federation of Clinical Chemistry and Laboratory Medicine, Milan, Italy
| |
Collapse
|
22
|
Swanson K, Dodd MR, VanNess R, Crossey M. Improving the Delivery of Healthcare through Clinical Diagnostic Insights: A Valuation of Laboratory Medicine through "Clinical Lab 2.0". J Appl Lab Med 2019; 3:487-497. [PMID: 33636908 DOI: 10.1373/jalm.2017.025379] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 03/29/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND As healthcare payment and reimbursement begin to shift from a fee-for-service to a value-based model, ancillary providers including laboratories must incorporate this into their business strategy. Laboratory medicine, while continuing to support a transactional business model, should expand efforts to include translational data analytics, proving its clinical and economic valuation. Current literature in this area is limited. CONTENT This article is a summary of how laboratory medicine can support value-based healthcare. Population health management is emerging as a method to support value-based healthcare by aggregating patient information, providing data analysis, and contributing to clinical decision support. Key issues to consider with a laboratory-developed population health management model are discussed, including changing reimbursement models, the use of multidisciplinary committees, the role of specialists in data analytics and programming, and barriers to implementation. Examples of data considerations and value are given. SUMMARY Laboratory medicine is able to provide meaningful clinical diagnostic insights for population health initiatives that result in improved short- and long-term patient outcomes and drive cost-effective care. Opportunities include data analysis with longitudinal laboratory data, identification of patient-specific targeted interventions, and development of clinical decision support tools. Laboratories will need to leverage the skills and knowledge of their multidisciplinary staff, along with their extensive patient data sets, through innovative analytics to meet these objectives.
Collapse
|
23
|
Greaves RF, Bernardini S, Ferrari M, Fortina P, Gouget B, Gruson D, Lang T, Loh TP, Morris HA, Park JY, Roessler M, Yin P, Kricka LJ. Key questions about the future of laboratory medicine in the next decade of the 21st century: A report from the IFCC-Emerging Technologies Division. Clin Chim Acta 2019; 495:570-589. [DOI: 10.1016/j.cca.2019.05.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/24/2019] [Indexed: 12/21/2022]
|
24
|
Messinger BL, Rogers DN, Hawker CD. Automation and Process Re-engineering Work Together to Achieve Six Sigma Quality: A 27-Year History of Continuous Improvement. Lab Med 2019; 50:e23-e35. [PMID: 30726943 DOI: 10.1093/labmed/lmy081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In most clinical laboratories, examination quality is considered excellent, whereas pre-/postexamination quality is an area for focused improvement. In our organization, 1 pre-/postexamination quality metric, namely, lost specimens, as tracked continuously for 27 years, has demonstrated steady improvement. During this period, many of our processes transitioned to highly automated effectors. Concurrently, we implemented behavioral controls and reengineered error-prone processes. We believe that this bilateral approach has conclusively lowered our lost specimen rates. METHODS Using data spanning 27 years, we plotted the correlation between lost specimens and the implementation dates for 8 major phases of automation, as well as 19 process improvements and engineering controls. RESULTS The lost specimen rate decreased nearly 100-fold. In Six Sigma terms, the 12 month moving average for lost specimens currently hovers at approximately 5.94 sigma, with 11 months at or better than 6 sigma. Although the combination of implementation of process improvements, engineering controls, and automation contributed to the reduction, automation was the most significant contributor. CONCLUSIONS The custom automation in use by our laboratory has led to improved pre-/postexamination quality. Although this automation may not be possible for all laboratories, our description of 19 behavior and engineering controls may be useful to others seeking to design high quality pre-/postexamination processes.
Collapse
Affiliation(s)
| | | | - Charles D Hawker
- Department of Pathology, University of Utah, Salt Lake City, UT (retired).,ARUP Laboratories, Inc, Salt Lake City, UT (retired)
| |
Collapse
|
25
|
Rubinstein ML, Kraft CS, Parrott JS. Determining qualitative effect size ratings using a likelihood ratio scatter matrix in diagnostic test accuracy systematic reviews. ACTA ACUST UNITED AC 2019; 5:205-214. [PMID: 30243015 DOI: 10.1515/dx-2018-0061] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/21/2018] [Indexed: 12/15/2022]
Abstract
Background Diagnostic test accuracy (DTA) systematic reviews (SRs) characterize a test's potential for diagnostic quality and safety. However, interpreting DTA measures in the context of SRs is challenging. Further, some evidence grading methods (e.g. Centers for Disease Control and Prevention, Division of Laboratory Systems Laboratory Medicine Best Practices method) require determination of qualitative effect size ratings as a contributor to practice recommendations. This paper describes a recently developed effect size rating approach for assessing a DTA evidence base. Methods A likelihood ratio scatter matrix will plot positive and negative likelihood ratio pairings for DTA studies. Pairings are graphed as single point estimates with confidence intervals, positioned in one of four quadrants derived from established thresholds for test clinical validity. These quadrants support defensible judgments on "substantial", "moderate", or "minimal" effect size ratings for each plotted study. The approach is flexible in relation to a priori determinations of the relative clinical importance of false positive and false negative test results. Results and conclusions This qualitative effect size rating approach was operationalized in a recent SR that assessed effectiveness of test practices for the diagnosis of Clostridium difficile. Relevance of this approach to other methods of grading evidence, and efforts to measure diagnostic quality and safety are described. Limitations of the approach arise from understanding that a diagnostic test is not an isolated element in the diagnostic process, but provides information in clinical context towards diagnostic quality and safety.
Collapse
Affiliation(s)
- Matthew L Rubinstein
- Department of Clinical Laboratory and Medical Imaging Sciences, Rutgers University, School of Health Professions, Newark, NJ, USA.,Department of Interdisciplinary Studies, Rutgers University, School of Health Professions, Newark, NJ, USA
| | - Colleen S Kraft
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA.,Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, GA, USA
| | - J Scott Parrott
- Department of Interdisciplinary Studies, Rutgers University, School of Health Professions, Newark, NJ, USA.,Department of Epidemiology, School of Public Health, Rutgers University, Piscataway, NJ, USA
| |
Collapse
|
26
|
van Balveren JA, Verboeket-van de Venne WP, Erdem-Eraslan L, de Graaf AJ, Loot AE, Musson RE, Oosterhuis WP, Schuijt MP, van der Sijs H, Verheul RJ, de Wolf HK, Kusters R, Hoedemakers RM. Impact of interactions between drugs and laboratory test results on diagnostic test interpretation – a systematic review. ACTA ACUST UNITED AC 2018; 56:2004-2009. [DOI: 10.1515/cclm-2018-0900] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/21/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Intake of drugs may influence the interpretation of laboratory test results. Knowledge and correct interpretation of possible drug-laboratory test interactions (DLTIs) is important for physicians, pharmacists and laboratory specialists. Laboratory results may be affected by analytical or physiological effects of medication. Failure to take into account the possible unintended influence of drug use on a laboratory test result may lead to incorrect diagnosis, incorrect treatment and unnecessary follow-up. The aim of this review is to give an overview of the literature investigating the clinical impact and use of DLTI decision support systems on laboratory test interpretation. Particular interactions were reported in a large number of articles, but they were fragmentarily described and some papers even reported contradictory findings. To provide an overview of information that clinicians and laboratory staff need to interpret test results, DLTI databases have been made by several groups. In a literature search, only four relevant studies have been found on DLTI decision support applications for laboratory test interpretation in clinical practice. These studies show a potential benefit of automated DLTI messages to physicians for the correct interpretation of laboratory test results. Physicians reported 30–100% usefulness of DLTI messages. In one study 74% of physicians sometimes even refrained from further additional examination. The benefit of decision support increases when a refined set of clinical rules is determined in cooperation with health care professionals. The prevalence of DLTIs is high in a broad range of combinations of laboratory tests and drugs and these frequently remain unrecognized.
Collapse
|
27
|
Vogeser M, Seger C. Irregular analytical errors in diagnostic testing - a novel concept. Clin Chem Lab Med 2018; 56:386-396. [PMID: 28902615 DOI: 10.1515/cclm-2017-0454] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 07/31/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND In laboratory medicine, routine periodic analyses for internal and external quality control measurements interpreted by statistical methods are mandatory for batch clearance. Data analysis of these process-oriented measurements allows for insight into random analytical variation and systematic calibration bias over time. However, in such a setting, any individual sample is not under individual quality control. The quality control measurements act only at the batch level. Quantitative or qualitative data derived for many effects and interferences associated with an individual diagnostic sample can compromise any analyte. It is obvious that a process for a quality-control-sample-based approach of quality assurance is not sensitive to such errors. CONTENT To address the potential causes and nature of such analytical interference in individual samples more systematically, we suggest the introduction of a new term called the irregular (individual) analytical error. Practically, this term can be applied in any analytical assay that is traceable to a reference measurement system. For an individual sample an irregular analytical error is defined as an inaccuracy (which is the deviation from a reference measurement procedure result) of a test result that is so high it cannot be explained by measurement uncertainty of the utilized routine assay operating within the accepted limitations of the associated process quality control measurements. SUMMARY The deviation can be defined as the linear combination of the process measurement uncertainty and the method bias for the reference measurement system. Such errors should be coined irregular analytical errors of the individual sample. The measurement result is compromised either by an irregular effect associated with the individual composition (matrix) of the sample or an individual single sample associated processing error in the analytical process. OUTLOOK Currently, the availability of reference measurement procedures is still highly limited, but LC-isotope-dilution mass spectrometry methods are increasingly used for pre-market validation of routine diagnostic assays (these tests also involve substantial sets of clinical validation samples). Based on this definition/terminology, we list recognized causes of irregular analytical error as a risk catalog for clinical chemistry in this article. These issues include reproducible individual analytical errors (e.g. caused by anti-reagent antibodies) and non-reproducible, sporadic errors (e.g. errors due to incorrect pipetting volume due to air bubbles in a sample), which can both lead to inaccurate results and risks for patients.
Collapse
Affiliation(s)
- Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Germany, Marchioninistr. 15, 81377 München, Germany
| | - Christoph Seger
- labormedizinisches zentrum Dr. Risch, Lagerstrasse 30, 9470 Buchs SG, Switzerland
| |
Collapse
|
28
|
Clerico A, Belloni L, Carrozza C, Correale M, Dittadi R, Dotti C, Fortunato A, Vignati G, Zucchelli GC, Migliardi M. A Black Swan in clinical laboratory practice: the analytical error due to interferences in immunoassay methods. Clin Chem Lab Med 2018; 56:397-402. [PMID: 29220884 DOI: 10.1515/cclm-2017-0881] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 10/22/2017] [Indexed: 12/11/2022]
Abstract
It is well known that the results of immunoassay methods can be affected by specific or non-specific interferences, ranging from 0.4% to 4.0%. The presence of interference may greatly compromise the accuracy of immunoassay analyses causing an error in the measurement, producing false-positive or false-negative results. From a clinical point of view, these analytical errors may have serious implications for patient care because they can cause misdiagnosis or inappropriate treatment. Unfortunately, it is a very difficult task to identify the irregular analytical errors related to immunoassay methods because they are not detectable by normal laboratory quality control procedures, are reproducible within the test system, may be clinically plausible and are relatively rare. The first line of defense against erroneous results is to use in laboratory practice only immunoassay systems with the highest level of robustness against interference. The second line of defense is always taking into account the possibility of interference in immunoassay results. A correct approach should be addressed on identification of samples at high risk of interference. The attainment of this goal requires a critical review of the test result in relation to patient's clinical conditions and literature data, taking into account the analytical characteristics of the immunoassay system. The experts in immunoassay systems should make every effort to find some specific and reliable quality indicators for irregular analytical errors in order to better detect and monitor erroneous immunoassay results due to specific or non-specific interferences.
Collapse
Affiliation(s)
- Aldo Clerico
- Laboratory of Cardiovascular Endocrinology and Cell Biology, Department of Laboratory Medicine, Fondazione CNR Toscana G. Monasterio, Scuola Superiore Sant'Anna, Via Trieste 41, 56126 Pisa, Italy
| | - Lucia Belloni
- Dipartimento di Medicina di laboratorio, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Cinzia Carrozza
- Laboratorio Analisi 1, Fondazione Policlinico Universitario "A. Gemelli", Roma, Italy
| | - Mario Correale
- Clinical Pathology Unit, IRCCS De Bellis, Castellana Grotte, Bari, Italy
| | - Ruggero Dittadi
- Medicina di Laboratorio, Ospedale dell'Angelo ULSS 3 Serenissima, Mestre, Italy
| | - Claudio Dotti
- Dipartimento di Medicina di laboratorio, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Antonio Fortunato
- U.O.C. Patologia Clinica, ASUR Marche Area Vasta 5, Ascoli Piceno, Italy
| | | | | | - Marco Migliardi
- S.C. Laboratorio Analisi, A.O. Ordine Mauriziano di Torino, Torino, Italy
| |
Collapse
|
29
|
Schifman RB, Perrotta PL, Souers R, Blond BJ. A Q-Probes Study Involving Utilization of Free Prostate-Specific Antigen, Factor V Leiden, and Hepatitis A Serology Tests. Arch Pathol Lab Med 2018; 143:151-156. [PMID: 30203988 DOI: 10.5858/arpa.2018-0010-cp] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Managing the utilization of laboratory tests is an important quality improvement activity that adds value to health care.
Objective.—
To examine utilization of 3 laboratory tests and identify factors that impact performance.
Design.—
Test utilization performance was evaluated by determining the frequency with which appropriate preconditions for testing were met. This included 30 testing episodes each involving (1) free prostate-specific antigen (PSA) when total PSA was within an appropriate interpretable range, (2) total anti–hepatitis A virus antibody when previous anti–hepatitis A virus antibody results were either negative or not done, and (3) factor V Leiden mutation when a previous result was not already available. Participants also provided information regarding some of their utilization policies and procedures for these 3 tests.
Results.—
The overall frequency with which testing criteria were met was 20.6% (163 of 790), 91.5% (649 of 709), and 95.2% (799 of 839) for free PSA, anti–hepatitis A virus antibody, and factor V Leiden, respectively. Utilization review was infrequent and done by 20.7% (6 of 29) of participants for factor V Leiden, 3.6% (1 of 28) for anti–hepatitis A virus antibody, and 3.6% (1 of 28) for free PSA. No practice or demographic characteristics were significantly associated with utilization performance for any test.
Conclusions.—
Utilization review was infrequent for the 3 tests examined. Variable amounts of unnecessary testing were observed for all tests, most frequently for free PSA, for which reporting results carried the added risk of diagnostic error from misinterpretation of results.
Collapse
Affiliation(s)
- Ron B. Schifman
- From Pathology and Laboratory Medicine, Southern Arizona VA Healthcare System, and the Department of Pathology, University of Arizona, Tucson (Dr Schifman); the Department of Pathology, University of West Virginia, and Clinical Laboratories, West Virginia University Hospital, Morgantown (Dr Perrotta); and Biostatistics (Ms Souers) and Surveys–Cytopathology (Ms Blond), College of American Patholog
| | - Peter L. Perrotta
- From Pathology and Laboratory Medicine, Southern Arizona VA Healthcare System, and the Department of Pathology, University of Arizona, Tucson (Dr Schifman); the Department of Pathology, University of West Virginia, and Clinical Laboratories, West Virginia University Hospital, Morgantown (Dr Perrotta); and Biostatistics (Ms Souers) and Surveys–Cytopathology (Ms Blond), College of American Patholog
| | - Rhona Souers
- From Pathology and Laboratory Medicine, Southern Arizona VA Healthcare System, and the Department of Pathology, University of Arizona, Tucson (Dr Schifman); the Department of Pathology, University of West Virginia, and Clinical Laboratories, West Virginia University Hospital, Morgantown (Dr Perrotta); and Biostatistics (Ms Souers) and Surveys–Cytopathology (Ms Blond), College of American Patholog
| | - Barbara J. Blond
- From Pathology and Laboratory Medicine, Southern Arizona VA Healthcare System, and the Department of Pathology, University of Arizona, Tucson (Dr Schifman); the Department of Pathology, University of West Virginia, and Clinical Laboratories, West Virginia University Hospital, Morgantown (Dr Perrotta); and Biostatistics (Ms Souers) and Surveys–Cytopathology (Ms Blond), College of American Patholog
| |
Collapse
|
30
|
Cano SJ, Pendrill LR, Barbic SP, Fisher WP. Patient-centred outcome metrology for healthcare decision-making. ACTA ACUST UNITED AC 2018. [DOI: 10.1088/1742-6596/1044/1/012057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
31
|
Selby PJ, Banks RE, Gregory W, Hewison J, Rosenberg W, Altman DG, Deeks JJ, McCabe C, Parkes J, Sturgeon C, Thompson D, Twiddy M, Bestall J, Bedlington J, Hale T, Dinnes J, Jones M, Lewington A, Messenger MP, Napp V, Sitch A, Tanwar S, Vasudev NS, Baxter P, Bell S, Cairns DA, Calder N, Corrigan N, Del Galdo F, Heudtlass P, Hornigold N, Hulme C, Hutchinson M, Lippiatt C, Livingstone T, Longo R, Potton M, Roberts S, Sim S, Trainor S, Welberry Smith M, Neuberger J, Thorburn D, Richardson P, Christie J, Sheerin N, McKane W, Gibbs P, Edwards A, Soomro N, Adeyoju A, Stewart GD, Hrouda D. Methods for the evaluation of biomarkers in patients with kidney and liver diseases: multicentre research programme including ELUCIDATE RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2018. [DOI: 10.3310/pgfar06030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BackgroundProtein biomarkers with associations with the activity and outcomes of diseases are being identified by modern proteomic technologies. They may be simple, accessible, cheap and safe tests that can inform diagnosis, prognosis, treatment selection, monitoring of disease activity and therapy and may substitute for complex, invasive and expensive tests. However, their potential is not yet being realised.Design and methodsThe study consisted of three workstreams to create a framework for research: workstream 1, methodology – to define current practice and explore methodology innovations for biomarkers for monitoring disease; workstream 2, clinical translation – to create a framework of research practice, high-quality samples and related clinical data to evaluate the validity and clinical utility of protein biomarkers; and workstream 3, the ELF to Uncover Cirrhosis as an Indication for Diagnosis and Action for Treatable Event (ELUCIDATE) randomised controlled trial (RCT) – an exemplar RCT of an established test, the ADVIA Centaur® Enhanced Liver Fibrosis (ELF) test (Siemens Healthcare Diagnostics Ltd, Camberley, UK) [consisting of a panel of three markers – (1) serum hyaluronic acid, (2) amino-terminal propeptide of type III procollagen and (3) tissue inhibitor of metalloproteinase 1], for liver cirrhosis to determine its impact on diagnostic timing and the management of cirrhosis and the process of care and improving outcomes.ResultsThe methodology workstream evaluated the quality of recommendations for using prostate-specific antigen to monitor patients, systematically reviewed RCTs of monitoring strategies and reviewed the monitoring biomarker literature and how monitoring can have an impact on outcomes. Simulation studies were conducted to evaluate monitoring and improve the merits of health care. The monitoring biomarker literature is modest and robust conclusions are infrequent. We recommend improvements in research practice. Patients strongly endorsed the need for robust and conclusive research in this area. The clinical translation workstream focused on analytical and clinical validity. Cohorts were established for renal cell carcinoma (RCC) and renal transplantation (RT), with samples and patient data from multiple centres, as a rapid-access resource to evaluate the validity of biomarkers. Candidate biomarkers for RCC and RT were identified from the literature and their quality was evaluated and selected biomarkers were prioritised. The duration of follow-up was a limitation but biomarkers were identified that may be taken forward for clinical utility. In the third workstream, the ELUCIDATE trial registered 1303 patients and randomised 878 patients out of a target of 1000. The trial started late and recruited slowly initially but ultimately recruited with good statistical power to answer the key questions. ELF monitoring altered the patient process of care and may show benefits from the early introduction of interventions with further follow-up. The ELUCIDATE trial was an ‘exemplar’ trial that has demonstrated the challenges of evaluating biomarker strategies in ‘end-to-end’ RCTs and will inform future study designs.ConclusionsThe limitations in the programme were principally that, during the collection and curation of the cohorts of patients with RCC and RT, the pace of discovery of new biomarkers in commercial and non-commercial research was slower than anticipated and so conclusive evaluations using the cohorts are few; however, access to the cohorts will be sustained for future new biomarkers. The ELUCIDATE trial was slow to start and recruit to, with a late surge of recruitment, and so final conclusions about the impact of the ELF test on long-term outcomes await further follow-up. The findings from the three workstreams were used to synthesise a strategy and framework for future biomarker evaluations incorporating innovations in study design, health economics and health informatics.Trial registrationCurrent Controlled Trials ISRCTN74815110, UKCRN ID 9954 and UKCRN ID 11930.FundingThis project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 3. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Peter J Selby
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rosamonde E Banks
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Walter Gregory
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jenny Hewison
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - William Rosenberg
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Christopher McCabe
- Department of Emergency Medicine, University of Alberta Hospital, Edmonton, AB, Canada
| | - Julie Parkes
- Primary Care and Population Sciences Academic Unit, University of Southampton, Southampton, UK
| | | | | | - Maureen Twiddy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Janine Bestall
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Tilly Hale
- LIVErNORTH Liver Patient Support, Newcastle upon Tyne, UK
| | - Jacqueline Dinnes
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Marc Jones
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | | | - Vicky Napp
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Alice Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sudeep Tanwar
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
| | - Naveen S Vasudev
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Baxter
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Sue Bell
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David A Cairns
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | | | - Neil Corrigan
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Francesco Del Galdo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Peter Heudtlass
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Nick Hornigold
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Claire Hulme
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Michelle Hutchinson
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Carys Lippiatt
- Department of Specialist Laboratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Roberta Longo
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Matthew Potton
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Stephanie Roberts
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Sheryl Sim
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Sebastian Trainor
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Matthew Welberry Smith
- Clinical and Biomedical Proteomics Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James Neuberger
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Paul Richardson
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - John Christie
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Neil Sheerin
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - William McKane
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul Gibbs
- Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - Naeem Soomro
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Grant D Stewart
- NHS Lothian, Edinburgh, UK
- Academic Urology Group, University of Cambridge, Cambridge, UK
| | - David Hrouda
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|
32
|
Rubinstein M, Hirsch R, Bandyopadhyay K, Madison B, Taylor T, Ranne A, Linville M, Donaldson K, Lacbawan F, Cornish N. Effectiveness of Practices to Support Appropriate Laboratory Test Utilization: A Laboratory Medicine Best Practices Systematic Review and Meta-Analysis. Am J Clin Pathol 2018; 149:197-221. [PMID: 29471324 PMCID: PMC6016712 DOI: 10.1093/ajcp/aqx147] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | | | | | | | - Thomas Taylor
- Centers for Disease Control and Prevention, Atlanta, GA
| | - Anne Ranne
- Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | - Nancy Cornish
- Centers for Disease Control and Prevention, Atlanta, GA
| |
Collapse
|
33
|
St John A, Cullen L, Jülicher P, Price CP. Developing a value proposition for high-sensitivity troponin testing. Clin Chim Acta 2018; 477:154-159. [DOI: 10.1016/j.cca.2017.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 11/24/2017] [Accepted: 12/05/2017] [Indexed: 11/26/2022]
|
34
|
Melanson SE, Petrides AK. Economics of Pain Management Testing. ACTA ACUST UNITED AC 2017; 2:587-597. [DOI: 10.1373/jalm.2017.023010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 08/18/2017] [Indexed: 11/06/2022]
|
35
|
Adeli K. Laboratory medicine – A hidden treasure in healthcare. Clin Biochem 2017; 50:645-647. [DOI: 10.1016/j.clinbiochem.2017.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 03/21/2017] [Accepted: 03/21/2017] [Indexed: 11/27/2022]
|
36
|
Crawford JM, Shotorbani K, Sharma G, Crossey M, Kothari T, Lorey TS, Prichard JW, Wilkerson M, Fisher N. Improving American Healthcare Through "Clinical Lab 2.0": A Project Santa Fe Report. Acad Pathol 2017; 4:2374289517701067. [PMID: 28725789 PMCID: PMC5497901 DOI: 10.1177/2374289517701067] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 02/04/2017] [Accepted: 02/21/2017] [Indexed: 11/16/2022] Open
Abstract
Project Santa Fe was established both to provide thought leadership and to help develop the evidence base for the valuation of clinical laboratory services in the next era of American healthcare. The participants in Project Santa Fe represent major regional health systems that can operationalize laboratory-driven innovations and test their valuation in diverse regional marketplaces in the United States. We provide recommendations from the inaugural March 2016 meeting of Project Santa Fe. Specifically, in the transition from volume-based to value-based health care, clinical laboratories are called upon to provide programmatic leadership in reducing total cost of care through optimization of time-to-diagnosis and time-to-effective therapeutics, optimization of care coordination, and programmatic support of wellness care, screening, and monitoring. This call to action is more than working with industry stakeholders on the basis of our expertise; it is providing leadership in creating the programs that accomplish these objectives. In so doing, clinical laboratories can be effectors in identifying patients at risk for escalation in care, closing gaps in care, and optimizing outcomes of health care innovation. We also hope that, through such activities, the evidence base will be created for the new value propositions of integrated laboratory networks. In the very simplest sense, this effort to create “Clinical Lab 2.0” will establish the impact of laboratory diagnostics on the full 100% spend in American healthcare, not just the 2.5% spend attributed to in vitro diagnostics. In so doing, our aim is to empower regional and local laboratories to thrive under new models of payment in the next era of American health care delivery.
Collapse
|
37
|
Accreditation in autoimmune diagnostic laboratories. A position paper of the European Autoimmunity Standardisation Initiative (EASI). Autoimmun Rev 2017; 16:81-86. [DOI: 10.1016/j.autrev.2016.09.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 08/27/2016] [Indexed: 11/19/2022]
|
38
|
Ngo A, Gandhi P, Miller WG. Frequency that Laboratory Tests Influence Medical Decisions. ACTA ACUST UNITED AC 2016; 1:410-414. [DOI: 10.1373/jalm.2016.021634] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 10/05/2016] [Indexed: 11/06/2022]
|
39
|
Kahn SE. Improving Laboratory Utilization Is a Top Priority for Laboratory Directors. ACTA ACUST UNITED AC 2016; 1:325-328. [DOI: 10.1373/jalm.2016.021105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/15/2016] [Indexed: 11/06/2022]
|
40
|
Abstract
The evolution of the concept of 'appropriateness', in the three past decades, from 'no harm' and 'no waste' to 'medical decision-making' and 'determining outcomes' highlights two main points: its foundation is evidence-based medicine, and it is a quality of every phase of the total testing process, not only for the selection of tests. Nevertheless, appropriateness in Laboratory Hematology, as well as in Laboratory Medicine, is an elusive concept: 'Appropriateness' interplays with 'patient's safety', 'healthcare costs', 'clinical decision-making', and 'effectiveness', and the criteria for appropriateness, mainly adherence to clinical guidelines, are often not evidence-based and not always consensus-based. Moreover, practising appropriateness is a complex issue because of the ambiguity of the criteria and targets, the never-ending work of implementing guidelines and their audit, and the uniqueness of the clinical situation of the individual patient. Authors agree on some practical rules: establishing a multidisciplinary and multiprofessional team, choosing carefully clinical targets, finding or building evidences, sharing guidelines with clinicians, choosing adequate tools for changing, working hard on implementation, identifying the 'right' laboratory methods and processes, checking progress indefinitely, providing information, interpretations, and consultations, and promoting feedback and audits. The success depends on the 'right' combination of educational, operative, and reinforcing interventions. Competences in organization, in implementation science, and in interpersonal relationship management are essential as well as knowledge and experience in Hematology, not only in Laboratory Hematology.
Collapse
Affiliation(s)
- P Cappelletti
- SIPMeL - Società Italiana di Patologia Clinica e Medicina di Laboratorio, Castelfranco Veneto (TV), Italy
| |
Collapse
|
41
|
Hallworth MJ. Improving clinical outcomes - towards patient-centred laboratory medicine. Ann Clin Biochem 2015; 52:715-6. [PMID: 26113738 DOI: 10.1177/0004563215595431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2015] [Indexed: 11/17/2022]
Abstract
Hard evidence of the specific contribution made by laboratory testing to patient outcomes and the delivery of health care is not easy to obtain. An understanding of the value of laboratory medicine, how that value can be measured and the various factors that influence it is vital to ensuring that laboratory services are provided and used optimally to improve patient care. To maximise the value of laboratory medicine, work is required to improve the utilisation of existing and new biomarkers, develop standard protocols for prospective patient-centred studies of biomarker clinical effectiveness or extra-analytical process effectiveness, benchmark existing and new tests in specified clinical situations with commonly accepted effectiveness measures, and define new roles for laboratory professionals that are focussed on optimising patient outcomes by adding value throughout the total testing process. This requires effective collaboration with clinical staff and a determination to accept patient outcome and patient experience as the primary measure of laboratory performance.
Collapse
Affiliation(s)
- Mike J Hallworth
- IFCC Task Force on the Impact of Laboratory Medicine on Clinical Management and Outcomes, Milan, Italy
| |
Collapse
|