Laboratory reflex testing strategy for the early identification of primary care patients with multiple myeloma

OBJECTIVES

Our objective was to shorten the screen for multiple myeloma (MM), through reflex testing.

DESIGN AND METHODS

The clinical laboratory in the public University Hospital of San Juan (Alicante, Spain), serves 234,551 inhabitants. Through an intervention agreed with general practitioners, the Laboratory Information System (LIS) automatically registered serum immunoglobulins (Ig) when serum total proteins (STP) > 80 g/L for the first time in primary care patients. When concomitantly one Ig presented a value above and one below its reference interval, the LIS automatically registered a serum protein electrophoresis (SPEP). When a monoclonal peak in SPEP, immunofixation electrophoresis (IFE) for the typification of monoclonal bands (MB) was performed. If MB were present, a comment in the report explained the intervention. The number of additionally registered Ig, SPEP, IFE, and new diagnosis of MM were counted. The number of days elapsed from the report of elevated STP result to the final MM diagnosis was also counted as median and interquartile range (IQR), and compared to a pre intervention period.

RESULTS

2071 cases of hyperproteinemia were identified, and had 91 a monoclonal peak, confirmed by IFE. In 35 patients it was a new finding, and 9 were diagnosed with MM, 3 Waldestrom macroglobulinemia, 2 lymphoplasmacytic lymphoma and 21 monoclonal gammopathy of undetermined significance. The number of days elapsed from hyperproteinemia to diagnosis was lower in the intervention period (21.5 vs 119.4) (P < 0.01). As our results show, in addition to shortening the time to diagnosis, an increased rate of detection of plasma cell disorders was observed when using our algorithm.

CONCLUSIONS

The above laboratory interventions agreed with clinicians, making use of laboratory technology resulted in early identification of MM.

A comparative analysis of Sigma metrics using conventional and alternative formulas

BACKGROUND AND AIM

The Six Sigma approach, employing Sigma Metrics (SM), is commonly used to evaluate analytical performance in clinical laboratories. However, there is ongoing debate regarding the suitability of the conventional SM formula, which incorporates total allowable error (TEa) and bias. To address this, an alternative formula based on within-subject biological variation (CVI) as the tolerance range (TR) has been proposed. The study aimed to calculate and compare SM values using both formulas.

MATERIAL AND METHODS

Twenty clinical chemistry parameters were evaluated, and SM values were calculated using conventional formula with two TEa goals and the alternative formula. Intermediate precision (CVA%) values were obtained from internal quality control data, while bias values were derived from external quality assessment reports.

RESULTS

The results showed that using the conventional formula, 11 SM values based on CLIA TEa goals and 21 SM values based on BV TEa goals were deemed unacceptable (SM < 3). Additionally, 22 SM values calculated using the alternative formula were below 3.

CONCLUSION

The choice of TR had a substantial impact on the assessed analytical performance. Laboratories should carefully consider the appropriateness of each approach based on their specific quality objectives, analyte characteristics, and laboratory operations.

Mapping the Evidence on Rapid Diagnosis of Bloodstream Infections: A Scoping Review

BACKGROUND

Laboratory and other healthcare professionals participate in developing clinical practice guidelines through systematic review of the evidence. A significant challenge is the identification of areas for analytic focus when the evidence consists of several categories of interventions and outcomes that span both laboratory and clinical processes. The challenge increases when these interventions present as sets of combined interventions. A scoping review may provide a transparent and defensible analytic route forward for systematic reviews challenged in this manner.

CONTENT

A scoping review was carried out to characterize the evidence on rapid identification of bloodstream infections. Fifty-five studies previously identified by the supported systematic review were charted in duplicate. Charted records were analyzed using descriptive content analysis and evidence mapping with a 5-step process.

SUMMARY

The 5-step analysis culminated in the characterization of 9 different intervention chain configurations that will facilitate the comparison of complex intervention practices across studies. Furthermore, our evidence map indicates that the current evidence base is strongly centered on 3 specific clinical outcomes, and it links these outcomes to the most represented intervention chain configurations. The scoping review effort generated a route forward for the supported systematic review and meta-analysis.

Clinical laboratory services for primary healthcare centers in urban cities: a pilot ACO model of ten primary healthcare centers

Background

Primary healthcare centers (PHC) ensure that patients receive comprehensive care from promotion and prevention to treatment, rehabilitation, and palliative care in a familiar environment. It is designed to provide first-contact, continuous, comprehensive, and coordinated patient care that will help achieve equity in the specialty healthcare system. The healthcare in Saudi Arabia is undergoing transformation to Accountable Care Organizations (ACO) model. In order for the Kingdom of Saudi Arabia (KSA) to achieve its transformational goals in healthcare, the improvement of PHCs’ quality and utilization is crucial. An integral part of this service is the laboratory services.

Methods

This paper presents a pilot model for the laboratory services of PHC's in urban cities. The method was based on the FOCUS-PDCA quality improvement method focusing on the pre-analytical phase of the laboratory testing as well as the Saudi Central Board for Accreditation of Healthcare Institutes (CBAHI) gap analysis and readiness within the ten piloted primary healthcare centers.

Results

The Gap analysis, revealed in-consistency in the practice, lead to lower the quality of the service, which was seen in the low performance of the chosen key performance indicators (KPI's) (high rejection rates, lower turn-around times (TAT) for test results) and also in the competency of the staff. Following executing the interventions, and by using some of the ACO Laboratory strategies; the KPI rates were improved, and our results exceeded the targets that we have set to reach during the first year. Also introducing the electronic connectivity improved the TAT KPI and made many of the processes leaner.

Conclusions

Our results revealed that the centralization of PHC's laboratory service to an accredited reference laboratory and implementing the national accreditation standards improved the testing process and lowered the cost, for the mass majority of the routine laboratory testing. Moreover, the model shed the light on how crucial the pre-analytical phase for laboratory quality improvement process, its effect on cost reduction, and the importance of staff competency and utilization.

How SARS-CoV-2 Transformed the Clinical Laboratory: Challenges and Lessons Learned

The COVID-19 pandemic has made a devastating impact on global health and continues to challenge healthcare infrastructure and delivery. The clinical laboratories were no exception as they are responsible for diagnostic testing that dictates many clinical, infection control and public health decisions. Information technology and laboratory management tools are critical assets for maintaining and adapting operations in response to crises and when utilized effectively, promote the integration between the clinical laboratory specialties (e.g., chemistry, hematology, microbiology, and molecular pathology). During the COVID-19 pandemic, our systems and processes were strained due to high testing volumes, demand for rapid turnaround times, supply chain constraints, and constantly evolving testing algorithms and result interpretations as our knowledge of the virus and of diagnostics increased over time. In this report, we describe those challenges and subsequent adaptations made by each clinical laboratory section. We hope these details help provide potential solutions and approaches for other hospitals facing COVID-19 surges or other future pandemics.

The LOINC Content Model and Its Limitations of Usage in the Laboratory Domain

To unambiguously encode the semantic meaning of laboratory tests, the LOINC terminology is widely used. With regard to the constantly changing and diverse requirements of the laboratory domain, LOINC's long-established content model and related publications are reviewed conjointly, revealing some obstacles for flexible adaptation in terms of new or varying application needs as well as issues regarding the comprehensive reusability of lab data. In a concise overview, four specific limitations are identified that require adaptation or the usage of other terminologies.

Cost-price estimation of clinical laboratory services based on activity-based costing: A case study from a developing country

BACKGROUND

It is believed that laboratory tariffs in Iran don't reflect the real costs. This might expose private laboratories at financial hardship. Activity Based Costing is widely used as a cost measurement instrument to more closely approximate the true cost of operations.

OBJECTIVE

This study aimed to determine the real price of different clinical tests of a selected private clinical laboratory.

METHODS

This study was a cross sectional study carried out in 2015. The study setting was the private laboratories in the city of Kerman, Iran. Of 629 tests in the tariff book of the laboratory (relative value), 188 tests were conducted in the laboratory that used Activity Based Costing (ABC) methodology to estimate cost-price. Analyzing and cost-price estimating of laboratory services were performed by MY ABCM software Version 5.0.

RESULTS

In 2015, the total costs were $641,645. Direct and indirect costs were 78.3% and 21.7% respectively. Laboratory consumable costs by 37% and personnel costs by 36.3% had the largest share of the costing. Also, group of hormone tests cost the most $147,741 (23.03%), and other tests group cost the least $3,611 (0.56%). Also after calculating the cost of laboratory services, a comparison was made between the calculated price and the private sector's tariffs in 2015.

CONCLUSION

This study showed that there was a difference between costs and tariffs in the private laboratory. One way to overcome this problem is to increase the number of laboratory tests with regard to capacity of the laboratories.

"This thing of testing our blood is really very important": a qualitative study of primary care laboratory services in Tete Province, Mozambique

BACKGROUND

Laboratory services are essential for diagnosis and management of patients, and for disease control, and should form an integral part of primary health services capable of contributing to Universal Health Coverage. Nevertheless, they remain among the most neglected health services in resource-poor countries, including Mozambique. The Health Directorate of Tete Province, Mozambique, developed this study to analyse the role and perceived impact of laboratory services in primary healthcare on access, perceived service quality and disease control.

METHODS

Qualitative research was done in three primary health facilities with and three without a laboratory in Tete Province, purposively sampled for their available services, accessibility and size. The role of the laboratory in primary health care was explored by reviewing documents, including records and monthly reports, interviews with clinicians, laboratory technicians and key informants (community leaders), and through focus group discussions with beneficiaries. Numeric data were summarized in Microsoft™ Excel. Qualitative data were analysed for content within generated categories, interpreted within the concept of Universal Health Coverage, cross validated between the researchers.

RESULTS

The results showed a greater use of health services, with more frequent diagnosis and monitoring of prevalent diseases, in facilities with a laboratory as compared with facilities without. Clinicians, patients and community leaders in facilities with a laboratory perceived an improved possibility of diagnosing and treating prevalent diseases, resulting in greater satisfaction with the provided services. Laboratory technicians confirmed that patients appreciated having access to laboratory tests. Clinicians, patients and community leaders in facilities without a laboratory protested its lack, claiming that it increased the likelihood of costly referrals, delays and even deaths.

CONCLUSIONS

The study concluded that the laboratory plays an important role in primary level health facilities, as it is associated with greater utilization and perceived higher quality of services. Lack of a laboratory hampers patient management, disease control and financial risk protection. Expansion of the clinical laboratory system at primary level health facilities should be a properly funded priority of the national health system in Mozambique and similar countries.

Nontyphoidal Salmonella: An Occupational Hazard for Clinical Laboratory Workers

Laboratory-acquired infections due to nontyphoidal Salmonella are rare. Yet, recent outbreaks in microbiology teaching laboratories show that these species are still an appreciable occupational hazard for laboratory employees. This article presents two cases of nontyphoidal Salmonella that occurred at the authors' institution-an infected patient and a clinical laboratory worker who acquired the infection by handling this patient's specimens.

A Map for Clinical Laboratories Management Indicators in the Intelligent Dashboard

INTRODUCTION

management challenges of clinical laboratories are more complicated for educational hospital clinical laboratories. Managers can use tools of business intelligence (BI), such as information dashboards that provide the possibility of intelligent decision-making and problem solving about increasing income, reducing spending, utilization management and even improving quality. Critical phase of dashboard design is setting indicators and modeling causal relations between them. The paper describes the process of creating a map for laboratory dashboard.

METHODS

the study is one part of an action research that begins from 2012 by innovation initiative for implementing laboratory intelligent dashboard. Laboratories management problems were determined in educational hospitals by the brainstorming sessions. Then, with regard to the problems key performance indicators (KPIs) specified.

RESULTS

the map of indicators designed in form of three layered. They have a causal relationship so that issues measured in the subsequent layers affect issues measured in the prime layers.

CONCLUSION

the proposed indicator map can be the base of performance monitoring. However, these indicators can be modified to improve during iterations of dashboard designing process.