Current status of testing intervals for antiphospholipid syndrome testing: a 13-year retrospective national data analysis in South Korea

OBJECTIVE

To assess the appropriateness of laboratory testing intervals and antiphospholipid syndrome (APS) incidence.

METHODS

Between January 2010 and August 2022, insurance claims data of patients with disease codes for other thrombophilia (D68.6) and APS (V253) were retrieved in South Korea. Patients who received antiphospholipid antibody tests more than twice were classified as having suspected APS. The interval between the first 2 antiphospholipid antibody tests was evaluated in the patients with suspected APS. Patients with suspected APS who received anticoagulants for >180 days were classified as having APS.

RESULTS

Overall, 8656 patients were classified as having suspected APS. The testing interval for the first 2 tests in patients with suspected APS was <6 and <12 weeks in 11.1% and 20.6% of cases, respectively, in 2010, gradually increasing to 21.0% and 35.4%, respectively, in 2021. Subsequently, 4344 patients were classified as having APS, with 65.0% being female. Only 330 patients were diagnosed with APS in 2021, down from 436 in 2020.

CONCLUSION

This study showed a gradual increase in patients receiving antiphospholipid antibody testing with an inappropriate short-term interval, underscoring the need for laboratory stewardship to ensure an appropriate interval for APS testing.

Improved Utilization of Serial Testing Without Increased Admissions after Implementation of High-Sensitivity Troponin I: a Controlled Retrospective Cohort Study

BACKGROUND

Guidelines recommend high-sensitivity cardiac troponin (hs-cTn) for diagnosis of myocardial infarction. Use of hs-cTn is increasing across the U.S., but questions remain regarding clinical and operational impact. Prior studies have had methodologic limitations and yielded conflicting results.

OBJECTIVE

To evaluate the impact of transitioning from conventional cardiac troponin (cTn) to hs-cTn on test and resource utilization, operational efficiency, and patient safety.

DESIGN

Retrospective cohort study in two New York City hospitals during the months before and after transition from conventional cTn to hs-cTn at Hospital 1. Hospital 2 served as a control.

PARTICIPANTS

Consecutive emergency department (ED) patients with at least one cTn test resulted.

INTERVENTION

Multifaceted hs-cTn intervention bundle, including a 0/2-h diagnostic algorithm for non-ST-elevation myocardial infarction, an educational bundle, enhancements to the electronic medical record, and nursing interventions to facilitate timed sample collection.

MAIN MEASURES

Primary outcomes included serial cTn test utilization, probability of hospital admission, ED length of stay (LOS), and among discharged patients, probability of ED revisit within 72 h resulting in hospital admission. Multivariable regression models adjusted for age, sex, temporal trends, and interhospital differences.

KEY RESULTS

The intervention was associated with increased use of serial cTn testing (adjusted risk difference: 48 percentage points, 95% CI: 45-50, P < 0.001) and ED LOS (adjusted geometric mean difference: 50 min, 95% CI: 50-51, P < 0.001). There was no significant association between the intervention and probability of admission (adjusted relative risk [aRR]: 0.99, 95% CI: 0.89-1.1, P = 0.81) or probability of ED revisit within 72 h resulting in admission (aRR: 1.1, 95% CI: 0.44-2.9, P = 0.81).

CONCLUSIONS

Implementation of a hs-cTn intervention bundle was associated with an improvement in serial cTn testing, a neutral effect on probability of hospital admission, and a modest increase in ED LOS.

Low antibody levels associated with significantly increased rate of SARS-CoV-2 infection in a highly vaccinated population from the US National Basketball Association

SARS-CoV-2 antibody levels may serve as a correlate for immunity and could inform optimal booster timing. The relationship between antibody levels and protection from infection was evaluated in vaccinated individuals from the US National Basketball Association who had antibody levels measured at a single time point from September 12, 2021, to December 31, 2021. Cox proportional hazards models were used to estimate the risk of infection within 90 days of serologic testing by antibody level (<250, 250-800, and >800 AU/mL1 ), adjusting for age, time since last vaccine dose, and history of SARS-CoV-2 infection. Individuals were censored on date of booster receipt. The analytic cohort comprised 2323 individuals and was 78.2% male, 68.1% aged ≤40 years, and 56.4% vaccinated (primary series) with the Pfizer-BioNTech mRNA vaccine. Among the 2248 (96.8%) individuals not yet boosted at antibody testing, 77% completed their primary vaccine series 4-6 months before testing and the median (interquartile range) antibody level was 293.5 (interquartile range: 121.0-740.5) AU/mL. Those with levels <250 AU/mL (adj hazard ratio [HR]: 2.4; 95% confidence interval [CI]: 1.5-3.7) and 250-800 AU/mL (adj HR: 1.5; 95% CI: 0.98-2.4) had greater infection risk compared to those with levels >800 AU/mL. Antibody levels could inform individual COVID-19 risk and booster scheduling.

Clinical Decision Support for Laboratory Testing

BACKGROUND

As technology enables new and increasingly complex laboratory tests, test utilization presents a growing challenge for healthcare systems. Clinical decision support (CDS) refers to digital tools that present providers with clinically relevant information and recommendations, which have been shown to improve test utilization. Nevertheless, individual CDS applications often fail, and implementation remains challenging.

CONTENT

We review common classes of CDS tools grounded in examples from the literature as well as our own institutional experience. In addition, we present a practical framework and specific recommendations for effective CDS implementation.

SUMMARY

CDS encompasses a rich set of tools that have the potential to drive significant improvements in laboratory testing, especially with respect to test utilization. Deploying CDS effectively requires thoughtful design and careful maintenance, and structured processes focused on quality improvement and change management play an important role in achieving these goals.

Underutilization of diagnostic assays for celiac disease in Korea

Background

Test utilization for the diagnosis of celiac disease may affect the prevalence and incidence of the disease in Korea. We aimed to investigate the test utilization of serological biomarkers for celiac disease in Korea.

Methods

We retrospectively investigated the test utilization of tissue transglutaminase IgA, gliadin IgA and IgG, and endomysial IgA antibody (Ab) assays between January 2011 and June 2020.

Results

During a nine‐year‐and‐six‐month study period, overall 307,322,606 clinical tests were requested from different clinical settings, such as local clinics, hospitals, university hospitals, and tertiary medical centers. Among them, only 58 tissue transglutaminase IgA, 22 gliadin IgA, 12 gliadin IgG, and 16 endomysial IgA Ab tests were performed on 79 Korean patients. Among them, one patient had positive transglutaminase IgA Ab result (1.3%).

Conclusion

Low prevalence and incidence of celiac disease in Korea may be due to an underutilization of diagnostic assays.

Is It Time to Remove Total Calcium from the Basic and Comprehensive Metabolic Panels? Assessing the Effects of American Medical Association-Approved Chemical Test Panels on Laboratory Utilization

BACKGROUND

The necessity of individual tests within the most commonly used disease-oriented test panels has not been well established. We evaluated test-ordering practices for total calcium, both before and after implementation of American Medical Association (AMA)-approved panels (basic metabolic panel [BMP] and comprehensive metabolic panel [CMP]) in our electronic ordering system.

METHODS

We performed a retrospective review of all total calcium orders placed during April and June 2018, before and after implementation of the panels. Orders from inpatient, outpatient, and emergency department (ED) care units were totaled, and the percentage of abnormal test results was calculated. We then queried institutional databases to determine the number of unique patients with calcium-related diagnoses and compared the rates from a 5-month period both before and after implementation of the panels.

RESULTS

Total test volumes and tests per unique patient increased by more than 3-fold after implementation of calcium-containing AMA-approved panels, with the majority of those orders coming from BMPs and CMPs. The rate of low calcium values increased because of the shift toward more inpatient testing; however, the percentage of abnormal results within each patient population (inpatient, outpatient, ED) decreased. The prevalence of hypo- and hypercalcemia-related diagnoses among patients in the 5 months after implementation did not change significantly (1.29% before implementation vs 1.27% after implementation).

CONCLUSIONS

Implementation of BMPs and CMPs dramatically increased total calcium testing volumes without changing the rate of calcium-related diagnoses. The results suggest that the increase in total calcium orders associated with panel-based testing largely constitutes excess or unnecessary testing.

Overutilization in laboratory medicine: tackling the problem with quality improvement science

Overutilization of tests and treatments is a widespread problem in contemporary heath care, and laboratory medicine is no exception. It is estimated that 10-70% of laboratory tests may be unnecessary, with estimates in the literature varying depending on the situation and the laboratory test. Inappropriate use of laboratory tests can lead to further unnecessary testing, adverse events, inaccurate diagnoses, and inappropriate treatments. Altogether, this increases the risk of harm to a patient, which can be physical, psychological, or financial in nature. Overutilization in healthcare is driven by complex factors including care delivery models, litigious practice environments, and medical and patient culture. Quality improvement (QI) methods can help to tackle overutilization. In this review, we outline the global healthcare problem of laboratory overutilization, particularly in the developed world, and describe how an understanding of and application of quality improvement principles can help to address this challenge.

Mater Artium Necessitas: The Birth of a COVID-19 Command Center

In February of 2020, New York City was unprepared for the COVID-19 pandemic. Cases of SARS-CoV-2 infection appeared and spread rapidly. Hospitals had to repurpose staff and establish diagnostic testing for this new viral infection. In the background of the usual respiratory pathogen testing performed in the clinical laboratory, SARS-CoV-2 testing at the Montefiore Medical System grew exponentially, from none to hundreds per day within the first week of testing. The job of appropriately routing SARS-CoV-2 viral specimens became overwhelming. Additional staff was required to triage these specimens to multiple in-house testing platforms as well as external reference laboratories. Since medical school classes and many research laboratories shut down at the Albert Einstein College of Medicine and students were eager to help fight the pandemic, we seized the opportunity to engage and train senior MD-PhD students to assist in triaging specimens. This volunteer force enabled us to establish the "Pathology Command Center," staffed by these students as well as residents and furloughed dental associates. The Pathology Command Center staff were tasked with the accessioning and routing of specimens, answering questions from clinical teams, and updating ever evolving protocols developed in collaboration with a team of Infectious Disease clinicians. Many lessons were learned during this process, including how best to restructure an accessioning department and how to properly onboard students and repurpose staff while establishing safeguards for their well-being during these unprecedented times. In this article, we share some of our challenges, successes, and what we ultimately learned as an organization.

A Shared Diagnostic Stewardship Approach toward Improving Autoimmune Encephalopathy Send-out Testing Utilization

BACKGROUND

For many laboratories, autoimmune encephalopathy (AE) panels are send-out tests. These tests are expensive, and ordering patterns vary greatly. There is also a lack of consensus on which panel to order and poor understanding of the clinical utility of these panels. These challenges were presented to our newly formed, multidisciplinary, diagnostic stewardship committee (DSC). Through this collaboration, we developed an algorithm for ordering AE panels; combining diagnostic criteria with practice guidelines.

METHODS

We analyzed test-ordering patterns in 2018 and calculated a true-positive rate based on clinical presentation and panel interpretation. An evidence-based approach was combined with input from the Department of Neurology to synthesize our algorithm. Efficacy of the algorithm (number of panels ordered, cost, and true positives) was assessed before and after implementation.

RESULTS

In 2018, 77 AE-related panels were ordered, costing $137 510. The true-positive rate was 10%, although ordering multiple, similar panels for the same patient was common. Before implementing the algorithm (January 1-July 31, 2019), 55 panels were ordered, costing $105 120. The total true-positive rate was 3.6%. After implementation, 23 tests were ordered in a 5-month period, totaling $50 220. The true-positive rate was 13%.

CONCLUSION

With the DSC-directed mandate, we developed an algorithm for ordering AE panels. Comparison of pre- and postimplementation data showed a higher true-positive rate, indicating that our algorithm was able to successfully identify the at-risk population for AE disorders. This was met with a 43% decrease in the number of tests ordered, with total cost savings of $25 000 over 5 months.

Test utilization for the diagnosis of vitamin B12 and folate deficiency in local clinics in Korea

Background

Current guidelines pertaining to diagnosing macrocytic anemia in association with vitamin B12 and folate deficiency recommend that vitamin B12, folate, homocysteine, and methylmalonic acid assays should be assessed concurrently due to their close relationship in metabolism. We aimed to investigate the completion of these assays in local clinics and hospitals without in‐house clinical laboratories in Korea.

Methods

We retrospectively reviewed data from the laboratory information system between September 25, 2017, and June 30, 2019, to investigate usage rates of vitamin B12, folate, homocysteine, and methylmalonic acid assays in patients with macrocytic anemia.

Results

During the study period, 14 894 Korean adults among 109 524 (13.6%) total hemoglobin‐tested subjects underwent concurrent erythrocyte mean corpuscular volume (MCV) tests. Among these 14,894 adults, 265 (1.2%) from 94 local clinics or hospitals without in‐house clinical laboratories in Korea had macrocytic anemia. Furthermore, among these 265 adults, only one woman underwent serum vitamin B12 and folate assay and one man underwent serum homocysteine testing during the study period. No patients among the 265 individuals with macrocytic anemia received erythrocyte folate or methylmalonic acid testing (with either serum, plasma, random urine, or 24‐hour collected urine).

Conclusions

The results of this study provide basic information regarding utilization rates of assays in association with vitamin B12 and folate deficiency. Making more data available is expected to improve rates of testing in patients with macrocytic anemia in local clinics and hospitals without in‐house clinical laboratories in Korea.

Reducing overutilisation of serum vitamin D testing at a tertiary care centre

INTRODUCTION

Testing of 25-hydroxy (25-OH) vitamin D serum levels has increased drastically in recent years and much of it is considered inappropriate based on current guidelines.

METHODS

In consultation with our physician groups (experts and frequent orderers), we modified existing guidelines and implemented a rational policy for 25-OH vitamin D testing and 1,25 dihydroxy (1,25 di-OH) vitamin D testing at a tertiary care centre. A computer decision support tool requiring selection of one of five acceptable testing indications was created for each test as part of a computerised physician order entry system.

RESULTS

As a result of our intervention, we observed a 27% decrease in the average monthly test volume for 25-OH vitamin D from 504±62 (mean±SD) tests per month to 370±33 (p<0.001). 1,25 di-OH vitamin D testing decreased 58% from 71±18 to 30±10 (p<0.001). The departments ordering the tests were similar during the preintervention and postintervention periods, and further audits, patient chart reviews and individualised physician feedback were required to ensure appropriate ordering of 1,25 di-OH vitamin D. The most common ordering reasons selected were malabsorption/dietary concerns (46%) for 25-OH vitamin D and renal failure (42%) for 1,25 di-OH vitamin D.

CONCLUSIONS

Limitations of our computer decision support tool include a dependence on an honour system in selecting the testing indication and an inability to limit ordering frequency. Periodic monitoring of test volumes will be required to ensure adherence to guidelines. Despite these limitations, we have improved appropriate utilisation of these tests and reduced costs by approximately $C60 375 per year.

Genetic testing costs and compliance with clinical best practices

We sought to determine the costs of genetic testing and compliance with published guidelines and clinical best practices at our institution. A cost analysis was performed comparing the costs of ordered tests to the cost of the recommended testing. This was an approved quality improvement project at a tertiary teaching hospital in California. We identified charts associated with the genetic testing billing codes for common genetic tests through our contracted laboratory (cystic fibrosis genotyping, Breast cancer susceptibility gene (BRCA 1&2), Methylenetetrahydrofolate reductase (MTHFR), factor V Leiden (FVL), prothrombin gene pathogenic variant, alpha-thalassemia, hemochromatosis, and cell-free fetal DNA). Charts were reviewed retrospectively by a licensed, certified genetic counselor to assess the compliance with published clinical practice guidelines identified on GeneReviews and the American College of Obstetricians and Gynecologists (ACOG). Tests were classified as: appropriate, misordered/not indicated, misordered/false reassurance, and misordered/inadequate. We performed a cost analysis for the recommended test changes. We reviewed 114 charts over a three-month period. Forty-four (38.6%) of the tests were misordered based on published clinical practice guidelines: 24 (21%) were misordered/not indicated, 8 (7%) were misordered/false reassurance, and 12 (10.5%) were misordered/inadequate. Costs of ordered testing ($75,177) were compared to recommended testing after review ($54,265), with a total cost savings of $20,912. In clinical practice, over one-third of genetic tests reviewed were misordered. As these tests are a small fraction of all genetic tests at our institution, future studies should broaden the scope of testing evaluated to understand the magnitude of this problem and potential cost savings. Genetic counselor review and involvement in genetic test ordering can decrease inappropriate healthcare expenditures and improve patient care.

Identifying tests related to breast cancer care in claims data

To develop a method for calculating rates of testing for breast cancer recurrence in patients who have already undergone initial treatment for breast cancer, we calculated rates in a cohort of Medicare breast cancer patients and an age-matched noncancer cohort. We first used only tests with claims including diagnosis codes indicating invasive breast cancer and then used all tests regardless of diagnosis code. For each method, we calculated testing rates in the breast cancer cohort above the background rate in the noncancer population. The two methods provided similar estimates of testing prevalence and frequency, with exception of prevalence of CT.

Understanding the patient population and test utilization for hepatitis B virus testing

BACKGROUND

Hepatitis B virus (HBV) infection remains a global concern with different epidemiologies due to several factors including migration, vaccination policies, and new antiviral treatment regimens. It is important to understand the characteristics of a patient population, including the prevalence of diseases, and to assess test utilization to understand and evaluate the clinical performance of laboratory tests and to improve the quality of clinical laboratories.

MATERIALS AND METHODS

In this study, we evaluated serologic and virologic laboratory tests including hepatitis B surface antigen, hepatitis B surface antibody, hepatitis B envelope antigen (HBeAg), hepatitis B envelope antibody, and HBV DNA in Korean adults who were exposed to HBV.

RESULTS

During the 1-year study period, we obtained 22 750 specimens from 17 523 adult Korean patients (>18.0 years; 9894 males and 7629 females) with a median age of 50.1 years (interquartile range, 42.2-58.2 years). Among them, five serologic and virologic laboratory tests were performed for 1340 (5.9%) specimens from 1172 adult Korean patients (>18.0 years; 647 males and 525 females) with a median age of 46.8 years (range, 19.0-84.5 years). The prevalence of serologic and virologic tests indicating several clinical situations was evaluated. The correlation coefficient between HBV DNA and HBeAg was ρ = 0.85 (P < .0001). However, 51.9% (695/1340) of samples did not show agreement between the two test results.

CONCLUSIONS

Analysis of the prevalence of patients categorized into five serologic and virologic laboratory results would be helpful to expand our knowledge about patient population characteristics and to improve test utilization.

The Choosing Wisely initiative and laboratory test stewardship

The United States Choosing Wisely initiative was started in 2012 by the American Board of Internal Medicine Foundation and focused on reducing medical resource overutilization. Since its inception in the US, similar efforts have arisen in at least a dozen countries. Strongly patient-focused, and in fact started in collaboration with the consumer magazine Consumer Reports, the effort has resulted in a collection of greater than 500 recommendations from over 80 US professional societies intended to inform both patients and doctors about medical practices whose necessity should be questioned or discussed. Targets of recommendations include practices that lack a basis in scientific evidence, practices that may be duplicative of other care already received, practices that may be harmful and practices that are simply unnecessary. While critiques have been levied against the Choosing Wisely initiative over its intent, methods and efficacy, it is clear that many of its recommendations have been adopted by large medical practices, and several positive outcomes, i.e. reductions in perceived waste, have been reported in relation to many of the recommendations, including those specifically targeting laboratory tests. The future success of Choosing Wisely will likely hinge on whether or not significantly positive and durable outcomes can be demonstrated, especially at a time where there is increasing pressure to drive down costs in medical care while concomitantly increasing quality.

Evaluation of thyroid test utilization through analysis of population-level data

BACKGROUND

Inappropriate laboratory test utilization can result in unnecessary patient testing and increased healthcare costs. While several thyroid function tests are available, thyroid-stimulating hormone (TSH) is recommended as the first-line test for investigating and monitoring thyroid dysfunction. We evaluate thyroid test utilization in Northern Alberta in terms of testing patterns, frequencies, and reflex cutpoints.

METHODS

This retrospective study analyzed thyroid test requests from January to December 2014. Each request was designated as appropriate or potentially inappropriate as per clinical practice guidelines and Choosing Wisely recommendations, and the frequencies of each testing pattern were calculated. Sub-analysis was performed to categorize testing patterns based on physician specialty. The number of test requests per patient was determined to assess the appropriateness of testing frequency. Receiver operating characteristic (ROC) curves were generated to define optimal TSH cutpoints for automatic reflex to FT4 testing.

RESULTS

Of 752,217 test requests, approximately 10% were potentially inappropriate in terms of testing patterns. Free thyroxine (FT4) and free triiodothyronine (FT3) requested with TSH accounted for 59% of all potentially inappropriate test requests, and 49% of requests from endocrinologists (ENDO) were potentially inappropriate, occurring most frequently among those with less experience. Excessive testing frequencies were observed in 869 patients, accounting for 9382 test requests. Adjustment of our TSH reflex cutpoint would significantly increase specificity for identifying a low FT4 without compromising sensitivity.

CONCLUSIONS

This study suggests that questionable testing patterns, excessive testing frequencies, and suboptimal reflexive testing cutpoints contribute to inappropriate thyroid test utilization.

Requirement for a Pathologist's Second Signature Limits Inappropriate Inpatient Thrombophilia Testing

Thromboembolism is a condition that leads to the hospitalization of thousands of patients in the United States annually. Recent guidelines suggest that testing for hereditary, acquired and combined forms of thrombophilia be delayed following hospitalization for a first-time acute thrombotic event. Instead, thrombophilia testing would be performed in an outpatient setting, at least 1 month after discontinuation of anticoagulant therapy or 3 months after the thrombotic event, on the understanding that anticoagulation may affect some testing. Here, we provide our experience in instituting a system-wide policy change to limit thrombophilia testing in the inpatient setting. The policy change implemented led to a 90% reduction in number of tests ordered. We discuss the cost savings realized by limiting testing. These changes cost nothing to implement. Overall, limiting inpatient thrombophilia testing improves compliance with testing guidelines, provides better care for patients, and allows our institution to better utilize resources.

Adding Value in the Postanalytical Phase

Apart from maintaining the highest quality of analytical test results, laboratories are now getting more focused on how to achieve the greatest impact of laboratory results on their patient's outcome. Laboratory professionals are now in the learning phase of implementing new practices at different steps of the extra-analytical phases of the testing process where laboratories used to contribute seldom, only sporadically. Recently, the achievable levels of harmonization and responsible contributors at various steps of the testing process have also been proposed. Based on this proposal some tasks of the extra-analytical phase should become primarily the responsibility of laboratories with the involvement of clinicians, like additive testing, individualized interpretative commenting and reporting results with clinical urgency in postanalytical (PA) phase. These tasks can be good targets to start with or to increase patient outcome-oriented extra-analytical activities of laboratories. The status of the present practice of the PA activities for which laboratories proposed to be primarily responsible in the testing process - laboratory-driven PA tasks - will be reviewed below. In addition, approaches of quality assessment (QA) with quality specifications of these laboratory-driven PA tasks and the available best practice recommendations in the light of the achievable level of harmonization will be discussed. Laboratory professionals are encouraged to improve their methodological, theoretical and communicational skills and take the lead and participate in the discussed PA activities that can assist in translating laboratory test results into clinical meaning and thereby lead to better clinical utilization of laboratory test results.

Default settings of computerized physician order entry system order sets drive ordering habits

BACKGROUND

Computerized physician order entry (CPOE) systems are quickly becoming ubiquitous, and groups of orders ("order sets") to allow for easy order input are a common feature. This provides a streamlined mechanism to view, modify, and place groups of related orders. This often serves as an electronic equivalent of a specialty requisition. A characteristic, of these order sets is that specific orders can be predetermined to be "preselected" or "defaulted-on" whenever the order set is used while others are "optional" or "defaulted-off" (though there is typically the option is to "deselect" defaulted-on tests in a given situation). While it seems intuitive that the defaults in an order set are often accepted, additional study is required to understand the impact of these "default" settings in an order set on ordering habits. This study set out to quantify the effect of changing the default settings of an order set.

METHODS

For quality improvement purposes, order sets dealing with transfusions were recently reviewed and modified to improve monitoring of outcome. Initially, the order for posttransfusion hematocrits and platelet count had the default setting changed from "optional" to "preselected." The default settings for platelet count was later changed back to "optional," allowing for a natural experiment to study the effect of the default selections of an order set on clinician ordering habits.

RESULTS

Posttransfusion hematocrit values were ordered for 8.3% of red cell transfusions when the default order set selection was "off" and for 57.4% of transfusions when the default selection was "preselected" (P < 0.0001). Posttransfusion platelet counts were ordered for 7.0% of platelet transfusions when the initial default order set selection was "optional," increased to 59.4% when the default was changed to "preselected" (P < 0.0001), and then decreased to 7.5% when the default selection was returned to "optional." The posttransfusion platelet count rates during the two "optional" periods: 7.0% versus 7.5% - were not statistically different (P = 0.620).

DISCUSSION

Default settings in CPOE order sets can significantly influence physician selection of laboratory tests. Careful consideration by all stakeholders, including clinicians and pathologists, should be obtained when establishing default settings in order sets.

Towards Better Test Utilization - Strategies to Improve Physician Ordering and Their Impact on Patient Outcomes

Laboratory medicine is the single highest volume medical activity in healthcare and demand for laboratory testing is increasing disproportionately to medical activity. It has been estimated that $6.8 billion of medical care in the US involves unnecessary testing and procedures that do not improve patient care and may even harm the patient. Physicians face many challenges in accurately, efficiently and safely ordering and interpreting diagnostic tests. In order to improve patient outcomes, laboratory tests must be appropriately ordered, properly conducted, reported in a timely manner, correctly interpreted and affect a decision for future diagnosis and treatment of the patient.

The 2013 symposium on pathology data integration and clinical decision support and the current state of field

Background:

Pathologists and informaticians are becoming increasingly interested in electronic clinical decision support for pathology, laboratory medicine and clinical diagnosis. Improved decision support may optimize laboratory test selection, improve test result interpretation and permit the extraction of enhanced diagnostic information from existing laboratory data. Nonetheless, the field of pathology decision support is still developing. To facilitate the exchange of ideas and preliminary studies, we convened a symposium entitled: Pathology data integration and clinical decision support.

Methods:

The symposium was held at the Massachusetts General Hospital, on May 10, 2013. Participants were selected to represent diverse backgrounds and interests and were from nine different institutions in eight different states.

Results:

The day included 16 plenary talks and three panel discussions, together covering four broad areas. Summaries of each presentation are included in this manuscript.

Conclusions:

A number of recurrent themes emerged from the symposium. Among the most pervasive was the dichotomy between diagnostic data and diagnostic information, including the opportunities that laboratories may have to use electronic systems and algorithms to convert the data they generate into more useful information. Differences between human talents and computer abilities were described; well-designed symbioses between humans and computers may ultimately optimize diagnosis. Another key theme related to the unique needs and challenges in providing decision support for genomics and other emerging diagnostic modalities. Finally, many talks relayed how the barriers to bringing decision support toward reality are primarily personnel, political, infrastructural and administrative challenges rather than technological limitations.

Computerized provider order entry in the clinical laboratory

Clinicians have traditionally ordered laboratory tests using paper-based orders and requisitions. However, paper orders are becoming increasingly incompatible with the complexities, challenges, and resource constraints of our modern healthcare systems and are being replaced by electronic order entry systems. Electronic systems that allow direct provider input of diagnostic testing or medication orders into a computer system are known as Computerized Provider Order Entry (CPOE) systems. Adoption of laboratory CPOE systems may offer institutions many benefits, including reduced test turnaround time, improved test utilization, and better adherence to practice guidelines. In this review, we outline the functionality of various CPOE implementations, review the reported benefits, and discuss strategies for using CPOE to improve the test ordering process. Further, we discuss barriers to the implementation of CPOE systems that have prevented their more widespread adoption.

Informatics methods for laboratory evaluation of HPV ordering patterns with an example from a nationwide sample in the United States, 2003-2009

Background:

Laboratory data is a rich source of information that can be used to estimate adherence to physician guidelines and motivate improvement in clinical practice. Human papillomavirus (HPV) testing is an important component of cervical cancer screening programs with established screening guidelines. The purpose of this study was to develop methods to estimate concordance with published guidelines for HPV testing in order to provide clinicians and payors specific feedback about overscreening.

Methods:

This retrospective analysis of laboratory test ordering patterns evaluated 454,532 HPV tests ordered from September 2003 to October 2009 from 110 facilities and performed at ARUP laboratories. We used laboratory data including patient demographics, ordering frequency, timestamps and results to examine the proportion of HPV tests ordered on women under 21 years, ordered on women between 21 and 29 years apparently before cytological examination, repeated less than 1 year after a positive HPV result in women over 30 years, and repeated less than 3 years after a negative HPV result in women over 30 years.

Results:

The absolute number and proportion of HPV tests performed on women under 21 years declined from 20% in 2005 to 5% in October 2009. The proportion of HPV tests performed women between 21 and 29 years also declined during this period. Approximately one-third of HPV tests performed on women between 21 and 29 years arrived for HPV testing before cervical screening had presumably been completed. The most common follow-up intervals for HPV testing on women over 30 years were 6 months following a positive HPV result and 12 months following a negative HPV result. Only 6% of repeat HPV testing in women over 30 years followed a negative HPV result by 3 years or more. Approximately one-fourth of HPV tests ordered the year ending October 2009 were unnecessary based on the American Society for Colposcopy and Cervical Pathology guideline.

Conclusions:

We demonstrate simple methods to evaluate appropriate utilization of HPV testing using laboratory data. Our data illustrates that some aspects of HPV test ordering have become more consistent with guidelines over time. However, a large portion of HPV testing in the United States is unnecessary. This highlights opportunities for optimization of a rational cancer prevention strategy to reduce unnecessary screening, colposcopy and biopsies.

Perspective on the clinical laboratory: new uses for informatics

Enhanced capabilities of modern information systems will have a major impact on the way that clinical laboratories generate diagnostic information and transmit that information to their physician clients. This article provides a perspective on how some of the most imminent changes in informatics are likely to alter laboratory practices and to create new roles for the clinical laboratory through the ability to manage vast quantities of information. The areas covered include utilization of laboratory services, process control in the laboratory, interpretation of test results, and laboratory economics.