Audit of laboratory sensitivity of human papillomavirus and cytology testing in a cervical screening program

The globally recommended public health policy for cervical screening is primary human papillomavirus (HPV) screening with cytology triaging of positives. To ensure optimal quality of laboratory services we have conducted regular audits of cervical smears taken before cervical cancer or cancer in situ (CIN3+) within an HPV-based screening program. The central cervical screening laboratory of Stockholm, Sweden, identified cases of CIN3+ who had had a previous cervical screening test up to 3 years before and randomly selected 300 cervical liquid-based cytology (LBC) samples for auditing. HPV testing with Roche Cobas was performed either at screening or with biobanked samples. HPV negative samples and subsequent biopsies were retrieved and tested with modified general primer HPV PCR and, if still HPV-negative, the LBCs and biopsies were whole genome sequenced. The Cobas 4800 detected HPV in 1020/1052 (97.0%) LBC samples taken before CIN3+. Further analyses found HPV in 28 samples, with nine of those containing HPV types not targeted by the Cobas 4800 test. There were 4 specimens (4/1052, 0.4%) where no HPV was detected. By comparison, the proportion of CIN3+ cases that were positive in a previous cytology were 91.6%. We find that the routine HPV screening test had a sensitivity in the real-life screening program of 97.0%. Regular laboratory audits of cervical samples taken before CIN3+ can be readily performed within a real-life screening program and provide assurance that the laboratory of the real-life program has the expected performance.

Impact of the COVID-19 pandemic on clinical research activities: Survey of study participants and health care workers participating in a hypertension trial in Vietnam

BACKGROUND

The COVID-19 pandemic has had a profound worldwide impact. Vietnam, a lower middle-income country with limited resources, has successfully slowed this pandemic. The objectives of this report are to explore the impact of the COVID-19 pandemic on the research activities of an ongoing hypertension trial using a storytelling intervention in Vietnam.

METHODS

Data were collected in a mixed-methods study among 86 patients and 10 health care workers participating in a clinical trial designed to improve hypertension control. Several questions related to the impact of COVID-19 on patient's daily activities and adherence to the study interventions were included in the follow-up visits. A focus group discussion was conducted among health care workers to discuss the impact of COVID-19 on research related activities.

RESULTS

Fewer patients in the intervention group reported that they faced difficulties in adhering to prescribed study interventions, wanted to receive a call from a dedicated hotline, or have a visit from a community health worker as compared with those in the comparison group. Most study patients are willing to participate in future health research studies. When asked about the potential use of mobile phones in health research studies, fewer patients in the intervention group felt comfortable using a mobile phone for the delivery of intervention and interviews compared with those in the comparison condition. Community health workers shared that they visited patient's homes more often than previously due to the pandemic and health care workers had to perform more virus containment activities without a corresponding increase in ancillary staff.

CONCLUSIONS

Both patients and health care workers in Vietnam faced difficulties in adhering to recommended trial interventions and procedures. Multiple approaches for intervention delivery and data collection are needed to overcome these difficulties during future health crises and enhance the implementation of future research studies.

TRIAL REGISTRATION

ClinicalTrials.gov. Registration number: https://clinicaltrials.gov/ct2/show/NCT03590691 (registration date July 17, 2018).

Clinical Predictors of SARS-CoV-2 Testing Pressure on Clinical Laboratories: A Multinational Study Analyzing Google Trends and Over 100 Million Diagnostic Tests

OBJECTIVE

Evidence has shown that Google searches for clinical symptom keywords correlates with the number of new weekly patients with COVID-19. This multinational study assessed whether demand for SARS-CoV-2 tests could also be predicted by Google searches for key COVID-19 symptoms.

METHODS

The weekly number of SARS-CoV-2 tests performed in Italy and the United States was retrieved from official sources. A concomitant electronic search was performed in Google Trends, using terms for key COVID-19 symptoms.

RESULTS

The model that provided the highest coefficient of determination for the United States (R2 = 82.8%) included a combination of searching for cough (with a time lag of 2 weeks), fever (with a time lag of 2 weeks), and headache (with a time lag of 3 weeks; the time lag refers to the amount of time between when a search was conducted and when a test was administered). In Italy, headache provided the model with the highest adjusted R2 (86.8%), with time lags of both 1 and 2 weeks.

CONCLUSION

Weekly monitoring of Google Trends scores for nonspecific COVID-19 symptoms is a reliable approach for anticipating SARS-CoV-2 testing demands ~2 weeks in the future.

Clinical and molecular practice of European thoracic pathology laboratories during the COVID-19 pandemic. The past and the near future

Background

This study evaluated the consequences in Europe of the COVID-19 outbreak on pathology laboratories orientated toward the diagnosis of thoracic diseases.

Materials and methods

A survey was sent to 71 pathology laboratories from 21 European countries. The questionnaire requested information concerning the organization of biosafety, the clinical and molecular pathology, the biobanking, the workload, the associated research into COVID-19, and the organization of education and training during the COVID-19 crisis, from 15 March to 31 May 2020, compared with the same period in 2019.

Results

Questionnaires were returned from 53/71 (75%) laboratories from 18 European countries. The biosafety procedures were heterogeneous. The workload in clinical and molecular pathology decreased dramatically by 31% (range, 3%-55%) and 26% (range, 7%-62%), respectively. According to the professional category, between 28% and 41% of the staff members were not present in the laboratories but did teleworking. A total of 70% of the laboratories developed virtual meetings for the training of residents and junior pathologists. During the period of study, none of the staff members with confirmed COVID-19 became infected as a result of handling samples.

Conclusions

The COVID-19 pandemic has had a strong impact on most of the European pathology laboratories included in this study. Urgent implementation of several changes to the organization of most of these laboratories, notably to better harmonize biosafety procedures, was noted at the onset of the pandemic and maintained in the event of a new wave of infection occurring in Europe.

•

Biosafety measures used in the first wave of the COVID-19 crisis were heterogeneous in 53 European pathology laboratories.

•

A dramatic decrease of the workload in pathology laboratories was noted.

•

No case of healthcare workers contaminated with SARS-CoV-2 associated with samples handling was identified.

Laboratory Quality Management System and Quality Indicators Implementation Status as Perceived by Laboratory Professionals in Preparation for the Accreditation Process from Selected Government Hospitals of Ethiopia

BACKGROUND

The aim was to produce quality results that clinical laboratories need to implement and maintain continuous quality improvement systems. In recent years, health organizations have increasingly prioritized the quality of laboratory services by implementing quality management systems (QMSs) and building quality improvement activities. Efforts to strengthen laboratory systems in the African region have received increased attention in recent years. Assessing the implementation levels of laboratory quality management system components is important to identify the gaps that need further improvements.

METHODS

A cross-sectional study design was used between March and May 2017 in selected government hospitals of Ethiopia, and sample size was determined using a finite population formula, and a proportional sampling technique was employed; a sample size of 184 (62%) was calculated from 295 laboratory professionals.

RESULTS

All respondents were informed about the laboratory's experience in the quality management system implementation; of those, only 138 (79%) engaged in the implementation process. From the 18 selected laboratory quality management components, 5 were observed to have the list implementation status, which are: (1) Performance of internal quality control for all tests, (2) Development and communication of a quality manual for all tests, (3) Adequacy of storage space for the supplies, (4) Development of an action plan based on internal audit, and (5) monitoring of environmental conditions. Running quality controls for all types of tests became a headache in almost all laboratories. From 12 selected quality indicators studied in this research, the 5 indicators with either poor or very poor performance outcome were: control of documents 136 (77.7%), control of records 123 (70.3%), development of manuals and policies 122 (69.7%), development of process and procedures 120 (68.6%), and internal communication 114 (65.1%).

CONCLUSIONS

This research indicated the top 3 LQMS components with either poor or very poor implementation status: (1) Performance of internal quality controls for all tests, (2) Development and communication of quality manuals for all tests, (3) Adequacy of storage space for the supplies. Of the quality indicators studied, control of documents was perceived to have poor performance outcome by 136 (77.7%) of study participants.

Confidential genetic testing and electronic health records: A survey of current practices among Huntington disease testing centers

Background

Clinical care teams providing presymptomatic genetic testing often employ advanced confidentiality practices for documentation and result storage. However, patient requests for increased confidentiality may be in conflict with the legal obligations of medical providers to document patient care activities in the electronic health record (EHR). Huntington disease presents a representative case study for investigating the ways centers currently balance the requirements of EHRs with the privacy demands of patients seeking presymptomatic genetic testing.

Methods

We surveyed 23 HD centers (53% response rate) regarding their use of the EHR for presymptomatic HD testing.

Results

Our survey revealed that clinical care teams and laboratories have each developed their own practices, which are cumbersome and often include EHR avoidance. We found that a majority of HD care teams record appointments in the EHR (91%), often using vague notes. Approximately half of the care teams (52%) keep presymptomatic results of out of the EHR.

Conclusion

As genetic knowledge grows, linking more genes to late‐onset conditions, institutions will benefit from having professional recommendations to guide development of policies for EHR documentation of presymptomatic genetic results. Policies must be sensitive to the ethical differences and patient demands for presymptomatic genetic testing compared to those undergoing confirmatory genetic testing.

What can millions of laboratory test results tell us about the temporal aspect of data quality? Study of data spanning 17 years in a clinical data warehouse

OBJECTIVE

To identify common temporal evolution profiles in biological data and propose a semi-automated method to these patterns in a clinical data warehouse (CDW).

MATERIALS AND METHODS

We leveraged the CDW of the European Hospital Georges Pompidou and tracked the evolution of 192 biological parameters over a period of 17 years (for 445,000 + patients, and 131 million laboratory test results).

RESULTS

We identified three common profiles of evolution: discretization, breakpoints, and trends. We developed computational and statistical methods to identify these profiles in the CDW. Overall, of the 192 observed biological parameters (87,814,136 values), 135 presented at least one evolution. We identified breakpoints in 30 distinct parameters, discretizations in 32, and trends in 79.

DISCUSSION AND CONCLUSION

our method allowed the identification of several temporal events in the data. Considering the distribution over time of these events, we identified probable causes for the observed profiles: instruments or software upgrades and changes in computation formulas. We evaluated the potential impact for data reuse. Finally, we formulated recommendations to enable safe use and sharing of biological data collection to limit the impact of data evolution in retrospective and federated studies (e.g. the annotation of laboratory parameters presenting breakpoints or trends).

Regarding the rights and duties of Clinical Laboratory Geneticists in genetic healthcare systems; results of a survey in over 50 countries

Specialists of human genetic diagnostics can be divided into four groups: Medical Geneticists (MDG), Genetic Nurses and/or Counsellors (GN/GC), Clinical Laboratory Geneticists (CLG) and Laboratory Genetics Technicians (LGT). While the first two groups are in direct patient contact, the work of the latter two, of equal importance for patient care, are often hidden as they work behind the scenes. Herein the first study on the rights and duties of CLGs is presented. We present the results of a survey performed in 35 European and 18 non-European countries with 100 participating specialists. A national CLG title is available in 60% of European countries, and in 77% of the surveyed European countries a CLG can be the main responsible head of the laboratory performing human genetic tests. However, in only 20% of European countries is a lab-report valid with only a CLGs' signature - even though the report is almost always formulated by the CLG, and an interpretation of the obtained results in a clinical context by the CLG is expected in nearly 90% of European countries. Interestingly, CLGs see patients in 30% of European countries, and are also regularly involved in student education. Overall, the CLG profession includes numerous duties, which are quite similar in all regions of the world. Strikingly, the CLG's rights and responsibilities of leading a lab, or signing a report are regulated differently according to country specific regulations. Overall, the CLG is a well-recognized profession worldwide and often working within a multidisciplinary team of human genetic diagnostics professionals.

Magnitude of delayed turnaround time of laboratory results in Amhara Public Health Institute, Bahir Dar, Ethiopia

BACKGROUND

Clinical decisions depend on timely laboratory result reporting. The timeliness is commonly expressed in turnaround time and serves as a quality improvement tool to assess the effectiveness and efficiency of the laboratory. According to the International Organization for Standardization (ISO) guidelines, each laboratory shall establish turnaround times for each of its examinations that reflect clinical needs, and shall periodically evaluate whether or not it is meeting the established turnaround times. Therefore, this study aimed to assess the TAT of laboratory results done in the reference laboratories of the Amhara Public Health Institute, Bahir Dar, Ethiopia.

METHODS

A retrospective cross sectional study was carried out from 01 January to 31 September 2018. Each patient sample was considered as a study unit. Nine months data were extracted from the sample tracking log and from the Laboratory Information System (LIS) database. Descriptive and summary statistics were calculated using SPSS version 20.0 statistical software.

RESULTS

A total of 34,233 patients samples were tested during the study period. Monthly average TAT ranged from 38.6 to 51.3 days for tuberculosis (TB) culture, 5.3 to 42.4 days for exposed infant diagnosis (EID) for HIV, 8.4 to 26 days for HIV 1 viral load, and 1.9 to 3.5 days for TB genexpert tests. Compared with the standard, 76.5% of the viral load, 68.1% of the EID for HIV and 53.8% of the TB genexpert tests had delayed TAT. Repeated reagent stock out, high workload, activities overlapping, and staff turnover were major reasons for the result delays.

CONCLUSIONS

There was a delayed turnaround time of laboratory results in APHI. HIV viral load, EID and TB genexpert results were the most affected tests. Workload reduction plan, proper stock management, specific work assignment and trained staff retention are important approaches to minimize the delayed TAT in the setting.

Microbiology Investigation Criteria for Reporting Objectively (MICRO): a framework for the reporting and interpretation of clinical microbiology data

BACKGROUND

There is a pressing need to understand better the extent and distribution of antimicrobial resistance on a global scale, to inform development of effective interventions. Collation of datasets for meta-analysis, mathematical modelling and temporo-spatial analysis is hampered by the considerable variability in clinical sampling, variable quality in laboratory practice and inconsistencies in antimicrobial susceptibility testing and reporting.

METHODS

The Microbiology Investigation Criteria for Reporting Objectively (MICRO) checklist was developed by an international working group of clinical and laboratory microbiologists, infectious disease physicians, epidemiologists and mathematical modellers.

RESULTS

In keeping with the STROBE checklist, but applicable to all study designs, MICRO defines items to be included in reports of studies involving human clinical microbiology data. It provides a concise and comprehensive reference for clinicians, researchers, reviewers and journals working on, critically appraising, and publishing clinical microbiology datasets.

CONCLUSIONS

Implementation of the MICRO checklist will enhance the quality and scientific reporting of clinical microbiology data, increasing data utility and comparability to improve surveillance, grade data quality, facilitate meta-analyses and inform policy and interventions from local to global levels.

Optimizing Utilization of Laboratory Investigations in Neonatal Intensive Care Unit

OBJECTIVE

To optimize utilization of laboratory tests by measuring baseline rates and appropriateness of investigations, assessing the barriers to rational use, and developing and implementing an educational package for resident doctors.

DESIGN

Quality improvement study.

SETTING

Neonatal intensive care unit (NICU) from August, 2015 to December, 2016.

PARTICIPANTS

All neonates admitted in NICU and resident doctors working in NICU.

INTERVENTION

Addressing barriers, educational package, posters and group discussions.

MAIN OUTCOME MEASURES

Laboratory test rates for hematology, biochemistry and blood gas. Proportion of tests judged to be inappropriate.

RESULTS

At the baseline, median (IQR) laboratory test rate patient/day was 0.6 (0.2-1.5) and one-fifth of tests were classified as inappropriate. Mechanical ventilation and sepsis were independent predictors of laboratory test rates but could explain only 35% of the disparities, indicating variations in clinical practice. Following a short period of intervention, hematology investigations showed a trend towards reduction, though overall test rates did not change significantly.

CONCLUSION

Addressing barriers, creating awareness and educational interventions were able to bring down hematology laboratory test rates in a short period. A longer period of sustained intervention is required to demonstrate significant effects on test ordering behavior.

Request Pattern, Pre-Analytical and Analytical Conditions of Urinalysis in Primary Care: Lessons from a One-Year Large-Scale Multicenter Study

BACKGROUND

To study the urinalysis request, pre-analytical sample conditions, and analytical procedures.

METHODS

Laboratories were asked to provide the number of primary care urinalyses requested, and to fill out a questionnaire regarding pre-analytical conditions and analytical procedures.

RESULTS

110 laboratories participated in the study. 232.5 urinalyses/1,000 inhabitants were reported. 75.4% used the first morning urine. The sample reached the laboratory in less than 2 hours in 18.8%, between 2 - 4 hours in 78.3%, and between 4 - 6 hours in the remaining 2.9%. 92.5% combined the use of test strip and particle analysis, and only 7.5% used the strip exclusively. All participants except one performed automated particle analysis depending on strip results; in 16.2% the procedure was only manual.

CONCLUSIONS

Urinalysis was highly requested. There was a lack of compliance with guidelines regarding time between micturition and analysis that usually involved the combination of strip followed by particle analysis.

Respiratory viral testing in laboratories serving acute care hospitals in Rhode Island

BACKGROUND

The rapid detection of respiratory viral infections is associated with several positive health outcomes. However, little is known about the availability of rapid respiratory viral testing in acute care hospital laboratories.

METHODS

A survey was sent to 13 hospital laboratories assessing results' turnaround time, the number of ordered tests and positive results.

RESULTS

Rapid viral panel (RVP), respiratory syncytial virus (RSV), and rapid influenza testing was available in 9 of 13, 13 of 13, and 13 of 13 hospitals, respectively. Results were available within 24 hours of specimen collection in 1 of 9 hospitals for RVP; RSV and rapid influenza results were available within 12 hours in 8 of 13 and 13 of 13 hospitals, respectively.

CONCLUSIONS

Rapid diagnosis of respiratory viral infections in RI acute care hospitals can be made for influenza and RSV. However, rapid results for other respiratory viruses are unavailable in most of RI hospitals. [Full article available at http://rimed.org/rimedicaljournal-2017-09.asp].

Reduction in Unnecessary Clinical Laboratory Testing Through Utilization Management at a US Government Veterans Affairs Hospital

OBJECTIVES

To implement an electronic laboratory utilization management system (laboratory expert system [LES]) to provide safe and effective reductions in unnecessary clinical laboratory testing.

METHODS

The LES is a set of frequency filter subroutines within the Veterans Affairs hospital and laboratory information system that was formulated by an interdisciplinary medical team.

RESULTS

Since implementing the LES, total test volume has decreased by a mean of 11.18% per year compared with our pre-LES test volume. This change was not attributable to fluctuations in outpatient visits or inpatient days of care. Laboratory cost savings were estimated at $151,184 and $163,751 for 2012 and 2013, respectively. A significant portion of these cost savings was attributable to reductions in high-volume, large panel testing. No adverse effects on patient care were reported, and mean length of stay for patients remained unchanged.

CONCLUSIONS

Electronic laboratory utilization systems can effectively reduce unnecessary laboratory testing without compromising patient care.

Laboratory Test Utilization Management: General Principles and Applications in Hematopathology

As the cost of health care continues to rise and reimbursement rates decrease, there is a growing demand and need to cut overall costs, enhance quality of services, and maintain as a top priority the needs and safety of the patient. In this article, we provide an introduction to test utilization and outline a general approach to creating an efficient, cost-effective test utilization strategy. We also present and discuss 2 test utilization algorithms that are evidence-based and may be of clinical utility as we move toward the future of doing the necessary tests at the right time.

[Excessive spending by misuse of clinical laboratory]

Seventy five percent or more of a diagnosis comes from a proper medical history along with an excellent physical examination. This leaves to the clinical laboratory the function of supporting the findings, determining prognosis, classifying the diseases, monitoring the diseases and, in the minimum of cases, establishing the diagnosis. In recent years there has been a global phenomenon in which the allocation of resources to health care has grown in an excessive way; the Instituto Mexicano del Seguro Social is not an exception with an increase of 29 % from 2009 to 2011; therefore, it is necessary to set containment and reduction without compromising the quality of patient care.

Reducing Overutilization of Testing for Clostridium difficile Infection in a Pediatric Hospital System: A Quality Improvement Initiative

OBJECTIVES

Study objectives included addressing overuse of Clostridium difficile laboratory testing by decreasing submission rates of nondiarrheal stool specimens and specimens from children ≤12 months of age and determining resultant patient and laboratory cost savings associated with decreased testing.

METHODS

A multifaceted initiative was developed, and components included multiple provider education methods, computerized order entry modifications, and automatic declination from laboratory on testing stool specimens of nondiarrheal consistency and from children ≤12 months old. A run chart, demonstrating numbers of nondiarrheal plus infant stool specimens submitted over time, was developed to analyze the initiative's impact on clinicians' test-ordering practices. A p-chart was generated to evaluate the percentage of these submitted specimens tested biweekly over a 12-month period. Cost savings for patients and the laboratory were assessed at the study period's conclusion.

RESULTS

Run chart analysis revealed an initial shift after the interventions, suggesting a temporary decrease in testing submission; however, no sustained differences in numbers of specimens submitted biweekly were observed over time. On the p-chart, the mean percentage of specimens tested before the intervention was 100%. After the intervention, the average percentage of specimens tested dropped to 53.8%. Resultant laboratory cost savings totaled nearly $3600, and patient savings on testing charges were ∼$32 000.

CONCLUSIONS

Automatic laboratory declination of nondiarrheal stools submitted for CDI testing resulted in a sustained decrease in the number of specimens tested, resulting in significant laboratory and patient cost savings. Despite multiple educational efforts, no sustained changes in physician ordering practices were observed.

Request of acute phase markers in primary care in Spain

OBJECTIVES

To study the inter-practice variability in Spain--by institution, management, and regional characteristics--of the frequency and appropriateness of test requests made by primary care practitioners for acute phase markers.

STUDY DESIGN

Observational cross-sectional study.

METHODS

One hundred forty-one clinical laboratories were invited to participate by providing the number of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count (CBC) tests requested by general practitioners. We calculated the ratio of test requests per 1000 inhabitants, ratios of related test requests, and variability index (90th percentile/10th percentile). We compared the results among the different areas according to their setting, location, and management.

RESULTS

We recruited 64 laboratories (14,846,065 inhabitants). There were almost twice as many ESR requests as CRP requests; the variability index for ESR was almost double that of CRP. Furthermore, the latter was underrequested in rural-urban areas compared with rural. The ESR/CBC and ESR/CRP ratios are lower in institutions with private management, and the number of ESR requested in institutions with private management are lower than that of public. The differences among Spanish regions were reported for ESR per 1000 inhabitants, ESR/CBC, and ESR/CRP.

CONCLUSIONS

There was significant variability in the requests made by primary care practitioners for patients' acute phase markers. Rates were influenced by geographic location, hospital setting, and institution management. ESR was inappropriately overrequested; strong efforts should be made to adjust the requests of ESR and to standardize the use of CRP measurement.

[How to Interpret Data of Routine Laboratory Tests (Basic Laboratory Tests)--Various Methods to Interpret Routine Laboratory Data in 3 Clinical Laboratory Facilities--A Method at Shinshu University Hospital]

Routine laboratory tests are the most frequently performed among clinical laboratory tests, and they can provide important information for the diagnosis and treatment of patients. They are more useful when several data are combined to interpret the pathophysiological state of a patient. Changes of routine laboratory data are important even when they are within their reference ranges, and they sometimes show a more detailed condition of the patient. In this symposium, we demonstrated our method at Shinshu University Hospital, involving the evaluation of 13 conditions of the whole body or each organ by simultaneously interpreting some to several laboratory data.

AUDIT OF ADVANCED LABORATORY INVESTIGATIONS

BACKGROUND

Advanced laboratory investigations at reference laboratories play a key role in the diagnosis of the disease, but misuse of this precious and expensive tool may misguide the physician in patient management. This study was carried out as an audit of investigations performed at a reference laboratory, in order to assess their cost effectiveness, to identify various errors, the degree of correlation of requested tests with the clinical diagnosis and benefit to the patients.

METHOD

A four phase audit of 337 laboratory investigation prescription was performed from April 2012 to March 2013 in the Medical, Administration in collaboration with Department of Medical Laboratory and various Clinics at the King Salman Armed Forces Hospital in Northwestern Region, - Kingdom of Saudi Arabia. All the information was recorded on a questionnaire pro forma.

RESULTS

On data compilation and analysis it was found that 174(51.63%) test results were within normal reference range, while 163 (48.37%) test results were reported as positive. Also 218 (64.69%) investigations results correlated with clinical assessment by the physician, while 119 (35.31%) investigation results did not correlate with the clinical assessment by the physician. The expenses incurred Euro 12868 were spent on non-correlated tests while on correlated tests were Euro 31831. In terms of benefit to the patients 243 (82.09%) patients were reported by clinicians to have benefited from the reference laboratory tests, while 53 (17.91%) cases did not benefit from the reference laboratory tests as assessed by the clinicians and 41 (12.16%) cases in which even clinician did not respond regarding the benefit to the patients. Three categories of errors were identified (26.40%), i.e., at the level of clinicians (12.75%), at the level of hospital lab (5.04%) and at the level of reference lab (8.60%).

CONCLUSION

Thorough clinical assessment and judicious utilization of available preliminary laboratory tests are the keys to precise diagnosis and are instrumental in reducing reliance on reference laboratory investigations.

Effect of family medicine residents on use of diagnostic investigations: in a rural community emergency department

OBJECTIVE

To determine the effect of the presence of family medicine residents on the use of laboratory and imaging investigations in a rural emergency department (ED).

DESIGN

A retrospective cross-sectional electronic chart audit was completed. Background characteristics, as well as type and number of ordered investigations, were compared between study groups.

SETTING

Strathroy Middlesex General Hospital in Strathroy, Ont, a rural community hospital that sees approximately 20 000 ED visits per year.

PARTICIPANTS

A total of 2000 sequential ED visits, including adult and pediatric patients. The test group consisted of patients seen while a resident was present in the ED. The control group consisted of patients seen while no residents were present in the ED.

MAIN OUTCOME MEASURES

Twenty-two distinct categories of common ED investigations were studied.

RESULTS

There was no statistically significant difference between study groups for 19 of the 22 categories of investigations. There were significant differences in 3 categories: an increased number of D-dimer assays for patients seen while there were no residents in the ED (1.7% of patients vs 0.5% of patients, P = .03) and increased computed tomography and ultrasound imaging for patients seen while a resident was in the ED (4.8% vs 1.8%, P = .0012, and 5.3% and 1.7%, P < .001, respectively). These differences are likely not owing to resident involvement but are explained by a difference in test availability between groups.

CONCLUSION

The study was underpowered for most categories of studied investigations. However, the trends demonstrated in this study suggest that the presence of family medicine residents in a rural community ED does not substantially affect the overall use of diagnostic investigations.

Monitoring health IT integration--the effect of an EMR on laboratory service timeliness across six Australian hospitals

The Electronic Medical Record (EMR) incorporates computerised provider order entry systems which allow clinicians to order diagnostic tests electronically, thus eliminating the need for cumbersome handwritten orders. In many situations the EMR relies on a manual transition of information across systems (e.g., integration with the Laboratory Information System). This study, based in a laboratory setting requiring such a transition across systems, aimed to compare the data entry time (from when a specimen arrives in the Central Specimen Reception [CSR] area of the laboratory, to when it is forwarded on for processing), along with a laboratory turnaround time (TAT) (from the time a specimen is received to the time a verified result is issued) for paper and EMR orders, for two high volume tests, across six hospitals. Results showed that the median data entry time for all hospitals combined, was three minutes shorter for EMR entered orders than paper orders. This difference was consistent and significant for Electrolytes, Urea, Creatinine (EUC) and Automated Differential (including full blood count) tests in 2010 and 2011. These decreases contributed to significantly lower median Laboratory TATs for EMR orders (for EUC tests the difference in medians was 12 minutes in 2010 and six minutes in 2011; for Automated Differential tests, the difference was four minutes in 2010 and two minutes in 2011).

Reference-based pricing: an evidence-based solution for lab services shopping

OBJECTIVES

To determine the effect of reference-based pricing (RBP) on the percentage of lab services utilized by members that were at or below the reference price.

STUDY DESIGN

Retrospective, quasi-experimental, matched, case-control pilot evaluation of an RBP benefit for lab services.

METHODS

The study group included employees of a multinational grocery chain covered by a national health insurance carrier and subject to RBP for lab services; it had access to an online lab shopping tool and was informed about the RBP benefit through employer communications. The reference group was covered by the same insurance carrier but not subject to RBP. The primary end point was lab compliance, defined as the percentage of lab claims with total charges at or below the reference price. Difference-in-difference regression estimation evaluated changes in lab compliance between the 2 groups.

RESULTS

Higher compliance per lab claim was evident for the study group compared with the reference group (69% vs 57%; P<.05). The online shopping tool was used by 7% of the matched-adjusted study group prior to obtaining lab services. Lab compliance was 76% for study group members using the online tool compared with 68% among nonusers who were subject to RBP (P<.01).

CONCLUSIONS

RBP can promote cost-conscious selection of lab services. Access to facilities that offer services below the reference price and education about RBP improve compliance. Evaluation of the effect of RBP on higher-cost medical services, including radiology, outpatient specialty, and elective inpatient procedures, is needed.

Rational use of blood calcium determinations

CONTEXT AND OBJECTIVE

This study was motivated by the recent excessive increase in requests for blood calcium determinations and laboratory tests in general, in the Hospital das Clínicas complex of Faculdade de Medicina, Universidade de São Paulo (HCFMUSP). Its aim was to suggest rules for the determination of total and ionized calcium in our intensive care units, emergency department, wards and outpatient services, thus contributing towards improving the quality of medical care and achieving more appropriate use of human and financial resources.

DESIGN AND SETTING

Critical analysis on clinical and laboratory data and the pertinent scientific literature, conducted by the study group for rational clinical laboratory use, which is part of the Central Laboratory Division, HCFMUSP.

METHODS

The study group reviewed scientific publications, statistics and clinical and laboratory data concerning requests for total and ionized calcium determinations in the settings of intensive care units, emergency department, wards and outpatient services.

RESULTS

From this critical analysis, clinical decision flow diagrams aimed at providing guidance for ordering these tests were constructed.

CONCLUSIONS

Use of the proposed flow diagrams may help to limit the numbers of inappropriate requests for ionized and total calcium determinations, with consequent reductions in the number of tests, risks to patients and unnecessary costs.

[Concordance in blood lead quantification between laboratories]

OBJECTIVE

To establish a blood lead quantification correlation from two occupational health laboratories (OHL1V and OHL2DF), and the ABC Hospital (LABC) metals laboratory.

METHODS

A cross-sectional study was performed in 84 workers from a voltage regulators company, where lead is welded; in 54 % (46 of them) a blood sample was taken and analyzed by OHL1V, and in 28.6 % (24) by OHL2DF. All samples were analyzed by atomic absorption spectrophotometry. Pearson correlation (r), coefficient of determination (r2), Lin (rho) concordance test, and Bland-Altman plots were calculated.

RESULTS

The blood lead mean: LABC was 5.8 ± 2.4 μg/dL vs. OHL2DF of 4.4 ± 3.6 μg/dL (r = 0.25 [p = 0.24], r2 = 0.06 [p = 0.24], and rho = 0.21 [p = 0.21]). And with LABC, 6.75 ± 3.3 μg/dL vs. OHL1V 5.6 ± 2.9 μg/dL (r = 0.91 [p < 0.001], r2 = 0.83 [p < 0001], and rho = 0.85 [p< 0.001]).

CONCLUSIONS

Agreement between LABC and OHL1V was poor (< 0.90), and with OHL2DF was null. An occupational health laboratory certification is needed in order to have reliable biological exposure index measurements in lead occupational exposure.

Laboratory test costs: attitudes and awareness among staff in a regional hospital

There continues to be an unrelenting rise in the volumes of laboratory tests ordered in medicine, which is both expensive and has the potential for over-investigation. We performed a quantitative, observational, cross-sectional study of staff with the authority to initiate a laboratory test, using a voluntary, anonymous questionnaire. Our aim was to assess the awareness of and attitudes towards laboratory test costs. 226 surveys were completed over 2 weeks in June, 2012. Most numerous respondents were Staff nurses 125 (55.3%) followed by senior house officers (SHOs) 26 (11.5%) and clinical nurse managers/specialists (CNMs and CNSs) 23 (10.2%). The majority of staff, 191(85.6%), felt unaware of the cost of laboratory tests, which they ordered. For non urgent tests, the majority of respondents, 136 (61.8%) felt cost was either quite of very important. For urgent tests, the majority of respondents, 188 (84.6%) felt cost was of minor or of no importance. Doctors felt more aware of costs than nurses (26.9% vs. 9.3%) and doctors test cost estimates were correct more often than nurses (33% vs. 21%). The results indicate poor awareness of laboratory test cost amongst doctors and nurses. Given the expenditure incurred by a rise in the volume of tests and the potential for over-investigation for patients, strategies for improving the awareness of and attitudes towards laboratory tests need to be developed.

Utilization management in toxicology

Recent upward trends in the prevalence of abuse of prescription drugs and illicit substances have resulted in increased demands for toxicology testing to support the emergency department and drug treatment in pain management programs. This review will discuss the challenges faced by clinical laboratories to manage the utilization of toxicology tests, particularly those ordered in managing poisoned patients in the emergency department and chronic pain patients on opioid therapy. Optimal utilization of toxicology tests to support the emergency department relies on selecting the appropriate tests for the patient, and the availability of the results in a timely fashion. Two tiers of toxicology testing systems with different requirements for turnaround time will be discussed. In patients with chronic pain urine drug testing, including screening and confirmation testing are used extensively in pain management to monitor patient compliance. A thorough understanding of the performance characteristics of the test methodologies and drug metabolism is a key to making a proper analytical and clinical interpretation of the test results and will contribute to effective utilization of these tests. In addition, the reimbursement system is an important factor in the decision making process for test selection utilization as significant costs can be incurred by both payers and patients. Collaboration, trust, and effective communication among clinicians, patients, and clinical laboratory professionals are essential for effective utilization of toxicology testing.

A clinician's perspective on laboratory utilization management

BACKGROUND

Excessive laboratory utilization is a common problem in the hospital setting. Physicians control up to 80% of healthcare costs and wield great influence.

METHODS

This review article describes reasons for overutilization of labs and recommends interventional strategies to change clinician ordering behavior.

RESULTS

Powerful factors exist that encourage overutilization, including fear of missing a diagnosis, provider inexperience, peer pressure, financial rewards, practice inertia, and fear of legal punishment. Features of automated order entry, such as bundling and "daily until discontinued" options contribute to wasteful ordering behavior.

CONCLUSION

The most successful and long-lasting interventions are multi-faceted and have included a combination of education, feedback and audit, and administrative changes. The support of senior physicians and top administration is critical to the success of any initiative and ideally, interventions should be original from a multi-disciplinary committee of respected individuals.

Utilization management in the core laboratory

The need for appropriate utilization management of diagnostic testing is increasingly important. The majority of laboratory tests are performed in highly automated core laboratories that combine chemistry, immunoassays, hematology, coagulation and esoteric assays. These core laboratories are designed for high throughput leveraging economies of scale to produce large numbers of test results relatively inexpensively. Most core laboratory tests can be categorized based on whether they should or should not be ordered at all and, if so, by the frequency with which test ordering is reasonably appropriate (e.g. unrestricted, daily, weekly, monthly, yearly or once in a lifetime). Classifying tests by this approach facilitates electronic rule-based logic to detect which tests are appropriate for a given clinical indication.

Management structure: establishing a laboratory utilization program and tools for utilization management

As laboratories are challenged to do more with fewer resources, the pathologist and laboratory director will play a greater role in improving the effectiveness of the laboratory, as well as addressing the overuse, misuse and underuse of laboratory testing. We describe the necessary characteristics for pathologists and laboratory directors to successfully lead utilization efforts, as well as key leadership tools and essential steps in creating a utilization management program. When we established a laboratory test utilization program de novo, it became clear how important the laboratory director was in guiding those initiatives by working with stakeholders outside of the laboratory, particularly clinicians, nurses and administrators.

Laboratory test use and primary care physician supply

OBJECTIVE

To determine the relative effects of population size, FP and GP supply, and other specialist supply on chemistry and hematology test volumes (ie, number of tests performed).

DESIGN

Population-level analysis using secondary data from the Calgary Health Zone for 2004 to 2009.

SETTING

Calgary, Alta.

MAIN OUTCOME MEASURES

The relative effects of population size, FP and GP supply, and other specialist supply on laboratory test use.

RESULTS

Population size was the strongest predictor of test volumes in a multivariate analysis. The FP and GP supply was significantly negatively correlated with chemistry test volume (partial r(2) = 0.186, P = .045). There was a trend toward decreasing use of hematology tests with increasing FP and GP supply (partial r(2) = 0.117, P = .119).

CONCLUSION

The relationship between FP and GP supply and laboratory test use is complex, but increasing numbers of FPs do not necessarily indicate an increase in laboratory test use and might be associated with a decrease in test use when other factors are controlled for.