Economic Evaluations of Pathology Tests, 2010-2015: A Scoping Review

BACKGROUND

Concerns about pathology testing such as the value provided by new tests and the potential for inappropriate utilization have led to a greater need to assess costs and benefits. Economic evaluations are a formal method of analyzing costs and benefits, yet for pathology tests, questions remain about the scope and quality of the economic evidence.

OBJECTIVE

To describe the extent and quality of published evidence provided by economic evaluations of pathology tests from 2010 to 2015.

METHODS

Economic evaluations relating to pathology tests from 2010 to 2015 were reviewed. Eight databases were searched for published studies, and details recorded for the country, clinical focus, type of testing, and consideration of sensitivity, specificity, and false test results. The reporting quality of studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist and cost-effectiveness ratios were analyzed for publication bias.

RESULTS

We found 356 economic evaluations of pathology tests, most of which regarded developed countries. The most common economic evaluations were cost-utility analyses and the most common clinical focus was infectious diseases. More than half of the studies considered sensitivity and specificity, but few studies considered the impact of false test results. The average Consolidated Health Economic Evaluation Reporting Standards checklist score was 17 out of 24. Cost-utility ratios were commonly less than $10,000/quality-adjusted life-year or more than $200,000/quality-adjusted life-year.

CONCLUSIONS

The number of economic evaluations of pathology tests has increased in recent years, but the rate of increase has plateaued. Furthermore, the quality of studies in the past 5 years was highly variable, and there is some question of publication bias in reporting cost-effectiveness ratios.

The American Society for Clinical Pathology's 2015 Wage Survey of Medical Laboratories in the United States

OBJECTIVES

To inform the pathology and laboratory field of the most recent national wage data from the American Society for Clinical Pathology (ASCP). Historically, the results of this biennial survey have served as a basis for additional research on laboratory recruitment, retention, education, marketing, certification, and advocacy.

METHODS

The 2015 wage survey was conducted through collaboration between the ASCP's Institute of Science, Technology, & Policy in Washington, DC, and the ASCP Board of Certification in Chicago, Illinois. Electronic survey invitations were sent to individuals who are currently practicing in the field.

RESULTS

Data reveal increased salaries since 2013 for all staff-level laboratory professionals surveyed except phlebotomists and pathologists' assistants. Laboratory assistants and phlebotomists, regardless of level, continue to have lower salaries while pathologists' assistants and administration personnel have higher salaries than the rest of the laboratory professions surveyed.

CONCLUSIONS

Survey results put emphasis on strategic recruitment and retention by laboratory training programs and institutions that hire laboratory professionals.

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.

[Laboratory management fee; laboratory physician's work at university hospital]

The laboratory additional management fee is subdivided into I to IV. Each additional management fee is a large source of income for hospitals. This is important in order to show the value to hospitals of laboratory physicians and clinical laboratory technologists. At this symposium, in order to charge an additional management fee correctly according to a laboratory physician's work at Surugadai Nihon University Hospital, an outline of a laboratory physician's duties is described.

[Problems to be solved to qualify to receive laboratory examination management fee III or IV for board-certified doctors in the fields of both laboratory medicine and anatomical pathology]

At least one full-time doctor in laboratory management and consultation on data analysis is required to receive laboratory examination management fee III or IV according to the rules for Japanese public health insurance medical fees. A qualified pathologist, board-certified as a clinical laboratory physician cannot receive this fee together with the pathological diagnosis management fee even if he or she manages laboratory examinations. As a result of this regulation, surgical pathologists working in laboratory examinations are gradually decreasing in Japan; however, it is possible for surgical pathologists working as full-time attending physicians in the Department of Laboratory Medicine to receive the laboratory examination management fee. Consultation regarding laboratory data analysis is required, and experience in diagnostic pathology is beneficial for data interpretation or tissue sample handling in the field of neoplastic diseases.

[Laboratory management fee in national health insurance; what is required from clinical laboratory physicians? --message from Chairpersons]

The laboratory management fee (LMF) in national health insurance ("Kentai-Kensa-Kanri-Kasan" in Japanese) has had a major impact on Japanese clinical laboratories, especially in recent years. In 2012, the fee was raised to approximately 5,000 yen per admitted patient. In order to address this national support, clinical pathologists are required to increase their knowledge and skills. On the other hand, there are insufficient clinical pathologists in Japan. In order to solve this problem, the Japanese Society of Laboratory Medicine (JSLM) approved a new license for Qualified Clinical Laboratory Managing Physicians (CLMPs), in addition to Certified Clinical Laboratory Physicians (CCLPs). The requirements to become a CLMP are less strict than for CCLP. There are approximately 500 CLMPs and 600 CCLPs in this country. The aim of this symposium was to offer opportunities to increase attendees' clinical skills, especially CLMPs and young clinical pathologists. Four CCLPs were chosen as speakers from a university hospital, a major city hospital, a medium-sized acute care hospital, and a university hospital anatomical pathologist, together with a chief medical technologist from a university hospital. All the speakers presented their ideal role models of clinical pathologists matching LMF requirements. JSLM together with the Japanese Association of Clinical Laboratory Physicians (JACLaP) sponsored this symposium. It was a successful meeting with more than two hundred attendees.

Position paper for health authorities: archived clinical pathology data-treasure to revalue and appropriate

Archived clinical pathology data (ACPD) is recognized as useful for research. Given our privileged de-identified ACPD from South West Pathology Service (SWPS), attempt is made to estimate what it would cost any researcher without such privilege to generate the same data. The Ethics Committee of the Area Health Service approved a request for Dr. Uba Nwose to use de-identified ACPD acquired by the SWPS for clinical laboratory-based translational biomedical science research. 10-years (1999-2008) have been pooled to constitute the database. Data include blood sugar, cholesterol, D-dime, ESR, glucose tolerance, haematocrit, HbA 1 c, homocysteine, serum creatinine, total protein and vitamins [C & E] amongst others. For this report, the bulk-billed-cost of tests were estimated based on number and unit price of each test performed. AU$ 17,507,136.85 is the cost paid by Medicare in the period. This amount is a conservative estimate that could be spent to generate such 10-years data in the absence of ACPD. The health/pathology service has not given any financial research grant. However, the support-in-kind is worth more than celebrated competitive research grants. It calls for revaluatrion by academic, research and scientific institutions the use ofACPD. For the countries where such provision is non-existent, this report provides a 'Position Paper' to present to the directorates or institutes of health authorities to appropriate the value of ACPD and approve of their use as a research treasure and resource management tool.

Bulls and bears: the stock market and clinical pathology research

AIMS

To analyse the level of funded research in clinical pathology in a recent bear and bull market to act as a predictor for future funding during the current global financial crisis.

METHODS

The level of funding for research published in three clinical pathology journals in 2005 and 2008 to coincide with the bear market of March 2000 to October 2002 and with the subsequent bull market to October 2007 was determined using a Medline query. Other parameters examined were the type of article, affiliation of the first author and the pathology subspecialty.

RESULTS

Approximately 30% of publications were funded and did not differ between the 2 years studied. Original research papers were more likely to be funded than case reports or reviews. Research from university departments of pathology was more likely to be funded than from hospital pathology departments but there were more publications from hospital pathology departments. The proportion of research in the different subspecialties that was funded did not differ significantly between each other and between 2005 and 2008.

CONCLUSIONS

Based on data from the previous bear market, which was the longest and deepest of the post 1950 era, and the subsequent bull market, which led to the all-time high in the Dow Jones Industrial Index, funding for clinical pathology research does not seem to be affected by bull or bear markets.

Cut-resistant protective gloves in pathology--effective and cost-effective

Cutting injuries and needle-stitch injuries constitute a potentially fatal danger to both pathologists and autopsy personnel. We evaluated such injuries in a large German institute of pathology from 2002 to 2007 and analysed the effect of the introduction of cut-resistant gloves on the incidence of these injuries. In the observation period, 64 injuries (48 cutting injuries and 16 needle-stitch injuries) were noted in the injury report books. Most injuries were located at the non-dominant hand, preferentially at the index finger and the thumb. Around one fifths of the injuries were at the side of handedness. The average number of injuries per month was 1.22 for the 50 months prior to the introduction of cut-resistant gloves, more than seven times higher than after their introduction (0.158; 19 months; p < 0.001). Considering the medical and administrational costs of such injuries, cut-resistant protective gloves are an effective and cost-effective completion of personal occupational safety measures in surgical pathology and autopsy. We strongly recommend the use of such gloves, especially for autopsy personnel.

The use of immunohistochemistry in an oral pathology laboratory

Immunohistochemistry has become part of normal routine diagnostic work in the Stomatology Unit, Institute for Medical Research, Kuala Lumpur. Of 9523 cases received from the year 2000 to 2005, 197 cases (2.1%) required immunohistochemical staining. These cases ranged from benign to malignant lesions. They include lymphomas (n=41), epithelial tumours (n=29), neural lesions (n=21), fibroblastic/myofibroblastic tumours (n=16), small round cell tumour (n=11), vascular tumours (n=4), smooth muscle tumours (n=4), myxomatous tumours (n=4) and skeletal muscle tumours (n=1). In most of the cases (69.5%), immunohistochemical staining was mandatory to reach a definite diagnosis, while 60 cases (30.5%) required immunohistochemistry in confirming the diagnosis. In 32 cases (16.2%), definitive diagnosis could not be made due to the small size of the specimens received or the results of immunohistochemistry were inconclusive. Standardization of techniques, competent medical laboratory technologists and sufficient budget allocation are important in producing a high quality immunohistochemistry service.

[Budget management in anatomical pathology: health technology assessment of new methodologies]

The author's experience in heath technology assessment of new methodologies for routine diagnosis at the Department of Anatomical Pathology at the Trento Hospital is presented. The workload of the department together with the annual budget trends (from 2000 to 2006) of the various costs is analysed. Budget analysis also allows evaluation of expenses relative to the introduction of new tests, which are increasingly requested in order to personalise therapy accordingly to the biological profile of individual patients. Health Technology Assessment permits in-depth analysis of the efficacy, safety, costs, benefits and feasibility in addition to providing a measurement of the contribution to improving the quality of work and life. This is an important tool in decision-making processes for pathologists, especially in consideration of the limited resources available in healthcare.

Branding an anatomic pathology practice to build revenue

Innovative Pathology Services (IPS) is an Associate Practice of Pathology Service Associates (PSA). PSA is an organization known as the "Business Solution for Pathology." IPS provides pathology services to nine hospitals, including two large tertiary-care medical centers, a progressive and renowned children's hospital, a cancer survival center, five surgery centers, and numerous physician's offices and clinics throughout east Tennessee. We accept specimen referrals from other pathology practices and providers from across the country. The center of operations is in Knoxville, a mid-sized metropolitan district. Until January 1, 2003, we were known as Knoxville Pathology Group (KPG). We renamed our practice because KPG did not reflect our service area, was limiting by perception, barely distinguished us from other groups, and did not describe our culture and philosophy. IPS is a new name for a well-established pathology group with a solid foundation and a long history of providing services at the point-of-care. As such, we offer all services that we offered through our foundation practice, and, in addition, these services were enhanced and new services were added. Our entire "team" and, in particular, the pathologists, were involved in the successful "branding" of IPS. Whether you are an independent anatomic pathology or clinical laboratory or you are hospital based, you may benefit from our experiences detailed in this article.

Best Practice No 177: Best practice guideline: writing a business case for service development in pathology

This guideline reviews the introduction and development of business planning in the National Health Service. A guideline for writing a business case for service development that would form part of a pathology business plan has been developed. This guideline outlines six steps that are required in the preparation of a business case. The format of the guideline has been developed largely from other national guidelines that have been published for the development of capital projects. In view of the publication of these guidelines, the scope of this guideline excludes business cases for information, management, and technology projects and large capital projects.

Establishment of a central laboratory serum tumor marker service on a consolidated immunodiagnostic platform: development of practice standards, service improvements, and operational efficiency

BACKGROUND

Laboratory testing for serum tumor markers traditionally has been performed in low volume in most hospitals. Many markers are sent out to reference laboratories. Over the past decade, serum tumor marker testing in patient management has become more defined, resulting in increasing test volume and wider availability of assays on automated immunodiagnostic platforms.

METHODS

A retrospective review of laboratory operations, test volumes, and budgets over a 10-year period. Results of utilization initiatives as part of a clinical practice management team also were reviewed.

RESULTS

The volume of serum tumor marker requests in our institution increased 2.25-fold over an 8-year period. In contrast, total laboratory test volume increased only 1.3-fold. Implementation of an on-site tumor marker laboratory using a consolidated platform (Elecsys 2010) decreased the average unit cost per test from $12.36/test to $6.79/test. This was accomplished by a combination of insourcing and by consolidation of multiple semi-automated instruments. Total savings were $219,972 per year, including direct budget reductions and cost avoidance due to volume increases. Various institutional practice standards were implemented, and turnaround time was markedly reduced for selected tests.

CONCLUSIONS

Testing for serum tumor markers is becoming more established in large hospital laboratories. Increasing test volumes and the availability of consolidated instrument platforms with a broad menu of tumor marker tests (such as the Elecsys 2010) facilitates consolidation and insourcing of many tumor marker assays. This permits the laboratory to reduce unit and overall cost, to leverage excess capacity on existing instrumentation, and to create an opportunity to add value to the service by reducing turnaround time and implementing practice standards.

Choosing between competing technologies in the cytology laboratory

Technological change often is internal to anatomic pathology services. When new technology requires collaborative development with clinical staff, it is important to systematically approach the rationale for the new technology, and be prepared to deal with its medical, financial, and, sometimes, even personal implications. Such a systematic approach involves sequentially evaluating the acceptability and the potential benefits of technologic alternatives among the laboratory leadership, with each potential vendor, the laboratory staff, and the clinical and institutional leadership, and must ultimately include effective communication with the entire clinical community. Among the benefits of such a systematic approach are resiliency of the process when challenged, and credibility of its leadership, within and outside of the laboratory.

[Cost-benefit analysis of the anatomo-pathological study of tonsillectomy specimens in the pediatric population]

To study the cost-benefit of the histological examination of tonsilar samples, we evaluated 567 cases (547 routine and 20 nonroutine cases) of patients under 14 years of age, operated between 1st January 1996 and 30th November 2000. There were 2 routine cases (0.3%), and 6 nonroutine cases (30%) with a diagnosis different to follicular hyperplasia. In this way, our clinical preoperative sensitivity was 75% and specificity 97%. The average cost per case at our Centro to study the tonsilar samples was 30$. We conclude that the histological examination of tonsilar specimens is economically worth only in nonroutine cases, although additional factors (e.g. training of residents of Pathology and the quality control of the institution must be taken into consideration.

Appropriate use of clinical microbiology tests

Laboratory medicine lacks the tools necessary to define appropriate test use; nonetheless, existing laboratory test characteristics, although inadequate, provide a common starting point for developing definitions of appropriate test use. As Lundberg [1], Szczepura [15], and van Walraven and Naylor [2] have emphasized, developing a process for defining appropriate laboratory use should receive a high priority. There is a particular need to develop methods for standardizing studies [59]. Laboratory medicine does not, however, lack the tools necessary to change test use. Although past interventions were largely ineffective, there is growing evidence that test use can be changed by use of a variety of approaches. By using the existing tools there is much that can be done to change inappropriate test use, such as minimizing redundant testing or the use of tests that have no clinical relevance. The real opportunities will come when there are scientifically and medically sound definitions of appropriate test use that can be used to change test use and improve patient care in a cost-effective way.

The use of ordering protocols and other maneuvers: the Canadian experience

Canada's socialized, single-provider, fee-for-service environment has provided an opportunity for widespread implementation and evaluation of a number of utilization control measures. Enforced consolidation of services certainly eliminates redundancy but the implementation cost and disruption of such a measure is high. Whether noncompetition will eventually eliminate any cost savings achieved is difficult to predict. Risk sharing in which ordering doctors and laboratories are paid from the same source of funds and both groups stand financially responsible for excess utilization seems to be an effective approach. From a fiscal standpoint it is, but such measures can create ill will. Establishing utilization caps has an absolute fiscal effect but, unless very carefully designed and monitored, may create more problems than they solve. Utilization control can be achieved using a minimal list requisition form. Form control is also essential to ensure the success of protocol and CPG implementation. The development of protocols and CPGs has proved to be very effective in reducing laboratory testing while also standardizing aspects of medical practice. Such guidelines work well when (1) dealing with testing areas of high volume (or high cost); and (2) amenable to simple rules on which there generally can be agreement. A collaborative implementation environment is necessary. After about 15 such protocols, however, it becomes increasingly difficult to define new areas to target. Physician chart audits are a useful adjunct to help deal with problem areas and to keep all physicians highly aware of good ordering practices. Utilization problems have not been solved in the Canadian system. Certain ventures, however, have proved to have a positive effect. It is likely that when electronic knowledge support tools become a standard feature of medical practice the protocol-CPG approach will be maximized.

Is pathology examination useful after early surgical abortion?

OBJECTIVE

To study if the pathologist's examination of surgical abortion tissue offers more information than immediate fresh tissue examination by the surgeon. Immediate examination of the fresh tissue aspirate after surgical abortion helps reduce the risk of failed abortion and other complications. Regulations in some states also require a pathologist to analyze abortion specimens at added cost to providers. We conducted this study to evaluate the incremental clinical benefit of pathology examination after surgical abortion at less than 6 weeks' gestation.

METHODS

As part of a prospective case series of women who had early surgical abortions at the Planned Parenthood League of Massachusetts during a 32-month period, we collected data on clinical outcomes and the results of postoperative tissue examinations. Using outcomes verified by in-person follow-up as the "gold standard," we calculated the validity of the tissue examinations by the surgeons and the outside pathologists.

RESULTS

A total of 676 women had documented outcomes and complete tissue examination data. The sensitivity (ability of the examiner to detect an outcome other than complete abortion) was 57% (95% confidence interval [CI] 35, 76) for the surgeons' tissue inspections and 22% (95% CI 8, 44) for the pathologists' examinations. The predictive value of a positive (abnormal) tissue screen was 14% (95% CI 8, 24) and 7% (95% CI 3, 17) for the surgeons and pathologists, respectively.

CONCLUSION

Routine pathology examination of the tissue aspirate after early surgical abortion confers no incremental clinical benefit. Although the surgeons' tissue inspections predicted abnormal outcomes poorly, the pathologists did no better. Our results challenge the rationale for state regulations requiring pathologic analysis of all surgical abortion specimens.

Commissioning laboratory services

Scientists often develop techniques that have obvious benefits for patients but then find great difficulty in introducing them into the National Health Service-usually because the necessary finance does not seem to be available. This article provides a practical guide.

[Present status and future problems of clinical laboratory from view points of an anatomical pathologist]

The medical situation surrounding laboratory examinations has changed remarkably. We, the staff of laboratory divisions, must offer the best medical care for patients and operate efficiently. Fertility management service(FMS) and branch laboratory(Branch Lab.) are examples of useful contributions to our hospital from the perspective of economy and personnel expenditure including staff attrition.