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Journal of the AmericanMedical Association.Vol 279: 6. 1998.Neilson, E. et al. TheImpact of PeerManagement on Test-Ordering Behaviour. TheAnnals of InternalMedicine. Vol 141. 196-204. 2004.Pansini, N. et al. TotalTesting Process:Appropriateness inLaboratory Medicine.Clinica Chemica Acta.Vol 333. 141-145. 2003.a study comparing results inphysicians’ office laboratories(POLs) with other settings.This article seeks to determinewhether persons conducting testsin POLs produce accurate andreliable test results comparable tothose produced by non-POLs. ASurvey of clinical laboratoriesusing proficiency testing data wasundertaken of all Californiaclinical laboratories participatingin the American Association ofBioanalysts proficiency testingprogram in 1996 (n=1110).Main Outcome Measures:“Unsatisfactory” (single testingevent failure) and “unsuccessful”(repeated testing event failure) onproficiency testing samples.This interrupted time-series studyuses peer management through aresource utilization committee(RUC) to favorably modify testorderingbehavior in a largeacademic medical center withinpatient care provider order entry(CPOE) system and database ofordered tests. The participantswere predominantly house staffphysicians at VanderbiltUniversity Hospital who usedCPOE systems.The RUC analyzed the orderinghabits of providers duringprevious years and made 2interventions by modifyingsoftware for the CPOE system.Measurements:• Pre- and post-interventionvolumes of tests;• Proportion of patients withabnormal targeted chemistrylevels after 48 hours;• Rates of repeated admission,transfer to intensive careunits, and mortality;• Adjusted coefficient ofvariation for test ordering;• Length of stay.The need to reduce costs inLaboratory Medicine is oftenrelated to the possibility ofreducing test requests withouttaking into account patients’outcomes. Therefore, the term‘‘appropriateness’’ in Laboratorymore than twice (4.4% vs 1.8%) the rate for thePOLs using laboratory professionals.Significant differences exist among POLs, POLsusing licensed clinical laboratory scientists (medicaltechnologists), and non-POLs. Testing personnel inmany POLs might lack the necessary education,training, and oversight common to larger facilities.There is a need to better understand the contributingfactors that result in the poorer results of POLsrelative to non-POLs. In the meantime, patientsshould be aware that preliminary findings suggestthat differences in quality of laboratory tests basedon testing site may exist. Laboratory directors at alltesting sites must ensure that they understandlaboratory practice sufficiently to minimize errorsand maximize accuracy and reliability. Directorsmust understand their obligation when they elect tooversee those assigned testing responsibility.Laboratory testing of hospitalized patients can beexpensive and sometimes excessive.Voluntary reduction of testing beyond 72 hours (firstintervention) decreased orders for metabolic panelcomponent tests by 24% and electrocardiograms by57% but not orders for portable chest radiographs.Prospective constraints on recurrent test orderingwith panel unbundling (second intervention)produced an additional decrease of 51% formetabolic panel component tests and 16% forportable chest radiographs. Incidence of patientswith abnormal targeted blood chemistry levels after48 hours decreased after the intervention. Postintervention-adjusted coefficients of variationdecreased for metabolic panel component tests andelectrocardiography. Rates of (adjusted) monthlyreadmission, transfers to intensive care units,hospital length of stay, and mortality wereunchanged.Peer management reduced provider variability byaddressing the imperfect ability of clinicians torescind testing in a timely manner. Hospitals withgrowing health care costs can improve their resourceutilization through peer management of testingbehaviors by using CPOE systems.Limitations: Other activities occurring during thetime period of the interventions might haveinfluenced some test-ordering behaviors, and weassessed effects on only a limited number ofcommonly ordered tests.The authors obtained an economic saving (119,580euro/year) in cardiac markers request (analyticalappropriateness = 60%, pre-analyticalappropriateness = 40%) and also an improvement inclinical appropriateness (diagnosis and therapy).The data confirm the need to improvecommunications between physicians and Laboratory14
Medicine as referred to thespecific steps (pre-analytical,analytical, post-analytical) andrelated to the clinical processcould allow the improvement ofclinical effectiveness andeconomic efficiency.Medicine with respect to the pre-analytical step andto implement educational programs for definingcriteria and procedures. Appropriateness in analyticaland post-analytical steps contributes to achieveeconomic saving (Core lab, POCT) andimprovement of the turn-around time (TAT).Plebani, M. Charting theCourse of MedicalLaboratories in aChanging Environment.Clinica Chemica Acta.Vol 319. 87-100. 2002.Poutanen, S. Superbugson the Rise: The Role ofthe Medical Laboratory.CMLTO Summit – April3, 2008.Price, C. Application ofthe Principles ofEvidence-BasedMedicine to LaboratoryMedicine. ClinicaChemica Acta. Vol 333.147-154. 2003.Experience has shown animprovement in analyticalappropriateness (reorganizationand re-engineering by Laboratoryautomation) and pre-analyticalappropriateness (critical revisionof the panel for cardiac markers)by evaluating the workload anderrors rate in the pre-analyticalphase.In recent decades, dramaticchanges have occurred in theorganization, number and type oftests, and role of medicallaboratories in healthcare. Therole of laboratory professionalshas undergone a radical change,which calls for greater analyticalaccuracy, and more stringent testselection, and interpretation ofresults.The ancillary role of clinicallaboratories in the past wasanalyzed in order to understandwhy the change has taken place,and to identify old and new areasin which laboratory information islargely used for improving upondecision making for treatment,and patient management.Presentation delivered at theCollege of Medical LaboratoryTechnologists of Ontario’sSummit in April 2008.The principles of evidence-basedmedicine and the search forrobust evidence on outcomes playa central role in the practice oflaboratory medicine.The availability of real-time laboratory results andmore effective tests, the enhanced clinical consultingrole, the involvement in therapeutic decisions, theefforts to prevent rather than cure disease, the shiftfrom anecdotal care to evidence-based medicine, andthe assessment of outcome for laboratory tests haveall contributed to the changing role and duties ofmedical laboratories.Crucial elements in sustaining the changes in the roleand contribution of medical laboratories to a highqualityhealthcare are the ability of laboratoryprofessionals to: guarantee the quality of laboratorytests irrespective of where they are performed;improve the quality of services; improve clinicaloutcomes; and perform joint clinical/ laboratoryresearch projects. A key factor in effecting thechange has been the awareness of the importance ofthe knowledge and skills required for the new role oflaboratory professionals.New classes of Antimicrobials have been discovered.Superbugs are rising because of 1) Antimicrobialselective pressure (inappropriate human use andanimal use), and 2) transmission in the communityand in hospitals (especially due to a lack of humanhygiene). Solutions include measures to controlselective pressure, control the transmission ofsuperbugs and develop new treatments.Laboratories can contribute to all three solutions. Inorder to effectively do so, laboratories needappropriate staffing, expertise, materials, qualitycontrols and collaborations.Good quality evidence lies at the foundation of allaspects of laboratory medicine. Good qualityevidence is also central to being able to demonstratethe value and role played by laboratory medicine inpatient care.15
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