Improving the utilization of clinical laboratory tests
01 Aug 1998-Journal of Evaluation in Clinical Practice (J Eval Clin Pract)-Vol. 4, Iss: 3, pp 171-181
TL;DR: Efficient utilization of laboratory services can be achieved by elimination of the general health panel, removal of old tests or those that provide redundant information, a reduction in the use of standing orders, more judicious use of drug assays, acceptance of clinical practice guidelines, and use of reflex testing algorithms.
Abstract: Reimbursement policies for health care services are greatly diminishing in the U.S. and Western Europe. Hence, there is an increasing need for doctors and other care givers to reduce costs without compromising the quality of the care being delivered. The clinical laboratory is viewed as an area of high costs where significant reductions have been targeted. Efficient utilization of laboratory services can be achieved by elimination of the general health panel, removal of old tests or those that provide redundant information, a reduction in the use of standing orders, more judicious use of drug assays, acceptance of clinical practice guidelines, and use of reflex testing algorithms. New technologies such as DNA probes can substantially improve diagnostic efficiency. Point-of-care testing devices which have higher costs than incremental central laboratory expenses should only be used if they reduce overall operating expenses. Implementation of expert systems can make remaining tests more effective. Doctors and laboratorians must collaborate to achieve more efficient utilization practices.
Citations
More filters
TL;DR: Preoperative testing is overused in patients undergoing low-risk, ambulatory surgery, and physician and/or facility preference and not only patient condition currently dictate use.
Abstract: Over the last 2 decades, the indications for ambulatory surgery have expanded, with an increasing number of surgical procedures performed in the ambulatory setting. Currently 60% to 70% of the surgical procedures performed in the United States each year are performed in the ambulatory setting.1,2 Ambulatory surgical procedures are generally less than 1 to 2 hours in duration, have low expected blood loss and complication rates, minimal expected postoperative care, and are usually performed in patients with no medical problems or with stable chronic medical conditions.
As surgical and anesthetic techniques have evolved, evidence-based guidelines regarding preoperative testing have lagged. In the United States, current recommendations for preoperative testing are based on the 2002 Practice Advisory from the American Society of Anesthesiologists (ASA) Task Force on Preanesthesia Evaluation.3 These recommendations represent a synthesis of expert opinion and are not based on a sufficient number of adequately powered and controlled trials. Moreover, there are inconsistencies between authorities, and the language of current recommendations is imprecise. For example, “advanced age” is often used as an indication for testing without a clear minimum age. Table 1 summarizes the recommendations of the ASA,3 the Canadian Anesthesiologists’ Society (CAS),4 and the Ontario Preoperative Testing Group (OPTG).5,6 In addition, recommendations for preoperative testing vary widely on the basis of single-institution studies and systematic reviews.7–10
TABLE 1
Summary of Current ASA, CAS, and OPTG Recommendations for Testing in Patients Undergoing Ambulatory Surgery
While the cost of individual tests may be low, the aggregate costs can be substantial.11,12 In the United States, the current estimated cost of preoperative testing is $3 billion to 18 billion annually.7,13,14 On the basis of single-institution studies and literature reviews, many advocate against routine preoperative laboratory testing in asymptomatic and clinically normal patients who are undergoing elective, low-risk surgery.5,7–12,14–17 It also has been shown that abnormal results in testing done before elective low-risk surgery change management in less than 3% of cases.5,11,15 Although these groups advocate against “routine” testing, they fail to outline clear and consistent guidelines or indications for specific tests. Several studies, including 2 randomized controlled trials, have evaluated the elimination of preoperative testing in patients undergoing low-risk surgery and have demonstrated no difference in adverse events.1,17,18
Despite these data, several single-institution studies document overuse of preoperative testing in the low-risk, ambulatory setting.5,11,19 However, the use of preoperative testing has not been studied at the population level. Our study uses the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to examine current patterns of preoperative laboratory testing in patients undergoing elective hernia repair, a representative low-risk ambulatory operation. Specifically, we examine preoperative testing in all patients and a subgroup with no NSQIP-measured comorbidities and, therefore, no clear indication for pre-operative testing. Finally, this study identifies factors associated with preoperative laboratory testing and examines 30-day outcomes in tested and untested patients and patients with normal and abnormal test results.
149 citations
TL;DR: Benefits of point-of-care testing include better therapeutic turnaround times, decreased blood loss as a result of reduced phlebotomy secondary to clinical improvement, and diminished resource utilization.
135 citations
TL;DR: It is concluded that while some data suggest that CPOE systems are beneficial for clinical and laboratory work processes, these data are limited, and further research is needed.
109 citations
Cites background from "Improving the utilization of clinic..."
...It may also be a mechanism to ensure that necessary tests are not missed [39,40]....
[...]
...But in many cases repeat testing is a convenience rather than a reflection of a belief that it improves patient care [39]....
[...]
...[39] A....
[...]
TL;DR: Near-maximal efficiency of reflex testing can be achieved, depending on the reflex and diagnostic thresholds applied, while effectiveness declined outside the euthyroid TSH range.
Abstract: BackgroundLaboratory investigations may be added to existing requests either automatically on the basis of algorithms (reflex testing) or by laboratory professionals (reflective testing). The clini...
71 citations
TL;DR: The most promising new management tools seem to be computerised laboratory management systems (CDSS), a reimbursement system based on the diagnosis-treatment combination (as in The Netherlands), and the allocation of laboratory budget to those requesting laboratory services.
69 citations
Cites background from "Improving the utilization of clinic..."
...The ordering of such tests is usually seen as resulting frommistaken ideas among doctors about the tests' performance, plus erroneous requesting policies (Table 2), [9,10]....
[...]