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Inappropriate pathology testing; Is there really a problem?
Pathology (2014) 46(S1), pp. S13–S15
Chemical Pathology
INAPPROPRIATE PATHOLOGY TESTING; IS THERE REALLY A PROBLEM? W. Stuart A. Smellie Department of Biochemistry, University Hospital of North Durham, Durham, England Inappropriate tests can be defined as those which could be avoided with no detriment to patient care, although definitions used in studies vary and Carl van Walraven1 found reported inappropriateness rates in studies of 5–95%! Others suggest an overall figure of around 30%, although these estimates are 15 years old. However, more recent comparative benchmarking of activity still shows differences of up to 2000% between high and low requestors. These differences remain after correcting for demographic factors.2 Initiatives such as the UK Quality and Outcomes Framework have set minimum activity standards for some tests using financial incentives. Appropriateness of testing appears to have improved in well codified areas of care such as diabetes, hypertension and lipid management, although large differences continue to exist elsewhere. Inappropriate use of testing therefore remains a problem. References 1. van Walraven C, Naylor CD. Do we know what inappropriate laboratory utilization is? A systematic review of laboratory clinical audits. JAMA 1998; 280: 550–8. 2. Smellie WSA, Galloway MJ, Chinn D. Is clinical practice variability the major reason for differences in pathology requesting patterns in general practice? J Clin Pathol 2002; 55: 312–4.
DATA MINING OF COMMON LABORATORY TESTS CAN BE USED TO IDENTIFY PATIENTS AT RISK Rinaldo Bellomo Department of Intensive Care, Austin Hospital, Heidelberg, Melbourne, Vic, Australia In deteriorating hospital patients, delayed intervention is associated with increased risk. Common laboratory tests may help identify such patients earlier. We studied the relationship between commonly measured laboratory variables and the occurrence within the next day of a rapid response team (RRT) call or unplanned intensive care unit (ICU) admission or death in patients admitted to hospital for >24 h or presenting to the Emergency Department (ED) over a 6 year period. We analysed 5.9 million individual measurements and 559,612 multi-test batches of laboratory tests. We specifically studied 405,826 batches in 41,417 ward patients (average age 64.8 17.5 years) and 153,786 batches in 65,363 ED patients (average age 58.1 20.7 years). Among 106,780 patients admitted to hospital, 1024 had at least one RRT call, 142 at least one unplanned ICU admission and 1286 died. In ward patients, total CO2 (bicarbonate equivalent) had an AUC-ROC of 0.713 for imminent unplanned ICU admission and plasma urea had an AUC-ROC of 0.774 for imminent death. In ED patients, pH had an AUC-ROC of 0.819 for imminent unplanned ICU admission and creatinine had an AUC-ROC of 0.756 for Print ISSN 0031-3025/Online ISSN 1465-3931
#
imminent death. In addition, combinations of variables resulted in AUC-ROC values in the 0.80–0.88 range. Laboratory tests could, on average, predict an RRT call 10.2 (ward) or 11.9 (ED) hours before it occurred. In conclusion, data mining of common laboratory tests can be used to quantify risk and assist in the identification of high risk ward or ED patients CHANGES IN CANCER PATTERNS FROM WIDESPREAD TESTING – COLORECTAL CANCER (CRC) SCREENING Graeme P. Young ACRF Cancer Prevention Unit, Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, SA, Australia Aim: Earlier stage at diagnosis of CRC is now evident. To assess the impact of the National Bowel Cancer Screening Program (NBCSP) on this we undertook a cohort comparison of CRC patient data from the NBCSP register and the South Australian Cancer Registry. Records of those invited to take part in the NBCSP, those who participated in the program, and those with positive test results were compared with those of the rest of the study population. Results: Of 3481 eligible patients, 221 had been invited to the NBCSP. Invitees were more likely to have stage A lesions compared with all others (34.8% versus 19.2%; p < 0.001), and half as likely to have stage D (5.4% versus 12.4%; p < 0.001). A further shift towards earlier stage was seen in those who participated and in those with positive test results compared with all others (e.g., 39.7% stage A and 2.6% stage D in those with positive results versus 19.3% stage A and 12.4% stage D in all others; p < 0.001). Conclusions: CRCs were diagnosed at a significantly earlier stage in people invited to the NBCSP compared with those who were not invited, regardless of participation status or test result.
POINT OF CARE (POC) TROPONIN TESTING IN THE PERIPHERAL HOSPITAL Hans G. Schneider Alfred Pathology Service and Monash University, Melbourne, Vic, Australia While large city hospitals have 24 hour laboratories attached that can provide reasonable turnaround times for troponin testing to the hospital Emergency Department and for other critical areas of the hospital, the situation is much more difficult in the peripheral or country hospitals. Frequently the laboratories are only open during daytime hours and might not be open during the weekend. POC assays for troponin T and I have been developed to help clinicians in this setting, however, there are a number of issues with the successful implementation. Drawbacks are the high reagent cost, occasionally inaccurate results and lack of interfacing. Participation in external quality assurance programs is crucial. Two POC troponin assays were
2014 Royal College of Pathologists of Australasia
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.
Chemical Pathology
INAPPROPRIATE PATHOLOGY TESTING; IS THERE REALLY A PROBLEM? W. Stuart A. Smellie Department of Biochemistry, University Hospital of North Durham, Durham, England Inappropriate tests can be defined as those which could be avoided with no detriment to patient care, although definitions used in studies vary and Carl van Walraven1 found reported inappropriateness rates in studies of 5–95%! Others suggest an overall figure of around 30%, although these estimates are 15 years old. However, more recent comparative benchmarking of activity still shows differences of up to 2000% between high and low requestors. These differences remain after correcting for demographic factors.2 Initiatives such as the UK Quality and Outcomes Framework have set minimum activity standards for some tests using financial incentives. Appropriateness of testing appears to have improved in well codified areas of care such as diabetes, hypertension and lipid management, although large differences continue to exist elsewhere. Inappropriate use of testing therefore remains a problem. References 1. van Walraven C, Naylor CD. Do we know what inappropriate laboratory utilization is? A systematic review of laboratory clinical audits. JAMA 1998; 280: 550–8. 2. Smellie WSA, Galloway MJ, Chinn D. Is clinical practice variability the major reason for differences in pathology requesting patterns in general practice? J Clin Pathol 2002; 55: 312–4.
DATA MINING OF COMMON LABORATORY TESTS CAN BE USED TO IDENTIFY PATIENTS AT RISK Rinaldo Bellomo Department of Intensive Care, Austin Hospital, Heidelberg, Melbourne, Vic, Australia In deteriorating hospital patients, delayed intervention is associated with increased risk. Common laboratory tests may help identify such patients earlier. We studied the relationship between commonly measured laboratory variables and the occurrence within the next day of a rapid response team (RRT) call or unplanned intensive care unit (ICU) admission or death in patients admitted to hospital for >24 h or presenting to the Emergency Department (ED) over a 6 year period. We analysed 5.9 million individual measurements and 559,612 multi-test batches of laboratory tests. We specifically studied 405,826 batches in 41,417 ward patients (average age 64.8 17.5 years) and 153,786 batches in 65,363 ED patients (average age 58.1 20.7 years). Among 106,780 patients admitted to hospital, 1024 had at least one RRT call, 142 at least one unplanned ICU admission and 1286 died. In ward patients, total CO2 (bicarbonate equivalent) had an AUC-ROC of 0.713 for imminent unplanned ICU admission and plasma urea had an AUC-ROC of 0.774 for imminent death. In ED patients, pH had an AUC-ROC of 0.819 for imminent unplanned ICU admission and creatinine had an AUC-ROC of 0.756 for Print ISSN 0031-3025/Online ISSN 1465-3931
#
imminent death. In addition, combinations of variables resulted in AUC-ROC values in the 0.80–0.88 range. Laboratory tests could, on average, predict an RRT call 10.2 (ward) or 11.9 (ED) hours before it occurred. In conclusion, data mining of common laboratory tests can be used to quantify risk and assist in the identification of high risk ward or ED patients CHANGES IN CANCER PATTERNS FROM WIDESPREAD TESTING – COLORECTAL CANCER (CRC) SCREENING Graeme P. Young ACRF Cancer Prevention Unit, Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, SA, Australia Aim: Earlier stage at diagnosis of CRC is now evident. To assess the impact of the National Bowel Cancer Screening Program (NBCSP) on this we undertook a cohort comparison of CRC patient data from the NBCSP register and the South Australian Cancer Registry. Records of those invited to take part in the NBCSP, those who participated in the program, and those with positive test results were compared with those of the rest of the study population. Results: Of 3481 eligible patients, 221 had been invited to the NBCSP. Invitees were more likely to have stage A lesions compared with all others (34.8% versus 19.2%; p < 0.001), and half as likely to have stage D (5.4% versus 12.4%; p < 0.001). A further shift towards earlier stage was seen in those who participated and in those with positive test results compared with all others (e.g., 39.7% stage A and 2.6% stage D in those with positive results versus 19.3% stage A and 12.4% stage D in all others; p < 0.001). Conclusions: CRCs were diagnosed at a significantly earlier stage in people invited to the NBCSP compared with those who were not invited, regardless of participation status or test result.
POINT OF CARE (POC) TROPONIN TESTING IN THE PERIPHERAL HOSPITAL Hans G. Schneider Alfred Pathology Service and Monash University, Melbourne, Vic, Australia While large city hospitals have 24 hour laboratories attached that can provide reasonable turnaround times for troponin testing to the hospital Emergency Department and for other critical areas of the hospital, the situation is much more difficult in the peripheral or country hospitals. Frequently the laboratories are only open during daytime hours and might not be open during the weekend. POC assays for troponin T and I have been developed to help clinicians in this setting, however, there are a number of issues with the successful implementation. Drawbacks are the high reagent cost, occasionally inaccurate results and lack of interfacing. Participation in external quality assurance programs is crucial. Two POC troponin assays were
2014 Royal College of Pathologists of Australasia
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.