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Strategies to promote rational clinical chemistry test utilization
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Clinical Biochemistry,Vol. 30, No. 4, 361. 1997 Copyright © 1997 The Canadian Society of Clinical Chemists Printed in the USA. All rights reserved 0009-9t20/97 $17.00 + .00
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ELSEVIER
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S0009-9120(97)00002-7
To the Editor: The article by J.T. H i n d m a r s h and A.W. Lyon entitled, "Strategies to Promote Rational Clinical Chemistry Test Utilization" was disappointing (1). The problem addressed--inappropriate use of laboratory services--is real, b u t the analysis was incomplete and most of the recommended solutions fail to meet the optimum needs of patients and clinicians• Requiring physicians to order individual tests only is not the optimum solution. It is diagnostically inefficient, and even dangerous to the well being of patients, for laboratorians to rely on a "one-test-ata-time" ordering program to improve the utilization of laboratory services. That is a reactive, negative, static and incomplete approach--not a proactive, solution-seeking, continually-improving approach. The laboratory, as a system, should make it impossible to order outdated tests, incorrect test combinations, tests at incorrect frequencies or times, etc. To expect a random collection of individual clinicians to do the right thing is doomed to fail. Problem-oriented progressive algorithms are a better solution. Take cardiac enzymes as an example. To offer fixed profiles is incorrect, but it is also incorrect to demand that physicians order individual tests. They m a y order incorrect individual tests and fail to order correct tests. What the clinician and patient seek is an answer to the question, "Does the patient have an acute myocardial infarction?" The answer is best addressed by a laboratorydefined combination of sequential tests designed to provide the most accurate and efficient answer to that question. In 1966, it would have been aspartate aminotransferase (AST) and lactate dehydrogenase (LD) isoenzymes levels, at pre-defined times• In 1976, it would have been creatinine kinase (CK) isoenzymes and LD isoenzymes levels, and elimination of AST. In 1986, it might have been CK-MB mass, and elimination of LD isoenzymes as a firststep test. In 1996, it should be cardiac troponin I and elimination of CK isoenzymes. In this scenario clinicians are never called upon to be as up-to-date as laboratory scientists• The clinical problem has remained the same for decades, whereas the efficiency and efficacy of the tests available to address the
CLINICAL BIOCHEMISTRY, VOLUME 30, J U N E 1997
problem has continually changed• A problem-oriented laboratory test ordering process is the best w a y to ensure optimum use of laboratory tests at all times. In 1967 I wrote, "Reliable laboratory service cannot be obtained when chance, whim, or chaos, rather than system, determines what tests are to be done. The director interested in reliable laboratory service will mould his service so that physicians can ask intelligent questions rather than make requests for specific tests. In this w a y he will decrease the number of outdated, unnecessary, redundant, or poor tests done in his laboratory. Physicians do not have an inalienable right to order any test they want--particularly if they are interested in reliability" (2). Finally, here is another simple example• If the clinical problem is "rule out appendicitis" then the laboratory should build the C-reactive protein (CRP) test into its test protocol for "?appendicitis." In that w a y the test is performed automatically. The physician never orders specific tests• He or she only informs the laboratory of the problem, which in this case is "?appendicitis•" The laboratory, not the clinician, orders the appropriate tests at the appropriate times and in the appropriate sequence. The laboratory knows far better than the clinician which tests most efficiently and effectively provide a possible answer and which do not. In 1996, for example, an absolutely normal CRP level effectively rules out a diagnosis of appendicitis• Optimum tests for appendicitis m a y change in the year 2000, b u t the clinical problem remains the same.
Raymond Gambino Adjunct Professor of Pathology Columbia University References 1. H i n d m a r s h J T , L y o n AW. S t r a t e g i e s to p r o m o t e r a t i o n a l c l i n i c a l c h e m i s t r y t e s t u t i l i z a t i o n . Clin Biochem 1996; 29: 2 9 1 - 9 . 2. G a m b i n o SR. L a b o r a t o r y l a w of d i m i n i s h i n g r e t u r n s . Lancet 27 M a y 1967; I: 1155.
361
Clinical Biochemistry,Vol. 30, No. 4, 361. 1997 Copyright © 1997 The Canadian Society of Clinical Chemists Printed in the USA. All rights reserved 0009-9t20/97 $17.00 + .00
,
ELSEVIER
PII
S0009-9120(97)00002-7
To the Editor: The article by J.T. H i n d m a r s h and A.W. Lyon entitled, "Strategies to Promote Rational Clinical Chemistry Test Utilization" was disappointing (1). The problem addressed--inappropriate use of laboratory services--is real, b u t the analysis was incomplete and most of the recommended solutions fail to meet the optimum needs of patients and clinicians• Requiring physicians to order individual tests only is not the optimum solution. It is diagnostically inefficient, and even dangerous to the well being of patients, for laboratorians to rely on a "one-test-ata-time" ordering program to improve the utilization of laboratory services. That is a reactive, negative, static and incomplete approach--not a proactive, solution-seeking, continually-improving approach. The laboratory, as a system, should make it impossible to order outdated tests, incorrect test combinations, tests at incorrect frequencies or times, etc. To expect a random collection of individual clinicians to do the right thing is doomed to fail. Problem-oriented progressive algorithms are a better solution. Take cardiac enzymes as an example. To offer fixed profiles is incorrect, but it is also incorrect to demand that physicians order individual tests. They m a y order incorrect individual tests and fail to order correct tests. What the clinician and patient seek is an answer to the question, "Does the patient have an acute myocardial infarction?" The answer is best addressed by a laboratorydefined combination of sequential tests designed to provide the most accurate and efficient answer to that question. In 1966, it would have been aspartate aminotransferase (AST) and lactate dehydrogenase (LD) isoenzymes levels, at pre-defined times• In 1976, it would have been creatinine kinase (CK) isoenzymes and LD isoenzymes levels, and elimination of AST. In 1986, it might have been CK-MB mass, and elimination of LD isoenzymes as a firststep test. In 1996, it should be cardiac troponin I and elimination of CK isoenzymes. In this scenario clinicians are never called upon to be as up-to-date as laboratory scientists• The clinical problem has remained the same for decades, whereas the efficiency and efficacy of the tests available to address the
CLINICAL BIOCHEMISTRY, VOLUME 30, J U N E 1997
problem has continually changed• A problem-oriented laboratory test ordering process is the best w a y to ensure optimum use of laboratory tests at all times. In 1967 I wrote, "Reliable laboratory service cannot be obtained when chance, whim, or chaos, rather than system, determines what tests are to be done. The director interested in reliable laboratory service will mould his service so that physicians can ask intelligent questions rather than make requests for specific tests. In this w a y he will decrease the number of outdated, unnecessary, redundant, or poor tests done in his laboratory. Physicians do not have an inalienable right to order any test they want--particularly if they are interested in reliability" (2). Finally, here is another simple example• If the clinical problem is "rule out appendicitis" then the laboratory should build the C-reactive protein (CRP) test into its test protocol for "?appendicitis." In that w a y the test is performed automatically. The physician never orders specific tests• He or she only informs the laboratory of the problem, which in this case is "?appendicitis•" The laboratory, not the clinician, orders the appropriate tests at the appropriate times and in the appropriate sequence. The laboratory knows far better than the clinician which tests most efficiently and effectively provide a possible answer and which do not. In 1996, for example, an absolutely normal CRP level effectively rules out a diagnosis of appendicitis• Optimum tests for appendicitis m a y change in the year 2000, b u t the clinical problem remains the same.
Raymond Gambino Adjunct Professor of Pathology Columbia University References 1. H i n d m a r s h J T , L y o n AW. S t r a t e g i e s to p r o m o t e r a t i o n a l c l i n i c a l c h e m i s t r y t e s t u t i l i z a t i o n . Clin Biochem 1996; 29: 2 9 1 - 9 . 2. G a m b i n o SR. L a b o r a t o r y l a w of d i m i n i s h i n g r e t u r n s . Lancet 27 M a y 1967; I: 1155.
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