No abstract

No abstract

Data on clinical chemistry test use and revenue expenditure per admission or per outpatient visit, were supplied monthly to three consultant physicians.3 The data were provided as eight histograms on four sheets of A4 paper. The first sheet compared clinical chemistry use and expenditure among the physicians on inpatients for that month. The other sheets provided data for the previous 12 months comparing each physician's use and expenditure with the mean of the other four physicians. These data were separated into within hours and out of hours for inpatients and for outpatients. Two consultant physicians who received no information served as controls. Unknown to the physicians, we also collected data on their haematology requests throughout the study period and on their clinical chemistry requests and costs after feedback had stopped. A request was defined as any number of samples taken from a patient at any one time and sent to the laboratory for one or more analyses (tests).Changes in the feedback and control groups were assessed by comparing laboratory use and expenditure before (baseline) (01.11.88 to 30.04.89), during (intervention) (01.05.89 to 30.04 90), and after (follow up) (01.05.90) to 31.10.90) the feedback using the Mann-WXhitney U test. P values of < 0 05 were regarded as significant. ResultsThe numbers of emergency admissions and new outpatient visits in the intervention (92% and 21%, respectively) and control (88% and 10%, respectively) groups remained unchanged throughout the three study periods.In the baseline period the variation in the physicians' clinical chemistry requests on inpatients was 1 5-fold and 3-6-fold on outpatients.In the one year intervention period, there was an immediate and sustained decrease of 15%, 27%, and 21% in clinical chemistry requests (p < 0 01), tests (p < 0-001), and expenditure (p < 0-001), respectively, and a 10% reduction in haematology tests (p < 0-05) per outpatient visit in the intervention group. These changes persisted in the six months after the feedback had stopped (tables 1 and 2). There were no significant decreases for inpatients in the intervention and control groups (tables 1 and 2).The cost of providing the feedback was £530 a year. The corresponding annual savings in revenue expenditure and cash (consumable costs) achieved through a reduction in out-248 on 11 May 2018 by guest. Protected by copyright.

The many strategies proposed for influencing the test requesting patterns of clinicians have had only limited success, largely because they are labour intensive and depend on motivation and commitment. Clinical protocols which have been locally agreed between laboratory staff and clinicians are potentially one of the more successful strategies, but detailed study of their application in different clinical settings has been limited by practical problems. Expert systems offer a way of implementing locally agreed protocols and, consequently, of assisting the identification, audit and refinement of laboratory testing strategies. Where these systems have been applied in specialist units they have resulted in savings in time by both clinical and laboratory staff, and an overall reduction in the number of clinical chemistry tests done within and out of hours. These systems offer promise as a method of improving laboratory utilization.

SUMMARY A method of costing clinical laboratory tests is described which avoids the assumptions and omissions of previous methods and overcomes the basic theoretical difficulty of allocating indirect (overhead) costs, which form the major component. The method develops the concept of a 'cost per request' to cover indirect costs, which reflect the cost of providing laboratory facilities, and a 'cost per test' to cover the direct analytical costs of the individual tests done. The direct cost per test was found 10 vary with the workload, which makes it difficult to predict the effect of changes in demand on expenditure. The Canadian Schedule of Unit Values was found to be an unreliable basis for calculating direct labour costs. Examples are given of the direct and indirect costs of consumables, labour, and capital, and their contribution to the total cost of clinical chemistry tests done either during or outside normal working hours. The total annual cost for each analyte may be a more useful indicator of expenditure than the cost per test.In many countries there is increasing concern about various automated systems.5--7 Both the methods the cost of high technology medicine and, because of used and the costs included vary widely, ranging its rapid expansion and dependence on expensive from reagent costs only (with or without taxes) to a capital equipment, clinical chemistry has come under complete analysis of all laboratory expenditure, special scrutiny. Although the annual expenditure of including consumables, staff, equipment, building individual laboratories is usually known, there is costs, and overheads. Often component costs, such surprisingly little information available about the as reagents or maintenance of equipment, are cost-or even relative cost-of individual tests. The assumed when they could be measured. Doubts price charged by commercial laboratories is a poor about the validity of these procedures have probably guide to this.' Costing information would not only inhibited acceptance of what may be valid conbe useful in laboratory management and planning, elusions about the relative costs of, for example, but is essential for realistic cost-benefit studies of different types of automated equipment. laboratory tests. Moreover, the provision of this Two studies have considered costing methods in information to clinicians might influence their more depth. The first of these" (usually referred to as requesting practices and possibly reduce costs.the Cooper-Lybrand procedure) has proved comTwo simple procedures are widely used to calculate plex to use and requires collection of some data the cost of a test. In the first, the total annual which are not used in the calculation of test costs. laboratory expenditure is divided by the number of In addition, some costs are excluded without tests done, giving an average cost per test. This explanation, and overhead costs are largely ignored," requires no technical knowledge but assumes that all A more comprehensive and logical scheme of cost tests cost the same,...

SUMMARY This paper urges the benefits of applying more widely a method for pathology laboratory costing originally devised for a clinical chemistry department, and illustrates these with examples drawn from costing studies in three clinical laboratories.Heads of pathology departments, laboratory managers, administrators and clinicians require different kinds of costing information, each of which can be obtained by the costing procedure outlined. The method also yields valuable and sometimes surprising insights into the workings of a pathology service. Cost comparisons between different laboratories can now become more informative.Flaws in the concept of the "cost per test" are discussed and the value of this concept is questioned; for most purposes the cost per request has greater application.In 1981 Broughton and Hogan published a method for costing a clinical chemistry department' which is simpler, more logical and more comprehensible than previously published methods.24 A novel feature of these authors' approach was to separate costs into those involved in providing the basic facility-that is, an appropriately staffed and equipped laboratory competent to fulfil the requests made to it-and the actual direct costs of performing individual test procedures, and to apply these figures separately to answer different types of management question.So far, there has been no stampede to apply this method in other clinical laboratories, despite the current financial restrictions and the concern about the cost of "high technology" diagnostic tests.5 Reluctance to embark on costing studies stems from a mistaken belief that the amount of effort necessary for reliable costing is incommensurate with the possible benefits.

In a 1 year prospective study we evaluated the effect of feedback of laboratory data on the requesting behaviour of physicians in general medicine. Data on within-hours and out-of-hours clinical chemistry laboratory usage and revenue expenditure for inpatients and outpatients, expressed in terms of clinical workload, were supplied monthly to a group of three consultant physicians in general medicine. With these data the physician could monitor his performance over a period of time and compare it with that of his peers. Two consultants in general medicine who received no information served as controls. Over a period of 6 months, there was a 25%, 13% and 18% decrease in tests (P less than 0.01), requests (P less than 0.05) and revenue expenditure (P less than 0.01) per outpatient visit, respectively, in the intervention group of physicians following the introduction of feedback when compared to their baseline period and to the control group. The decrease (P less than 0.01) was in the commonly requested and 'seemingly cheap' tests. There was no significant change in laboratory use and expenditure on inpatients. The feedback of laboratory data was acceptable to the physicians, raised their awareness of laboratory usage and costs and decreased laboratory workload and expenditure.

No abstract