Inappropriateness in laboratory medicine: an elephant in the room?

Abstract

Appropriateness of diagnostic testing can be conventionally described as prescription of the right test, using the right method, at the right time, to the right patient, with the right costs and for producing the right outcome. There is ongoing debate about the real burden of inappropriateness in laboratory diagnostics. The media coverage of this issue has also recently led to either over-or under-emphasizing the clinical, organizational and economic consequences. This is quite problematic, inasmuch as some reliable data are available in the current scientific literature, showing that inappropriateness of laboratory testing can be as high as 70%. This is especially evident for, though not limited to, cancer biomarkers testing, in which the practice of avoidable tests ordering is dramatically magnified. The reasons beyond inappropriateness are many and multifaceted, entailing wrong habits, resistance to changes, poor culture, insufficient education and healthcare inefficiencies. There are many unfavorable consequences attributable to avoidable testing, including unjustified incremental costs, derangement of laboratory efficiency and potential patient safety issues. The tentative solutions to this important problem necessitate that policymakers, local hospital administrators, laboratory professionals, clinicians, patients' associations and diagnostic companies join the efforts and embark in the same landmark effort for disseminating a better culture of appropriateness.

BRCA population screening for predicting breast cancer: for or against?

“…Consistent with a financial and organizational perspective, genetic testing in clinical laboratories is not like screening for cholesterol, glucose or prostate specific antigen (PSA). We may all agree that the cost of measuring cholesterol, regardless of established criteria of appropriates (8), may produce a relatively modest impact on healthcare economics (i.e., the cost of a cholesterol test is approximately 0.045 US$ in the local laboratory). Unlike cholesterol, the cost of BRCA testing currently ranges between 300 and 5,000 US$, depending on the analytical technique and the number or type of mutations being assessed.…”

Microalbuminuria and Traditional Serum Biomarkers of Nephropathy among Diabetic Patients at Mbarara Regional Referral Hospital in South Western Uganda

“…Whereas the above-mentioned traditional serum renal markers are implicated in the pathogenesis of renal disease, information from health personnel at MRRH diabetic clinic indicates that many patients cannot afford to pay for all these tests and so the tests are not done at the time of diabetes diagnosis. Lippi et al [8] recently provided the definition of appropriateness in laboratory test requesting as "the Right test, using the Right method, at the Right time, to the Right patient, with the Right costs and for producing the Right outcome." Thus, the objectives of this study were to determine the prevalence of microalbuminuria in diabetic patients, assess the factors associated with it, and establish its association with traditional serum renal markers (serum uric acid, urea, creatinine levels, sodium, potassium, chloride, and glucose) in assessment of incipient nephropathy.…”

Preanalytical issues that may cause misdiagnosis in haemophilia and von Willebrand disease

“…Although tests as performed represent analytical events, what tests are performed in response to clinical requests are preanalytical decisions that may affect final interpretations or outcomes. Some of these considerations are similar to previous discussion around clinical requests . For example, clinicians may request “factor assays” without specifying which factor to test.…”