Transforming Laboratory Utilization Review into Laboratory Stewardship: Guidelines by the PLUGS National Committee for Laboratory Stewardship

Dickerson, Jane A.; Fletcher, Andrew; Procop, Gary W.; Keren, David F.; Singh, Ila R.; García, Joaquín J.; Carpenter, Robert B.; Miles, Joseph R.; Jackson, Brian R.; Astion, Michael L.

doi:10.1373/jalm.2017.023606

Cited by 33 publications

(24 citation statements)

References 10 publications

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“…If testing were to continue at the same rate for 1 year, these inconsistent testing indications would account for almost $500 000 in our hospital. Fortunately, stewardship of laboratory testing is not a new concept [ 17 , 28 ]. Well-designed and carefully thought-out testing strategies have been shown to help increase the awareness of limitations (ie, false positivity and negativity rates) and of the appropriateness of a specific test.…”

Section: Discussionmentioning

confidence: 99%

Clinical Ordering Practices of the SARS-CoV-2 Antibody Test at a Large Academic Medical Center

Wiencek

Head

Sifri

et al. 2020

Open Forum Infectious Diseases

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Background The novel severe acute respiratory coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) originated in December 2019 and has now infected almost 5 million people in the United States. In the spring of 2020, private laboratories and some hospitals began antibody testing despite limited evidence-based guidance. Methods We conducted a retrospective chart review of patients who received SARS-CoV-2 antibody testing from May 14, 2020, to June 15, 2020, at a large academic medical center, 1 of the first in the United States to provide antibody testing capability to individual clinicians in order to identify clinician-described indications for antibody testing compared with current expert-based guidance from the Infectious Diseases Society of America (IDSA) and the Centers for Disease Control and Prevention (CDC). Results Of 444 individual antibody test results, the 2 most commonly described testing indications, apart from public health epidemiology studies (n = 223), were for patients with a now resolved COVID-19-compatible illness (n = 105) with no previous molecular testing and for asymptomatic patients believed to have had a past exposure to a person with COVID-19-compatible illness (n = 60). The rate of positive SARS-CoV-2 antibody testing among those indications consistent with current IDSA and CDC guidance was 17% compared with 5% (P < .0001) among those indications inconsistent with such guidance. Testing inconsistent with current expert-based guidance accounted for almost half of testing costs. Conclusions Our findings demonstrate a dissociation between clinician-described indications for testing and expert-based guidance and a significantly different rate of positive testing between these 2 groups. Clinical curiosity and patient preference appear to have played a significant role in testing decisions and substantially contributed to testing costs.

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Section: Discussionmentioning

confidence: 99%

Clinical Ordering Practices of the SARS-CoV-2 Antibody Test at a Large Academic Medical Center

Wiencek

Head

Sifri

et al. 2020

Open Forum Infectious Diseases

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“…Fortunately, stewardship of laboratory testing is not a new concept. (18,29) Well-designed and carefully thought-out testing strategies have been shown to help increase the awareness of limitations (i.e., false positivity and negativity rate) and appropriateness of a specific test. A possible evidence-based approach to control unnecessary SARS-CoV-2 antibody testing may be in the development and implementation of clinical decision support (CDS) tools that leverage the EMR.…”

Section: Discussionmentioning

confidence: 99%

Clinical Ordering Practices of the SARS-CoV-2 Antibody Test at a Large Academic Medical Center

Wiencek

Head

Sifri

et al. 2020

Preprint

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Background: The novel severe acute respiratory coronavirus 2 (SARS-CoV-2) that causes COVID-19 originated in December 2019 and has now infected over 3 million people in the United States. In Spring of 2020, private laboratories and some hospitals began antibody testing despite lacking evidence-based guidance. Objective: To describe clinician-described indications for SARS-CoV-2 antibody testing, including cost implications, immediately following testing availability. Design: Retrospective chart review of patients who received antibody testing from May 14, 2020 to June 15, 2020. Setting: A large academic medical center, one of the first in the US to provide antibody testing capability to individual clinicians. Patients: 447 consecutive patients who received SARS-CoV-2 antibody testing. Measurements: Clinician-described indications for SARS-CoV-2 antibody testing, cost implications, and comparison with current expert-based guidance from the IDSA and CDC. Results: Of 444 individual antibody test results meeting inclusion criteria, the two most commonly described indications for ordering the antibody test, apart from public health epidemiology studies (n=223), were for patients with a now resolved COVID-19 compatible illness (n=105) with no previous molecular testing and in asymptomatic patients believed to have had a past exposure or contact with a person with COVID-19 compatible illness (n=60). The rate of positive SARS-CoV-2 antibody testing among those indications consistent with current IDSA and CDC guidance was 17% compared with 5% (p<0.0001) among those indications inconsistent with current IDSA and CDC guidance. Total cost estimates ranged from $57,720 to $97,680, of which 42% was for testing inconsistent with current expert-based guidance. Limitations: The duration of antibody response following infection is unclear and asymptomatic individuals may not develop a positive antibody response. Conclusions: Our findings demonstrate a dissociation between clinician described indications for testing and expert-based guidance and a significantly different rate of positive testing between these two groups. Clinical curiosity and patient preference appear to have played a significant role in testing decisions and substantially contributed to testing costs.

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“…Second, appropriate stewardship of laboratory resources may improve patient care by ensuring the correct tests are performed at the appropriate time while unnecessary tests are avoided. At the end of the testing process, appropriate test interpretation and utilization should be pursued, as shown in Figure 1 [32,33]. The figure represents the concept of clinical laboratory stewardship in the context of the wellknown "brain-to-brain cycle" emphasizing the critical issues of the laboratory-clinical interface [34].…”

Section: Toward An Outcome-based Evaluation Of Clinical Laboratory Sementioning

confidence: 99%

Clinical laboratory: bigger is not always better

Plebani

2018

Diagnosis

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Laboratory services around the world are undergoing substantial consolidation and changes through mechanisms ranging from mergers, acquisitions and outsourcing, primarily based on expectations to improve efficiency, increasing volumes and reducing the cost per test. However, the relationship between volume and costs is not linear and numerous variables influence the end cost per test. In particular, the relationship between volumes and costs does not span the entire platter of clinical laboratories: high costs are associated with low volumes up to a threshold of 1 million test per year. Over this threshold, there is no linear association between volumes and costs, as laboratory organization rather than test volume more significantly affects the final costs. Currently, data on laboratory errors and associated diagnostic errors and risk for patient harm emphasize the need for a paradigmatic shift: from a focus on volumes and efficiency to a patient-centered vision restoring the nature of laboratory services as an integral part of the diagnostic and therapy process. Process and outcome quality indicators are effective tools to measure and improve laboratory services, by stimulating a competition based on intra- and extra-analytical performance specifications, intermediate outcomes and customer satisfaction. Rather than competing with economic value, clinical laboratories should adopt a strategy based on a set of harmonized quality indicators and performance specifications, active laboratory stewardship, and improved patient safety.

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Transforming Laboratory Utilization Review into Laboratory Stewardship: Guidelines by the PLUGS National Committee for Laboratory Stewardship

Cited by 33 publications

References 10 publications

Clinical Ordering Practices of the SARS-CoV-2 Antibody Test at a Large Academic Medical Center

Clinical Ordering Practices of the SARS-CoV-2 Antibody Test at a Large Academic Medical Center

Clinical Ordering Practices of the SARS-CoV-2 Antibody Test at a Large Academic Medical Center

Clinical laboratory: bigger is not always better

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