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Articles |
1
Department of Pathology and Information Technology Program, Baylor College of Medicine, Houston, TX 77030-3498.
2
Department of Clinical Pathology, Kawasaki Medical
School, Kurashiki, Okayama 701-0192, Japan.
3
Department of Medical Informatics, Yamaguchi University
School of Medicine, Ube, Yamaguchi 755-8505, Japan.
4
Department of Laboratory Medicine, National Defense
Medical College, Tokorozawa, Saitama 359-8513, Japan.
a Address correspondence to this author at: Department of Pathology and Information Technology, Baylor College of Medicine, One Baylor Plaza, Room 126E, Texas Medical Center, Houston, TX 77030-3498. Fax 713-790-7052; e-mail takemura{at}bcm.tmc.edu
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Abstract |
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Methods: The "Essential Laboratory Tests" panel (2) [ELT(2) panel], a package of common diagnostic tests added to the ELT(1) baseline health-status screening panel, was applied to 540 new outpatients who visited the Comprehensive Medicine Clinics in an academic medical center during 1991 to 1997. A "useful result" (UR) of testing was defined as a finding that contributed to a change in a physician's diagnosis- or decision-making, relating to a "tentative initial diagnosis" (TID) obtained from history and physical examination alone.
Results: Clinical usefulness was demonstrated in 259 patients with ELT(2), in whom 398 URs were generated. Clinical effectiveness (UR/TID) ranged from 1.65 (hematological) to 0.088 (neurological disease), with a cost disparity from ¥1251 (~$10) to ¥23 037 (~$200) per UR. A total of 1137 tests generated URs. We further assessed the clinical effectiveness and economic efficiency (cost/UR) of ELT(1) and restructured panels. Use of the ELT(1) alone generated 244 URs in 167 patients. The poor efficiency of the ELT(1) panel was markedly improved with the addition of certain ELT(2)-specific tests in liver/pancreatobiliary, metabolic/endocrine, and cardiovascular disease groups.
Conclusions: A wide disparity in the utility of ELT panels in different patient groups does not support the JSCP recommendation of their routine use for new outpatients. Selective test combinations should be used in selected patient groups.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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); JSCP intends the ELT(1) basic panel to be universally ordered
in every new outpatient as routine testing to obtain minimally
essential information for a disease or patient status, whereas the
ELT(2) panel tests, including chest and abdominal plain x-rays and
electrocardiograms (ECGs), should be performed selectively to focus the
initial clinical diagnosis if necessary.
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Our preliminary study demonstrated that the clinical usefulness2 of the ELT for a physician's diagnosis- or decision-making was classified into (a) establishment of an initial clinical diagnosis in a patient with an undetermined pre-test diagnosis; (b) negation and/or correction of a pre-test diagnosis; (c) confirmation of a pre-test diagnosis; and (d) estimation of the nature or degree of seriousness of a disease as well as evaluation of a patient's general condition (2). The ELT may lead to proper treatment for, and management of, a patient on the basis of a more accurate diagnosis without time delay and save time for the next diagnostic evaluation when the ELT is used as the basis for on-site testing. In fact, one study demonstrated that panel chemistry testing led to fewer return visits of patients to clinics and substantially lower costs than with selective testing (3). Panel testing is also much more informative and more convenient to patients who need not be subjected to multiple blood samplings.
Another advantage in panel testing has been cost: the direct charges to the patient or payer are often lower when profile testing is done than when a selected smaller group of tests is ordered (4). Lehmann and Leiken (5) compared "a la carte" test ordering with panel testing for a common set of analytes in 1985 and found a 32% cost saving from ordering the panel, with few false-positive test results. However, the advances in discrete chemical analyzers have continued, and programmable machines can now match the frugality of high-throughput continuous flow analyzers in most settings. Others have shown that unbundling component tests saved costs (6). With the recent interest in cost-effective resource utilization, there have been several attempts to reduce test volume, eliminating unnecessary diagnostic tests and procedures (7)(8)(9)(10)(11)(12)(13). Panel testing has been changed toward more carefully selected individual tests or small groups of tests in the United States (14)(15). Reimbursement is granted only to limited small panels based on automated multichannel analyzers under the Medicare billing regulations that became effective in April 1998 (16). In contrast to the United States under the fixed-fee reimbursement system, charges for clinical laboratory testing are still reimbursed on a cost basis in Japan, although the government has attempted to introduce generalized cost-containment programs for medical care. Considering the social and economic forces against current laboratory testing, persuasive utilization of a panel testing system must depend on its distinct cost-effectiveness, at least for selected patient groups.
Lack of evidence of the validity of the JSCP-advocated ELT test panels urged us to study their clinical effectiveness and economic efficiency for clinical evaluation of new outpatients in primary care medicine. After careful evaluation of cost and effectiveness in different disease categories, our efforts were directed toward the development of highly efficient new test combinations that can provide maximal effectiveness at a minimal cost increment. In this study, we focused on the utility of the ELT for establishing a diagnosis and physicians' decision-making against primary diseases related to patients' complaints. Disease screening or case-finding efficiency in general patient populations was analyzed only tangentially.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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with the addition of serum cholinesterase after a history and physical
examination. The diagnostic sensitivity, specificity, and positive
predictive values of the individual panel components were analyzed in
our preliminary study and described elsewhere (17). Chest
and abdominal plain x-rays, ECGs, fecal occult blood tests, and
serological tests for hepatitis-related virus antigen or
antibody and syphilis were optional choices. Diagnoses were
divided into the "tentative initial diagnosis" (TID), which was
made tentatively by the primary care physician from the history and
physical examination alone, and the "initial clinical diagnosis",
which was established after integrating the results of diagnostic
tests. The TID was made at the first visit of a patient to the
outpatient clinic, and the initial clinical diagnosis was established
at that patient's next visit to the same clinic. Physicians
participating in the clinical practice were not given information
relating to the test results, irrespective of ELT(1) or ELT(2), at the
time of initial clinical evaluation (the TID process), except for
emergency cases. A diagnosis related to a patient's chief complaint
was defined as the "primary diagnosis", whereas those uncovered
with abnormal test results that were unexpectedly elicited by the
enforcement of the ELT and not related directly to a patient's
illness, were defined as "additional diagnoses".
assay methods
Dipstick urinalysis was performed with Ames reagent strips
(Multistix SGL; Miles-Sankyo). Serum samples were collected for
analyses of chemistry test items, C-reactive protein (CRP), and sialic
acid by an automated multichannel analyzer (model 736; Hitachi).
Because sialic acid is considered as a delayed responder to
inflammation and to show a different movement in the inflammation
process from CRP, this test was also adopted in the ELT(2) panel. Serum
protein profiles (protein fractions) were determined after
electrophoresis of sera on a cellulose acetate membrane by an automated
analyzer (model CTE1200; Johkoh). The complete blood count (CBC) was
measured by an automated blood cell counter equipped with a function
for leukocyte differential counts (LDCs; model E-5000; Sysmex). This
instrument can also measure red blood cell (RBC) indices, including
mean corpuscular volume, mean corpuscular hemoglobin, and mean
corpuscular hemoglobin concentration. Microscopic examination of
peripheral blood smears was performed on samples with any abnormalities
in CBC or qualitative abnormalities detected by the analyzer. The
standard Westergren method was used for measurement of the erythrocyte
sedimentation rate (ESR). Chest and abdominal plain x-rays, ECGs, and
fecal occult blood tests were ordered optionally if necessary.
Serological tests for hepatitis-related virus antigen or antibody and
syphilis were also optional and not evaluated. Triglyceride values were
excluded for diagnosis-making or assessment of clinical usefulness of
ELT because of large fluctuations related to postprandial status,
although random blood glucose values were evaluated in this study.
determination of useful result, clinical effectiveness, costs, and
cost-effectiveness
The clinical usefulness of the ELT was determined by assessing the
impact of its results on a physician's diagnosis- or decision-making.
A "useful result" (UR), which is the unit of usefulness of the ELT
and is classified into four categories, was assigned according to
criteria shown in Table 2
. For determination of URs, patients' medical records were
reviewed closely to find any changes or modifications in the clinical
diagnosis of, treatment for, or management of, a patient before and
after interpretation of test results. Additional ordering of organ- or
disease-specific diagnostic tests and reference to a specialist after
interpretation of the ELT were also counted as URs. A UR in any
category was deemed to have equivalent weight in this study, and a
patient may have had more than one UR. Three physicians participated
the determination of URs; one of these physicians was a participant in
the initial clinical practice of the patients. The diagnosis- and
decision-making of that physician or other physicians were strictly
reviewed by the other two physicians examining the URs assigned. The
clinical effectiveness of the ELT is expressed as the number of URs per
TID in each disease category.
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Because of a lack of availability of cost data at the National Defense Medical College Hospital, costs3 were calculated by considering all expenditures required to obtain test results at the Kawasaki Medical School Hospital (Kurashiki, Japan), which is a tertiary hospital similar to the National Defense Medical College Hospital with respect to size, geographic location, and surrounding population distribution. These include costs for test reagents and analyzer operation, equipment amortization, and personnel expenses for medical technologists. Indirect costs were excluded. The economic efficiency of the ELT is defined as the cost required per UR generated in each disease category. The cost-effectiveness was determined as incremental cost for tests added to the ELT(1) baseline panel per additional UR generated.
simulation studies
The test package performed for 540 new outpatients included all
components of the ELT(1) panel. We modified the accumulated database to
contain patients' chief complaints, TIDs, and test data of ELT(1)
items alone but not to include initial diagnoses obtained from
interpretation of all test items actually performed; we then
re-established the initial diagnosis, assigning URs based on the ELT(1)
in individual patients. The results were compared with those obtained
from test components corresponding to the ELT(2). We further extended
the study to pursue a test combination that can provide maximal
effectiveness at a minimal cost increment in each disease category,
analyzing the UR generated and costs required after certain
ELT(2)-specific test components were added to the ELT(1) basic panel.
In this study, RBC indices, which can be calculated by CBC data in the ELT(1), were moved to the ELT(1), although the JSCP guideline incorporates them into the ELT(2).
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Results |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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compares the type and number of URs generated by the ELT(1) and
ELT(2). A patient may have more than one UR with ELT panel
testing, particularly as increasing test components are
performed. Consider, for example, a patient who had a TID of fever of
unknown origin but who demonstrated pneumonia by chest x-ray with a
markedly increased CRP value and leukocytosis with striking
neutrophilia. Three URs that contributed to a physician's diagnosis-
and decision-making could be assigned in this case: (a)
establishment of the initial clinical diagnosis; (b)
evaluation of the degree of seriousness of the disease; and
(c) evaluation of the nature of the disease (possibly
bacterial infection). The latter two led to hospitalization of the
patient and administration of antibacterial chemotherapeutic agent(s)
according to the chemosusceptibility of the causative microorganisms.
Clinical usefulness was demonstrated in 259 patients with the ELT(2),
in whom 398 URs were generated against 633 TIDs, whereas the use of the
ELT(1) panel alone yielded 244 URs in 167 patients.
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clinical effectiveness and economic efficiency of the elt
panels
The clinical effectiveness and economic efficiency of the ELT(1)
and ELT(2) panels in each disease category are shown in Table 4
. The clinical effectiveness of the ELT(2) ranged from 1.65
UR/TID (hematological) to 0.088 UR/TID (neurological disease group),
and the cost per UR generated was distributed (from ¥1251 to
¥23 037 per UR) between these two disease groups. Comparison of the
ELT(1) with the ELT(2) demonstrated substantial decreases in clinical
effectiveness: UR/TID with the ELT(1) was 0.39 overall compared with
0.64 with the ELT(2). The ELT(1) generated UR/TID ratios of only 0.080
and 0.18 in metabolic/endocrine and liver/pancreatobiliary disease
groups, whereas the ELT(2) generated UR/TID ratios of 0.68 and 1.30,
respectively. Remarkable increases in clinical effectiveness with the
ELT(2) led to improved cost efficiency, which decreased from
¥11 426/UR and ¥5126/UR with the ELT(1) to ¥3263/UR and
¥1482/UR with the ELT(2) for the metabolic/endocrine and
liver/pancreatobiliary disease groups, respectively, producing the best
cost-effectiveness (
cost/UR) for the ELT(2) in the
liver/pancreatobiliary disease group (¥890/additional UR). A similar
decrease in cost/UR with the ELT(2) was also demonstrated in the
cardiovascular disease group, although the disparity was not as large
[from ¥7519 with the ELT(1) to ¥5533/UR with the ELT(2)]. In
patients with neurological problems, there were very few URs generated
with the ELT(1) or the ELT(2); therefore, this group yielded the
poorest clinical effectiveness and the lowest economic efficiency with
testing in both ELT panels. In contrast, the ELT(1) yielded the
best UR/TID (1.57) in the hematological disease group at a cost of only
¥579/UR, but additional ELT(2) test items scarcely produced
incremental URs. The ELT(2) was substantially less cost-effective in
the gastrointestinal disease group (¥7656) than in the infectious or
inflammatory disease group (¥3556/additional UR).
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test panel components contributing to generation of URs
In total, 1137 tests contributed to 398 URs generated among 540
new outpatients with 633 TIDs. Basic diagnostic tests constituting the
ELT(1) made up 44% of the total tests contributing to UR. Fig. 1
illustrates the frequency of test components contributing to
UR. Not only test values out of reference intervals but also those
within them, indicating negative results against a TID, could
contribute to UR because the latter may have URs for negation and/or
correction of the TID. Chest and abdominal x-rays, ECGs, and fecal
occult blood tests, which were optional choices in this study, were
ordered in 198, 17, 79, and 53 patients, respectively, and their
contribution rates were 13.6%, 35.3%, 17.7%, and 5.7%,
respectively.
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Because the clinical usefulness of individual tests varied depending on
the disease category of TID, we further analyzed the pattern and
frequency of tests contributing to the generation of URs in each
disease category (Fig. 2
). Basic components in the ELT(1) panel were major contributors
to the generation of URs in hematological diseases, whereas
ELT(2)-specific test items primarily produced URs in
liver/pancreatobiliary, metabolic/endocrine, cardiovascular, and
renal/urinary tract disease groups. In infectious or inflammatory
diseases, major contributing test components were inflammation
indicators: the usefulness of the LDC, sialic acid, and protein
fraction profile in the ELT(2) panel overlapped with that of CRP,
leukocyte count, and ESR in the ELT(1) panel; thus, there was a
relatively small increment in URs produced only by ELT(2)-specific test
items [121 and 179 URs with the ELT((1)) and ELT(2) panels,
respectively], despite the dominance of ELT(2)-specific test items
contributing to UR. A similar effect was observed in the renal/urinary
tract disease group. The frequency of tests generating URs was
extremely low irrespective of ELT(1) or ELT(2) test items in
neurological and other (miscellaneous) disease categories, reflecting
the very low clinical effectiveness of the ELT panels in the aggregate
in these groups.
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simulation studies for cost-effective test combinations in selected
patient groups
Considering individual test components that were major
contributors to the generation of URs (Fig. 2
), we attempted to seek
more effective test combinations, adding some ELT(2) test items to the
ELT(1) baseline panel. Substantial increases in clinical effectiveness
with the ELT(2) were observed in infectious or inflammatory,
cardiovascular, metabolic/endocrine, liver/pancreatobiliary, and
renal/urinary tract disease groups (Table 4
), indicating that certain
test items in the ELT(2) panel have substantial effectiveness in these
disease groups. Table 5
demonstrates the cost-effectiveness parameters of redesigned
panels of common diagnostic tests based on the ELT(1) in these five
disease categories. As expected in Fig. 2
, clinical effectiveness and
economic efficiency were improved to a great extent by the addition of
five automated analyzer-based chemistry tests and a protein fraction
profile to the ELT(1) in liver/pancreatobiliary diseases at a
cost-effectiveness of ¥192/additional UR. Addition of only three
chemistry tests [alkaline phosphatase (ALP), total cholesterol, and
glucose] to the ELT(1) produced fairly improved clinical effectiveness
at ¥91/additional UR in metabolic/endocrine diseases. Although chest
x-rays and ECGs with the ELT(1) increased clinical effectiveness more
than threefold (from 0.12 UR/TID to 0.43 UR/TID) in cardiovascular
diseases, cost/UR was only moderately decreased (from
¥7519/UR to ¥4159/UR) because of higher costs for both tests (¥877
and ¥699 per test, respectively). In infectious or inflammatory and
renal/urinary tract disease groups, cost/UR increased as the number of
added test items increased.
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Discussion |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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According to the JSCP guideline, individual new outpatients receive the ELT(1) panel as routine testing to obtain basic information at the initial clinical evaluation. Additional tests should be selected from the ELT(2) panel at the initial visit if necessary, and then organ-directed or disease-specific diagnostic approaches would follow the ELT in a step-by-step manner (1). However, the guideline does not refer to the following fundamental issues on the basis of clinical evidence: (a) How efficacious is the guideline with regard to clinical effectiveness and performance cost when the ELT is applied to every new outpatient? (b) Does the guideline have the same weight in effectiveness and economic efficiency in patients in different disease categories? (c) To elicit maximal effectiveness at reasonable cost, which test items should be selected from the ELT(2) panel for a patient with specific symptoms and sign? The above questions arose in part from our preliminary studies, which indicated that the clinical usefulness of the ELT varied depending on disease categories (2)(18). In addition, the limited value of routine laboratory panel testing has been reported previously in the literature (19). Furthermore, in the current trend of cost-effective resource utilization throughout the world (14)(15)(20)(21)(22), more careful use of laboratory tests, based on distinct cost-effectiveness, is now consensus in many countries. These were the incentives that we sought to analyze: not only the clinical effectiveness, but also the economic efficiency of the JSCP test panels.
The usefulness of the ELT was not equivalent among common diseases seen
in primary care medicine; in fact, there was a large disparity in
clinical effectiveness and economic efficiency of the ELT in different
disease categories (Table 4
). TIDs can be classified into four groups
according to clinical effectiveness and economic efficiency of the ELT:
(a) neurological and other (miscellaneous) disease groups,
in which little or no effectiveness of ELT was demonstrated;
(b) liver/pancreatobiliary, metabolic/endocrine and
cardiovascular disease groups, in which the limited effectiveness of
the ELT(1) panel was remarkably improved by application of the ELT(2)
panel, demonstrating an excellent cost-effectiveness of the ELT(2)
panel; (c) infectious or inflammatory and renal/urinary
tract disease groups, in which the ELT(2) increased clinical
effectiveness but decreased cost efficiency (increased cost/UR); and
(d) hematological and respiratory disease groups or
gastrointestinal disease and diagnosis-undetermined groups, in which
excellent (hematological and respiratory disease groups) or limited
(gastrointestinal disease and diagnosis-undetermined groups) clinical
effectiveness of the ELT(1) panel was not demonstrably improved by
application of the ELT(2) panel. Our results clearly indicate that the
ELT panels are not cost-effective for certain patients, such as those
with neurological problems. In fact, a careful history and physical
examination would be much more helpful for the establishment of
clinical diagnosis than would routine laboratory panel testing in the
majority of patients in this group; thus, these patients should be
forwarded directly to organ-specific tests without application of the
ELT. Similarly, the limited effectiveness of ELT(2)-specific test
components in patients with gastrointestinal diseases might allow a
physician to forward these patients for further diagnostic approaches
without consideration of ELT(2) test items. Although there is a
well-recognized consensus on important roles for platelet counts and
LDCs or chest x-rays in establishing diagnoses of hematological
diseases or respiratory diseases, respectively, the ELT(2) panel in the
aggregate generated only slight additional effectiveness in these
disease groups. This may be attributed to the relatively small
number of patients entered in these groups. Movement of the RBC indices
back to the ELT(2) panel would improve the effectiveness of the ELT(2)
in the hematological disease group.
Excellent (liver/pancreatobiliary and metabolic/endocrine diseases) or
fair (infectious or inflammatory, renal/urinary tract and
cardiovascular diseases) cost-effectiveness of the ELT(2) panel led to
a possibility of establishing more efficient test panels, which yield
equivalent clinical effectiveness at a minimal cost increment, for
these patient groups by adding certain ELT(2) test items to the ELT(1)
basic panel. Taking into account test components largely contributing
to UR generation (shown in Fig. 2
), we analyzed the cost-effectiveness
parameters of redesigned test combinations proposed for these disease
groups (Table 5
). The best cost-effectiveness was given by a
combination of aspartate aminotransferase (AST) and alanine
aminotransferase (ALT) with ELT(1) in liver/pancreatobiliary diseases,
and clinical effectiveness could be further improved with the
incorporation of six automated chemistry tests into ELT(1) (1.24 UR/TID
at a cost of ¥914/UR). Although testing of AST and ALT alone without
the ELT(1) was reasonably effective (0.82 UR/TID) at a low cost
(¥417/UR), this served only to confirm or negate liver diseases and
was not informative for possible alternative diseases corresponding to
clinical illness or for estimation of the patient's general physical
condition. In the metabolic/endocrine disease group, addition of only
three chemistry tests to the ELT(1) panel appreciably improved the
clinical effectiveness and economic efficiency, with a
cost-effectiveness of ¥91/additional UR, although this should take
into account the small number of patients in this group and the
distribution of patients leaning largely against thyroid diseases and
diabetes mellitus. Major contributors to UR generation were chest
x-rays and ECGs in cardiovascular diseases; addition of these items to
the ELT(1) increased the clinical effectiveness 3.5-fold but reduced
costs by less than 50% per UR because of the much higher performance
costs for these tests than the automated multichannel analyzer-based
test items. Even taking into account that costs were increased as tests
were added to obtain adequate clinical effectiveness in infectious or
inflammatory and renal/urinary tract disease groups, our findings
clearly lead to the conclusion that there are substantial advantages to
using selected test panels for the different groups of patients, at
least for disease groups mentioned above.
Recently, laboratory testing performed in testing sites outside the main centralized clinical laboratory in a hospital (alternative site or point-of-care testing) has been growing in the United States because of the importance of timely diagnostic results obtained within patient care sites (23)(24)(25). The ELT(1) panel with the addition of some common tests from the ELT(2) panel can be applied to new outpatients as point-of-care satellite laboratory testing, either manually or using smaller-sized, automated discrete instruments. The immediate availability of data at the initial clinical evaluation might offer an increased convenience to patients (e.g., fewer return visits to clinics) and lead to a prompt and optimized diagnostic-therapeutic process in new primary care outpatients. Utility of the JSCP panel test system must be elicited in this setting, and in fact, the guideline recommends that the ELT(1) panel be performed in parallel with a history and physical examination (1). The integrated patient-physician-laboratory relationship based on patient-focused principles is an ultimate goal of the JSCP guideline. Cost-benefit evaluation of ELT panels in this setting should be the next project undertaken in this research.
Another social and economic aspect of ELT panel testing is the effect on cost-containment for diagnostic tests. Recent advances in laboratory technology as well as changes in the healthcare system and reimbursement practices in the United States have stimulated increased use of diagnostic tests in hospital outpatient facilities or nonhospital settings such as physicians' office laboratories during the past two decades (14)(26)(27)(28). However, payment on a cost-reimbursed basis for hospital outpatient and office-based laboratory testing has raised issues of possible overuse of diagnostic tests because of financial incentives to hospital administrators and practitioners (29). Unlike the United States, in which cost containment has been achieved through government policies or managed care, the ELT guidelines themselves aim to constrain test volumes and unnecessary spending.
In conclusion, this study provides some insights for cost-effective utilization of common diagnostic tests in primary care medicine. Although the ELT panels offer much relevant clinical information, the wide disparity of effectiveness of the ELT shown in different patient groups does not match the JSCP's recommendation for their routine use for all new outpatients. Furthermore, our finding that clinical effectiveness of the ELT(1) basic panel can be enhanced and made cost-efficient by adding some specified ELT(2) test items in selected patient groups certainly indicates the necessity for selective test combination corresponding to each patient group. We proposed such redesigned panels with distinct cost-effectiveness for testing new outpatients in this study.
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Acknowledgments |
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Footnotes |
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2 Definitions for descriptions used specifically: clinical usefulness, values of testing contributing to physician's diagnosis- or decision-making; clinical effectiveness, the number of URs per TID (UR/TID) in each disease category; economic efficiency, the cost required per UR generated (cost/UR) in each disease category; cost-effectiveness, incremental cost for tests added/additional UR generated (cost/UR).
3 Costs (¥) can be converted to US dollars at a rate of US $1.00 
¥120.00 on May 1, 1999.
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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The following articles in journals at HighWire Press have cited this article:
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  Y Takemura, K Ebisawa, H Kakoi, H Saitoh, H Kure, H Ishida, and M Kure Antibiotic selection patterns in acutely febrile new outpatients with or without immediate testing for C reactive protein and leucocyte count J. Clin. Pathol., July 1, 2005; 58(7): 729 - 733. [Abstract] [Full Text] [PDF]
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 Y. Takemura, H. Kakoi, H. Ishida, H. Kure, Y. Tatsuguchi-Harada, M. Sugawara, Y. Inoue, K. Ebisawa, and M. Kure Immediate Availability of C-Reactive Protein and Leukocyte Count Data Influenced Physicians' Decisions to Prescribe Antimicrobial Drugs for New Outpatients with Acute Infections Clin. Chem., January 1, 2004; 50(1): 241 - 244. [Full Text] [PDF]
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Y. Takemura, H. Ishida, Y. Inoue, and J. R. Beck Yield and Cost of Individual Common Diagnostic Tests in New Primary Care Outpatients in Japan Clin. Chem., January 1, 2002; 48(1): 42 - 54. [Abstract] [Full Text] [PDF]
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Y Takemura and J R Beck Laboratory testing under managed care dominance in the USA J. Clin. Pathol., February 1, 2001; 54(2): 89 - 95. [Abstract] [Full Text] [PDF]
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Y. Takemura, H. Ishida, Y. Inoue, H. Kobayashi, and J. R. Beck Opportunistic Discovery of Occult Disease by Use of Test Panels in New, Symptomatic Primary Care Outpatients: Yield and Cost of Case Finding Clin. Chem., August 1, 2000; 46(8): 1091 - 1098. [Abstract] [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
-glutamyltransferase; LD, lactate dehydrogenase. *,
optional tests that were ordered.