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Electronic Letters to:
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Electronic letters published:
![[Read eLetter]](/icons/misc/sectionDOWN.gif){kind=icon}
The Laboratory Advisory System is a Tool to Optimize Utilization.
Test utilisation and outcomes
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B Smith Acquired Intelligence Inc, "McNeely, M.D.D."
Send letter to journal:
bsmith{at}aiinc.ca B Smith, et al.
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In response to John Place:
The issue of laboratory utilization is more than the issue of costs. Fundamentally it is making the best use of available resources to maximize patient outcomes. The LAS was developed as a tool to encapsulate some of the expertise of a specialist in laboratory medicine and make it available to assist primary care doctors make the best use of laboratory services to optimize patient outcome. This approach offers a significant advantage over such strategies as ordering as many tests as possible on the first sample. Would such assistance affect the cost of testing, the number of tests ordered, the outcome for the patients? Undoubtedly, but how? In the context of the Canadian study of hypertension guidelines, utilization - as an ongoing process of making the best use of lab resources - could be defined as ordering the right tests and interpreting them properly to complete the diagnosis and evaluation of hypertension. Over- utilization would be from the tests that were ordered during a hypertension workup that do not provide information about hypertension. Under-utilization would be from the tests that do provide critical information for the diagnosis and evaluation of hypertension that were not ordered. If the tools became widely available to assist family practitioners with the implementation of practice guidelines (assist in ordering the correct tests and interpreting the results appropriately) we would likely see the cost of testing and the number of tests vary. The number of test ordered for some disorders would go up (presumably the right tests) and for other disorders (presumably the uninformative tests) would go down. Costing models vary so greatly (e.g., fee-for-service, regional budgets) that a costing analysis would have to be undertaken region by region. In terms of outcomes for patients the authors of the guidelines believe it would be better. |
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John Place, Director General EDMA
Send letter to journal:
edma{at}edma-ivd.be John Place
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To the Editor The interpretation of laboratory test results into meaningful information for the doctor (and for the patient!) is a neglected facet of clinical laboratory medicine. A study in 1997 commissioned by the British In Vitro Diagnostics Association (BIVDA) in collaboration with the Association of Clinical Biochemists (ACB) (Executive Report “In Vitro Diagnostics in Healthcare” BIVDA, London, July 1997, page 2) showed that for hospital doctors inadequate test interpretation was a major problem and that primary care doctors were confused by multiple parameters. It is therefore refreshing to see that Laboratory Advisory Systems (LAS) can be used to help the clinician, both in the ordering of tests and in their interpretation. However, Smith & McNeely (1), in common with many other publications that consider clinical laboratory costs, open their paper with a statement that perpetuates a misconception and is not supported by good evidence : “Over the last decade, the cost of laboratory testing has increased considerably around the world”. The reference given is van Walraven & Naylor (2), who measured utilisation in terms of numbers of tests performed and based their statement “The utilisation of diagnostic laboratories has increased over the last several decades in many medical jurisdictions around the World” on three references from the early 1980s. It is time to be more critical and accurate about laboratory utilisation. Van Walraven & Naylor’s review builds on 44 articles including 31 articles from the US and only 6 articles from Europe (United Kingdom and Netherlands only). So it is hardly representative of the World. According to the Organisation for Economic Co-operation and Development (OECD), per capita spending on health care in the European Economic Area is only about half of that of the United States (US). The European Diagnostic manufacturers Association (EDMA) estimates (based on independent market audits) that per capita annual purchases of in vitro diagnostic (IVD) products in Europe is only 14 Euro, compared with 25 Euro in the US (1 Euro = 1.05 US Dollars). Laboratory testing certainly costs more in the US than it does in Europe and the implication is that more testing is performed in the US. Van Walraven & Naylor cite a 130% increase in the number of tests in Ontario from 1976 to 1992, which is significantly greater than the 90% increase in numbers of tests between 1980 and 1996, estimated by Verband der Diagnostica-Industrie (VDGH), the German trade association. Maybe there is an over-utilisation in North America, but the figures do not support generalisation to Europe. EDMA’s estimates of the IVD market in Europe indicate a real increase over the last five years of only 1.4% per year. Such weak growth overall is one of the reasons for the current wave of consolidation in the IVD industry. In an era in which targeted therapy will become increasingly steered by objective testing for individual susceptibility to treatment (that hopefully will lead to increased patient benefits in the form of better therapy and lower doses of more powerful drugs), we should not expect overall test utilisation to decrease. Instead, we should expect and indeed welcome an increase in utilisation. Under-utilisation can also be a problem. Smith & McNeely also report that a recent Canadian study of guidelines for utilisation control found that 24% of essential hypertension cases did not receive the laboratory testing recommended by the guidelines of the Canadian Hypertension Society, whereas >50% received tests that were not specifically recommended. Does this result support control (limiting) of utilisation? Should we focus on the 24% who did not receive the recommended testing (that presumably has utility) or on the >50% who received other tests (that presumably did no harm)? If I were a hypertensive patient, I know which group I would prefer to be in. We should be happy if LASs can improve diagnostic accuracy. Otherwise, the recommendation resulting from this study might be that physicians should be taught to call the laboratory to order extra tests on the same sample or even (dare I suggest it?) that as many tests as possible should be performed on the first sample. They would not need a LAS to do this. References List of abbreviations |
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