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Unnecessary duplicate laboratory testing is common and costly. Systems-based means to avert unnecessary testing should be investigated and employed. We compared the effectiveness and cost savings associated with two clinical decision support tools to stop duplicate testing. The Hard Stop required telephone contact with the laboratory and justification to have the duplicate test performed, whereas the Smart Alert allowed the provider to bypass the alert at the point of order entry without justification. The Hard Stop alert was significantly more effective than the Smart Alert (92.3% vs 42.6%, respectively; P < .0001). The cost savings realized per alert activation was $16.08/alert for the Hard Stop alert vs $3.52/alert for the Smart Alert. Structural and process changes that require laboratory contact and justification for duplicate testing are more effective than interventions that allow providers to bypass alerts without justification at point of computerized physician order entry.

Objectives: Very little is known about the relative contributions of physician specialty groups and individual physicians to overall clinical laboratory expenditures. The objectives of this study were to determine the costs of clinical laboratory test expenditures attributable to 30 medical specialties and the associated per capita physician expenditures for an entire major Canadian city. Only chemistry, hematology, and microbiology tests were included in this study. Methods: Retrospective cohort study involving all physicians in Calgary, Canada, and surrounding areas (n = 3,499) and secondary data on laboratory test orders. Results: Data were obtained on approximately 20 million test requests. The mean clinical laboratory test expenditure, in Canadian dollars, per physician was $27,945 for all physicians combined. Total expenditures by primary care physicians (family physicians and general practitioners) accounted for 58% of total expenditures. Conclusions: There was wide variation in clinical laboratory test expenditures among specialties and on a per capita basis within medical specialties.

Background Laboratory services are essential for diagnosis and management of patients, and for disease control, and should form an integral part of primary health services capable of contributing to Universal Health Coverage. Nevertheless, they remain among the most neglected health services in resource-poor countries, including Mozambique. The Health Directorate of Tete Province, Mozambique, developed this study to analyse the role and perceived impact of laboratory services in primary healthcare on access, perceived service quality and disease control. Methods Qualitative research was done in three primary health facilities with and three without a laboratory in Tete Province, purposively sampled for their available services, accessibility and size. The role of the laboratory in primary health care was explored by reviewing documents, including records and monthly reports, interviews with clinicians, laboratory technicians and key informants (community leaders), and through focus group discussions with beneficiaries. Numeric data were summarized in Microsoft™ Excel. Qualitative data were analysed for content within generated categories, interpreted within the concept of Universal Health Coverage, cross validated between the researchers. Results The results showed a greater use of health services, with more frequent diagnosis and monitoring of prevalent diseases, in facilities with a laboratory as compared with facilities without. Clinicians, patients and community leaders in facilities with a laboratory perceived an improved possibility of diagnosing and treating prevalent diseases, resulting in greater satisfaction with the provided services. Laboratory technicians confirmed that patients appreciated having access to laboratory tests. Clinicians, patients and community leaders in facilities without a laboratory protested its lack, claiming that it increased the likelihood of costly referrals, delays and even deaths. Conclusions The study concluded that the laboratory plays an important role in primary level health facilities, as it is associated with greater utilization and perceived higher quality of services. Lack of a laboratory hampers patient management, disease control and financial risk protection. Expansion of the clinical laboratory system at primary level health facilities should be a properly funded priority of the national health system in Mozambique and similar countries.

Background. Timely pulmonary function testing is crucial to improving diagnosis and treatment of pulmonary diseases. Perceptions of poor access at an academic pulmonary function laboratory prompted analysis of system demand and capacity to identify factors contributing to poor access. Methods. Surveys and interviews identified stakeholder perspectives on operational processes and access challenges. Retrospective data on testing demand and resource capacity was analyzed to understand utilization of testing resources. Results. Qualitative analysis demonstrated that stakeholder groups had discrepant views on access and capacity in the laboratory. Mean daily resource utilization was 0.64 (SD 0.15), with monthly average utilization consistently less than 0.75. Reserved testing slots for subspecialty clinics were poorly utilized, leaving many testing slots unfilled. When subspecialty demand exceeded number of reserved slots, there was sufficient capacity in the pulmonary function schedule to accommodate added demand. Findings were shared with stakeholders and influenced scheduling process improvements. Conclusion. This study highlights the importance of operational data to identify causes of poor access, guide system decision-making, and determine effects of improvement initiatives in a variety of healthcare settings. Importantly, simple operational analysis can help to improve efficiency of health systems with little or no added financial investment.

Background Ireland had the highest incidence of prostate cancer in Europe in 2008, due to widespread prostate specific antigen (PSA) testing.AimsTo investigate practices and costs of PSA testing in Ireland, 2008–2010.MethodsPostal laboratory questionnaire. Results were compared with 2006 and 2007 surveys.ResultsResponse rate was 95 % (42/44). In 2010, 37 laboratories measured total PSA (tPSA); 10 measured free PSA (fPSA). Eight assays were used and cut-offs to define ‘normal’ tPSA varied widely. There was a 9.9 % annual increase in the number of tPSA tests and a −31 % annual decrease in the number of fPSA, 2006–2010. A 100-fold difference in tPSA workload was observed across laboratories. In 2010, the estimated cost of PSA testing was €3,649,984 (95 % CI €2,532,745–€4,767,222).ConclusionsHealth service costs of PSA testing are significant. The number of tPSA tests continues to rise; fPSA use fell by almost one-third. Inter-laboratory variation in testing practices persists. These have potentially important clinical consequences for men and need to be addressed.

BackgroundThe Laboratory modernisation process in Ireland will include point of care testing (POCT) as one of its central tenets. However, a previous baseline survey showed that POCT was under-resourced particularly with respect to information technology (IT) and staffing.AimsAn audit was undertaken to see if POCT services had improved since the publication of National Guidelines and if such services were ready for the major changes in laboratory medicine as envisaged by the Health Service Executive.MethodsThe 15 recommendations of the 2007 Guidelines were used as a template for a questionnaire, which was distributed by the Irish External Quality Assessment Scheme.ResultsThirty-nine of a possible 45 acute hospitals replied. Only a quarter of respondent hospitals had POCT committees, however, allocation of staff to POCT had doubled since the first baseline survey. Poor IT infrastructure, the use of unapproved devices, and low levels of adverse incident reporting were still major issues.ConclusionsPoint of care testing remains under-resourced, despite the roll out of such devices throughout the health service including primary care. The present high standards of laboratory medicine may not be maintained if the quality and cost-effectiveness of POCT is not controlled. Adherence to national Guidelines and adequate resourcing is essential to ensure patient safety.

Abstract Objectives To evaluate the effectiveness of practices used to support appropriate clinical laboratory test utilization. Methods This review followed the Centers for Disease Control and Prevention (CDC) Laboratory Medicine Best Practices A6 cycle method. Eligible studies assessed one of the following practices for effect on outcomes relating to over- or underutilization: computerized provider order entry (CPOE), clinical decision support systems/tools (CDSS/CDST), education, feedback, test review, reflex testing, laboratory test utilization (LTU) teams, and any combination of these practices. Eligible outcomes included intermediate, systems outcomes (eg, number of tests ordered/performed and cost of tests), as well as patient-related outcomes (eg, length of hospital stay, readmission rates, morbidity, and mortality). Results Eighty-three studies met inclusion criteria. Fifty-one of these studies could be meta-analyzed. Strength of evidence ratings for each practice ranged from high to insufficient. Conclusion Practice recommendations are made for CPOE (specifically, modifications to existing CPOE), reflex testing, and combined practices. No recommendation for or against could be made for CDSS/CDST, education, feedback, test review, and LTU. Findings from this review serve to inform guidance for future studies.

Management of laboratory test utilization presents an ongoing challenge. Most studies reported in the literature have described efforts to control one or a few tests, but the results cannot be generalized to a broader utilization management strategy. Herein we report our experiences with an organizational utilization management program during a 10-year period. Cumulatively, our program has achieved significant success, saving millions of dollars in blood components and reducing inpatient tests per discharge by 26%. Highlights from our experiences include the importance of implementing an institutional organizational structure to support utilization management, the central role fulfilled by clinical pathologists as leaders of the program, the ability to obtain timely utilization data, and careful selection of the most appropriate implementation tools tailored to the unique circumstances of each utilization management initiative.

Healthcare budgets worldwide are facing increasing pressure to reduce costs and improve efficiency, while maintaining quality. Laboratory testing has not escaped this pressure, particularly since pathology investigations cost the National Health Service £2.5 billion per year. Indeed, the Carter Review, a UK Department of Health-commissioned review of pathology services in England, estimated that 20% of this could be saved by improving pathology services, despite an average annual increase of 8%–10% in workload. One area of increasing importance is managing the demands for pathology tests and reducing inappropriate requesting. The Carter Review estimated that 25% of pathology tests were unnecessary, representing a huge potential waste. Certainly, the large variability in levels of requesting between general practitioners suggests that inappropriate requesting is widespread. Unlocking the key to this variation and implementing measures to reduce inappropriate requesting would have major implications for patients and healthcare resources alike. This article reviews the approaches to demand management. Specifically, it aims to (a) define demand management and inappropriate requesting, (b) assess the drivers for demand management, (c) examine the various approaches used, illustrating the potential of electronic requesting and (d) provide a wider context. It will cover issues, such as educational approaches, information technology opportunities and challenges, vetting, duplicate request identification and management, the role of key performance indicators, profile composition and assessment of downstream impact of inappropriate requesting. Currently, many laboratories are exploring demand management using a plethora of disparate approaches. Hence, this review seeks to provide a ‘toolkit’ with the view to allowing laboratories to develop a standardised demand management strategy.