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Consultation by Clinical Pathologists on
Laboratory Test Selection and Result Interpretation
Michael Laposata, M.D., PhDEdward and Nancy Fody Professor of PathologyProfessor of Medicine
Vanderbilt University School of MedicinePathologist in Chief, Vanderbilt University Hospital
Consultation by Clinical Pathologists on
Laboratory Test Selection and Result Interpretation
Michael Laposata, M.D., PhDEdward and Nancy Fody Professor of PathologyProfessor of Medicine
Vanderbilt University School of MedicinePathologist in Chief, Vanderbilt University Hospital
Consultation by Clinical Pathologists on
Laboratory Test Selection and Result Interpretation
Michael Laposata, M.D., PhD
I have no disclosures to make that are relevant to thispresentation and will make no reference to any specific
product or company with which I am connected.
Consultation by Clinical Pathologists on
Laboratory Test Selection and Result Interpretation
Michael Laposata, M.D., PhD
I have no disclosures to make that are relevant to thispresentation and will make no reference to any specific
product or company with which I am connected.
Consultation by Clinical Pathologists on Laboratory Test Selection and Result Interpretation
•Learn how to assist doctors in selecting the correct laboratory tests.
•Appreciate the value of a personalized, patient specific interpretation of test results in complex clinical laboratory evaluations.
•Learn current developments which will have a potentially great effect on interpretive services in 2011and beyond.
Consultation by Clinical Pathologists on Laboratory Test Selection and Result Interpretation
•Learn how to assist doctors in selecting the correct laboratory tests.
•Appreciate the value of a personalized, patient specific interpretation of test results in complex clinical laboratory evaluations.
•Learn current developments which will have a potentially great effect on interpretive services in 2011and beyond.
Consultation by Clinical Pathologists on Laboratory Test Selection and Result Interpretation
Reflex testing is which of the following?
a) The performance of a group of tests in a panel.b) The performance of tests ordered each day
on the same patient for a week.c) The performance of tests from a single sample in
which one test result indicates the next test to be performed.d) Testing a group of patients with similar findings
with the same test panel.
Consultation by Clinical Pathologists on Laboratory Test Selection and Result Interpretation
Reflex testing is which of the following?
a) The performance of a group of tests in a panel.b) The performance of tests ordered each day
on the same patient for a week.c) The performance of tests from a single sample in
which one test result indicates the next test to be performed.d) Testing a group of patients with similar findings
with the same test panel.
Lundberg, 1981
Error between resultreceipt and action?
Has the right testbeen ordered?
Action
The nine steps in the performance of any laboratorytest. The brain-to-brain turnaround time loop.
Interpretation
Reporting
Analysis
PreparationTransportation
Identification
Collection
Ordering
Two major unmet needs of clinicians from the clinical laboratory
Consultation on :
Appropriate test selection
Correct interpretation of test results
Two major unmet needs of clinicians from the clinical laboratory
Consultation on :
Appropriate test selection
Correct interpretation of test results
The clinical environment --
Today and Yesterday
The clinical environment --
Today and Yesterday
1960 1960
Is There a Need for Advice on Test Selection and Result Interpretation ?
Radiology: Chest/Abdominal Films Bone X-rays
Test Menus
Lab Medicine: Test Menu < 100 Assays
Anatomic Pathology: Autopsy/Biopsy/Surgical Pathology
2011 2011
Is There a Need for Advice on Test Selection and Result Interpretation?
Radiology: Dozens of imaging modalities
Test Menus
Lab Medicine: Test Menu > 2000 Assays without the impending thousands of genetic tests
Anatomic Pathology: Autopsy/Biopsy/Surgical Pathology/Cytopathology
Consequences of Vast Array of Testing Options
Consequences of Vast Array of Testing Options
Doctors pick unnecessary tests or miss the necessary ones
Dozens of approaches emerge for diagnosis of the same condition – some better than others
The correct diagnosis may be achievable promptly, but it is missed or very commonly delayed, with adverse clinical consequences to the patient and/or adverse financial consequences to the institution.
Diagnostic Test Advice Has Been Provided for a Long Time in Radiology and Anatomic Pathology
- but not in Lab Medicine
Diagnostic Test Advice Has Been Provided for a Long Time in Radiology and Anatomic Pathology
- but not in Lab Medicine
Within Radiology: Treating doctors informally consult radiologists about diagnostic testing.
Within Anatomic Pathology: Treating doctors can learn best testing among biopsy, surgical pathology, cytopathology – because further testing such as immunochemistry, is guided by pathologist and not treating doctor.
Patient safety errors associated with incorrect laboratory test selection and misinterpretation of test results have
been largely unrecognized for 20 years:
A 40-year review of the literature
Patient safety errors associated with incorrect laboratory test selection and misinterpretation of test results have
been largely unrecognized for 20 years:
A 40-year review of the literature
The number of articles written per decade since 1970 that discussed the problem
of too many tests being ordered (left bar in pair) and the number of papers written
offering a solution to the problem (right bar in pair)
The number of articles written per decade since 1970 that discussed the problem
of too many tests being ordered (left bar in pair) and the number of papers written
offering a solution to the problem (right bar in pair)
The number of articles written per decade since 1970 that discussed the problem of errors in test selection (left bar in pair) and the number of
papers written offering a solution to the problem (right bar in pair)
The number of articles written per decade since 1970 that discussed the problem of errors in test result interpretation (left bar in pair) and the number of papers written
offering a solution to the problem (right bar in pair)
Number of articles written per decade since 1970 regarding the adverse outcomes as a result of errors in test selection and result interpretation
Amount of information
available
Amount of information possible to
knowModified from Dr. Bill Stead
1990 2000 2009
The rapid growthof molecular testing begins
In the last decade it has become virtually impossible to have enough facts in one’s brain to provide optimum care
In the last decade it has become virtually impossible to have enough facts in one’s brain to provide optimum care
Challenge # 1:Too many lab tests from which to select
Challenge # 1:Too many lab tests from which to select
What is the challenge introduced with the availability of molecular
diagnostic testing ?
The example of cystic fibrosis
What is the challenge introduced with the availability of molecular
diagnostic testing ?
The example of cystic fibrosis
The Diagnosis of Cystic Fibrosis in the Mid-1980s
The Diagnosis of Cystic Fibrosis in the Mid-1980s
• Use of the sweat chloride test
• No genetic testing
The Diagnosis of Cystic Fibrosis in the Mid-1990s
The Diagnosis of Cystic Fibrosis in the Mid-1990s
• Use of the sweat chloride test
• Genetic testing for less than 50 mutations
The Diagnosis of Cystic Fibrosis in the Mid-2000s
The Diagnosis of Cystic Fibrosis in the Mid-2000s
• Use of the sweat chloride test
• Genetic testing for hundreds of mutationswould be informative because minor cystic fibrosis mutations have become associated with chronic sinusitis and chronic pancreatitis -
But testing for these indications is not often performed
The Diagnosis of Cystic Fibrosis in the Mid-2000s
The Diagnosis of Cystic Fibrosis in the Mid-2000s
• Use of the sweat chloride test
• Genetic testing for hundreds of mutationswould be informative because minor cystic fibrosis mutations have become associated with chronic sinusitis and chronic pancreatitis
And now, it is realized that individual mutations are now classified into groups 1 to 5 and treatment for patients in these groups may be different !
CDC sponsored activities to improve patient safety by reducing incorrect test selection and
misinterpretation of test results
CDC sponsored activities to improve patient safety by reducing incorrect test selection and
misinterpretation of test resultsThe Clinical Laboratory Integration into Healthcare CollaborativeTM is currently
active
And
Each of its projects to improve the correct selection of laboratory tests and the interpretation of test results is briefly described in this presentation
Challenge # 1:Too many lab tests from which to select
Challenge # 1:Too many lab tests from which to select
Project to illustrate the challenge ofcorrect test selection for clinicians
There are many tests in diagnostic coagulation – how difficult is
correct test selection for evaluation of a patient with a prolonged PTT ?
Project to illustrate the challenge ofcorrect test selection for clinicians
There are many tests in diagnostic coagulation – how difficult is
correct test selection for evaluation of a patient with a prolonged PTT ?
Project co-leaders : Marisa Marques and Michael LaposataProject co-leaders : Marisa Marques and Michael Laposata
Challenge # 1:Too many lab tests from which to select
Challenge # 1:Too many lab tests from which to select
3 experts in clinical coagulation were askedto independently design algorithms for
evaluation of a prolonged PTT
The hypothesis was that a simple algorithmcould be used to help clinicians correctly select
tests to effectively evaluate such patients
3 experts in clinical coagulation were askedto independently design algorithms for
evaluation of a prolonged PTT
The hypothesis was that a simple algorithmcould be used to help clinicians correctly select
tests to effectively evaluate such patients
Is this the correct evaluation of a prolonged PTT for every patient?
Degrade heparin in sample and repeat PTT -if the PTT normalizes, heparin is the cause
PTT Normalizes PTT remains prolonged
PTT mixing study (50:50 mix of patient & normal plasma)
Factor deficiency-measure factors VIII,
IX, XI, and XII
Inhibitor, most often a Lupus anti-coagulant; may be a Factor VIII inhibitor if PTT mixing study first normalizes and then becomes
prolonged
Perform tests for specific inhibitor suggested by results of PTT mixing study
Challenge # 1:Too many lab tests from which to select
Challenge # 1:Too many lab tests from which to select
The experts concluded that one universal algorithm failed to suggest the correct tests to evaluate a prolonged PTT in a large
percentage of cases-
Clinical variables – limited in number – also needed to be considered to order the correct tests
Notably, whether the patient is bleeding, is an inpatient or outpatient, and if the patient is a neonate
Three different algorithms had to be designed to maximize the likelihood for correct test selection to evaluate a prolonged PTT
Challenge # 1:Too many lab tests from which to select
Challenge # 1:Too many lab tests from which to select
Conclusion : Even in the absence of molecular testing in the evaluation of a prolonged PTT, selection of the correct tests to
evaluate a prolonged PTT is a significant challenge for most clinicians –
Because there is not only a large number of tests to consider, but depending on the clinical circumstances, different large
groups of tests may need to be considered –
Even for the simple evaluation of a prolonged PTT
Challenge # 1:Too many lab tests from which to select
Challenge # 1:Too many lab tests from which to select
Potential Solution
Extensive development of acceptable testing algorithms developed by experts for clinicians
to use –
That actually makes it difficult to order the incorrect tests – as an Iphone Application !
Challenge # 2: Inconsistent test nomenclature across
laboratories for the same test
Challenge # 2: Inconsistent test nomenclature across
laboratories for the same test
With the large number of names and abbreviations for the same test –
How can the clinician know with certainty if the test selected is the desired one ?
Project co-leaders : Elissa Passiment and James MeiselProject co-leaders : Elissa Passiment and James Meisel
Existing nomenclature options for vitamin D and its multiple forms
Existing nomenclature options for vitamin D and its multiple forms
:
Vitamin D2ErgosterolVitamin D3Cholecalciferol25-0H vitamin D225-0H vitamin D325-0H vitamin D25 hydroxy vitamin D225 hydroxy vitamin D325 hydroxy vitamin D1,25 (OH)2 vitamin D21,25 (OH)2 vitamin D31,25 (OH)2 vitamin D1,25 dihydroxy vitamin D21,25 dihydroxy vitamin D31,25 dihydroxy vitamin DVitamin D 25 Hydroxy D2 and D3Vitamin D 1,25 Dihydroxy
In addition –
The number of abbreviationscreated for laboratory informationsystems for vitamin D and itsmultiple forms is almost limitless
In addition –
The number of abbreviationscreated for laboratory informationsystems for vitamin D and itsmultiple forms is almost limitless
Challenge # 2: Inconsistent test nomenclature across
laboratories for the same test
Challenge # 2: Inconsistent test nomenclature across
laboratories for the same test
Potential solution
Software development that processes clinician test requests and compares named tests to
those in a large indexed database of names and abbreviations and asks the clinician
“Did you mean…” if there is any uncertainty
Challenge # 3:Significant variability in clinician use of laboratory tests
Challenge # 3:Significant variability in clinician use of laboratory tests
It is important to determine what practicing clinicians know about laboratory test selection and result interpretation
A project was initiated to survey cliniciansto determine the opportunity for improved assistance on laboratory test selection and result interpretation
This would include laboratory consultation and enhanced decision support
Project leader : John Hickner
Challenge # 3:Significant variability in clinician use of laboratory tests
Challenge # 3:Significant variability in clinician use of laboratory tests
Establish from focus groups of physicians “behind the glass”, key challenges physicians
face in laboratory test ordering and result reporting / interpretation
Then
Use results of the national survey of primary care physicians to identify strategies that lessen
those challenges
MethodsMethods
• Subject areas – Atlanta
• Laboratory test ordering and result interpretation
– San Antonio• Laboratory test ordering
– Ann Arbor• Laboratory test interpretation
Challenge # 3:Significant variability in clinician use of laboratory tests
Challenge # 3:Significant variability in clinician use of laboratory tests
Results from behind the glass interviews indicate that :
Some physicians continue to use only routine tests for diagnosis and are confident with their knowledge about a limited number of
test results
Some physicians understand their lack of knowledge in test ordering and test interpretation but turn most frequently to resources, such
as online resources and colleagues, for help
Nearly all physicians do not think of consulting with the laboratory but are very desirable of expert information from laboratory
directors, if it were easily available.
Behind the Glass CommentsBehind the Glass Comments
• Issues with accessing and communicating with laboratories“You don’t talk to a Radiologist or Pharmacist in a hospital, you talk to a colleague. You talk to a lab, it’s a black box…”
• Access and relationships with laboratory professionals
“I don’t think about say calling the clinical pathologist. They have not made themselves available to help me; I don’t know who they are”
• Difficulties in accessing and communicating with laboratory professionals
“Getting through the maze on the telephone [with the laboratory] is difficult.”
Behind the Glass CommentsBehind the Glass Comments
• Follow-up testing information and reflex testing, when appropriate
“there’s no follow-up, it’s up to us, if we miss it…Why couldn’t they have some reminder system in the lab for abnormal results?”
• Using laboratory consultation for advice is less common and pathologists and other laboratory professionals are generally seen as somewhat inaccessible than other medical professionals
Questionnaire DevelopmentQuestionnaire Development
• Questionnaire development by core Focus Group team– CDC representatives– Expert consultants– Survey research experts
• Development process included:– Iterative refinement of drafts by core team– Cognitive testing with primary care physicians– Expert review by national authorities
Survey MethodsSurvey Methods
• National sample of Family Practice and Internal Medicine physicians drawn from AMA Master File
• Target sample size of 1600 cases• Survey delivered via Web• Full OMB approval • Robust statistical design to support analysis
Potential SolutionsPotential Solutions
• Prioritize the problems identified by users of the clinical laboratory as the results emerge at the end of 2011
• Address them with appropriate resources
Challenge # 4: Lack of data on the impact of advice on test selection and
result interpretation
Challenge # 4: Lack of data on the impact of advice on test selection and
result interpretation
The Prospective Generation of Data to Test Whether:
Failing to order necessary laboratory tests delays diagnosis, appropriate treatment and/or worsens
patient outcomes
and if
Inappropriate utilization of laboratory test results delays diagnosis, appropriate treatment and/or worsens
patient outcomes
Research on Improvements in Test Selection and Result Interpretation by Clinicians (ITSRI)
Research on Improvements in Test Selection and Result Interpretation by Clinicians (ITSRI)
Do Errors in Test Selection and Result Interpretation Adversely Affect
Patient Outcome ?
Project leader : Paul Epner
Research on Improvements in Test Selection and Result Interpretation by Clinicians (ITSRI)
Research on Improvements in Test Selection and Result Interpretation by Clinicians (ITSRI)
Studies will be performed in multiple clinical areas :
Hepatitis, Coagulation, Autoimmunity, Thyroid, Tumor Markers
In several medical centers
Research on Improvements in Test Selection and Result Interpretation by Clinicians (ITSRI)
Research on Improvements in Test Selection and Result Interpretation by Clinicians (ITSRI)
To establish a system in pilot studies which estimates the magnitude of the problems of incorrect test
selection and result interpretation
To use the data from the pilot studies to establish an assessment system for errors in test selection and result interpretation across the field of laboratory
medicine
Challenge # 5:Limited teaching of laboratory medicine in US
medical schools
Challenge # 5:Limited teaching of laboratory medicine in US
medical schools
A project will be performed to collect data from medical schools in the US that reveal :
The amount of instruction on test selection and result interpretation
And
The courses in which such training exists
Project Co-leaders : Brian Smith and John Hickner
What is taught to students becoming physicians in the US?What is taught to students becoming physicians in the US?
The limited knowledge of clinicians about how the laboratory functions and how to interpret test results may
have arisen because the pathology taught in medical school is predominantly anatomic pathology
To pass, most medical students must know what a heart looks like under the microscope after a heart attack – and
not what blood tests are needed to diagnose a heart attack
But no one does a heart biopsy to diagnose a heart attack!
Challenge # 5:Limited teaching of laboratory medicine in US medical schools
Challenge # 5:Limited teaching of laboratory medicine in US medical schools
In the coming months, the survey will be prepared and sent to all medical schools in the United States
Medical students in the individual schools will assist in the completion of the survey of the curriculum
Collaborators from the American Medical Student Association and the American Association of Medical Colleges will assist in
the design and distribution of the survey
Survey MethodsSurvey Methods
Goal: Survey all 133 allopathic and 26 osteopathic U.S medical schools
Letter to Deputy Dean for Education, Course Director for Laboratory Medicine & Pathology, accompanied by letter of support from CDC
Recruit one medical student (via AMSA) per school to help complete the survey. Incentive: lottery for 3 iPads for the students (not the faculty)
Analyze survey and subdivide by basic demographics
Potential SolutionsPotential Solutions
Include a required rotation in the clinical years that involves exposure to the diagnostic specialties, including laboratory medicine
Include laboratory medicine concepts in the pre-clinical curriculum in some way
Challenge # 6:Lack of training on clinical consultation during
laboratory medicine residency and clinical fellowships
Challenge # 6:Lack of training on clinical consultation during
laboratory medicine residency and clinical fellowships
Major goals of this project in the coming months for pathology residents
To collect from educators and residents perceptions about components of training that promote the trainees' ability to
provide consultative service in laboratory medicine
To observe resident training activities identified by educators of residents as promoting the trainees' ability to provide consultative
service
Project co-leaders : Robert Hoffman and Michael LaposataProject co-leaders : Robert Hoffman and Michael Laposata
Survey Design:Survey Design:
• Goals:– To study in multiple academic institutions,
assess resident training activities identified by the program as providing education in consultative practice in clinical pathology.
• Method:– Observational study:
• Solicit participation from program directors
• Observe practices identified
Design:Design:
• Method:– 14 accredited programs within 300 miles of Nashville, 8
States in Southeast and Midwest– Email to program directors soliciting participation
• Project in support of a CDC-sponsored work group• IRB-approved• No “right” answers• Looking for practices and barriers to implementation• Participating sites not to be named in presentations
– Follow-up emails if no response– Arrange visits to observe training activities
Results:Results:
• 14 programs contacted– 8 responses
• 5 declined participation• 3 site visits
– 6 non-responders even after follow-up
Some responses from decliners:Some responses from decliners:
• “You would be surprised to see how little consultation there is.”
• “Nothing to show.”• “CP people are not interested in
participating.”• “After two requests to CP faculty, no
interest in participation.”• “Visit not feasible at this time per
department leadership.”
Clinical Laboratory Integration into Healthcare CollaborativeTMClinical Laboratory Integration into Healthcare CollaborativeTM
• Co-Lead: John Hickner, MD, MSc Cleveland Clinic
• Co-Lead: Michael Laposata, MD, PhD Vanderbilt University Hospital • Scott Endsley MD, MSc
Cleveland Clinic
• Paul Epner, MEd, MBA Paul Epner, LLC
• Marisa B. Marques, MD University of Alabama at Birmingham
• James L. Meisel, MD Boston Medical Center
• Elissa Passiment, EdM
American Society for Clinical Laboratory Science
• Brian Smith, MD
Yale School of Medicine
Collaborative Group SupportCollaborative Group Support
Altarum
• Kim Bellis• Beth Costello• Fabian D'Souza• Jim Lee• Dana Loughrey • Megan Shaheen• Tom Wilkinson
CDC
Julie Taylor – Leader of CDC Team
• Diane Bosse
• MariBeth Gagnon
• James Peterson
• Anne Pollock
• Pam Thompson
An Overview of Existing and Planned Diagnostic Management
Teams --
at Vanderbilt
An Overview of Existing and Planned Diagnostic Management
Teams --
at Vanderbilt
Diagnostic Management Teams introduce a system which minimizes the risk for :
Underutilization and Overutilization of tests
Misinterpretation of Test Results because :
•There is limited knowledge about the significance of the test results in achieving a specific diagnosis
•There is uncertainty or lack of knowledge about whether a result truly reflects a disease state or a condition – do the results reflect false positives or false negatives because of
analytical interferences
like drugs or hemolysis from difficult sample collection
or clinical conditions like hyperlipidemia, pregnancy, or an acute phase response
Diagnostic Management Teams introduce a system which minimizes the risk for :
Underutilization and Overutilization of tests
Misinterpretation of Test Results because :
•There is limited knowledge about the significance of the test results in achieving a specific diagnosis
•There is uncertainty or lack of knowledge about whether a result truly reflects a disease state or a condition – do the results reflect false positives or false negatives because of
analytical interferences
like drugs or hemolysis from difficult sample collection
or clinical conditions like hyperlipidemia, pregnancy, or an acute phase response
Coagulation Rounds Coagulation Rounds
Coagulation Lab
Neurology
Multiple Attendings
Expert Driven, PatientSpecific Diagnostic
Interpretation
Diagnostic Test SelectionAlgorithms
Selected by TreatingPhysicians
Financial Benefits:On Test Selection
On DiagnosisBut Difficult to
Quantify
Cardiology
HematologyOncology
Ob-Gyn
Rheumatology
Hematopathology RoundsHematopathology Rounds
Expert Driven,Patient Specific Interpretation
of Tests FromMultiple Laboratories Synthesized
by the Hematopathologist
Financial Benefits:Easily Quantifiablefor Test Selection
Less Easily Quantifiablefor Improved Diagnostic
Speed and Accuracy
Diagnostic Test Selectionby Hematopathologists
Hematologic-OncologistsPresented With Case
of Hematologic Malignancy
Histopathology
Molecular Genetics
Cytogenetics FlowCytometry
Multiple Attendings
Transfusion Medicine RoundsTransfusion Medicine Rounds
Expert Driven,Patient Specific Interpretations
on Appropriateness ofTransfusion, Adverse Events
Associated With Transfusion, andIdentify Underlying Diagnosis
Financial Benefits:Improved UtilizationOf Blood ProductsEasily Quantified
Less Easily Quantifiablefor Improved Diagnostic
Speed and Accuracy
A Review of allPreoperative Cases WithProlonged PT or PTT or
Low Platelet Count toEstablish Diagnosis and
Develop Treatment Plan for Excess Bleeding
All Clinical Services ProvidingBlood Products – With
Dominant Users IncludingSurgery/Anesthesia,
Hematology/Oncology,Emergency Department
Multiple AttendingsBlood Bank
All Clinical Services EvaluatingPatients for Infectious Disease –
With Infectious DiseaseDivision as Prominent User
Microbiology RoundsMicrobiology Rounds
Microbiology Laboratories(Including Virology and
Molecular Infectious Disease)
Multiple Attendings
Expert Driven,Patient Specific Interpretations
(With Regular Follow Up by DMT)For Clinically or
Diagnostically Complex Cases – Define Ad Hoc Now and
Formally With Increased Experience
Financial Benefits:Improved Use of Antibiotics
Could be Quantified
Less Easily Quantifiablefor Improved Diagnostic
Speed and Accuracy
Expert Driven,Patient-Specific
Interpretation of TestsFrom Multiple Areas –
Synthesized by the Pathologist
Financial Benefits:Increased Diagnostic Speed and Accuracy May be Highly Recognized by Oncologists
Diagnostic Test Selectionby Pathologists
OncologistPresented With Case
of Malignancy inOrgan
Histopathology
Immunohisto chemistry
Cytogenetics MolecularGenetics
Multiple Attendings
On The Drawing Board For Anatomic Pathology: The Diagnosis of Cancer in Multiple Organs and Tissues
On The Drawing Board For Anatomic Pathology: The Diagnosis of Cancer in Multiple Organs and Tissues
Coagulation Rounds Coagulation Rounds
Coagulation Lab
Neurology
Multiple Attendings
Expert Driven, PatientSpecific Diagnostic
Interpretation
Diagnostic Test SelectionAlgorithms
Selected by TreatingPhysicians
Financial Benefits:On Test Selection
On DiagnosisBut Difficult to
Quantify
Cardiology
HematologyOncology
Ob-Gyn
Rheumatology
Coagulation Rounds – Predominant Case Material
Coagulation Rounds – Predominant Case Material
For All Clinical Services
For the patient with a prolonged PT, PTT or both – what is the explanation for the prolongation and, possibly, what is the risk of bleeding or thrombosis?
Coagulation Rounds – Predominant Case Material
Coagulation Rounds – Predominant Case Material
Hematology and any clinical service including surgery
For the adult or pediatric patient with a deep vein thrombosis and or pulmonary embolism – is a hypercoagulable state contributory to the thrombotic event? Do the test results suggest the need for lifelong anticoagulation?
Coagulation Rounds – Predominant Case Material
Coagulation Rounds – Predominant Case Material
For any clinical service including surgery
For the bleeding patient - Does the patient have von Willebrand’s disease? Does the patient have a platelet function disorder? Does the patient have a coagulation factor defiency and if so, what is the cause of the defiency? Does the patient have DIC?
Coagulation Rounds – Predominant Case Material
Coagulation Rounds – Predominant Case Material
Neurology
For thrombotic strokes – is there a hypercoagulable state contributing to cause(s) for stroke?
Coagulation Rounds – Predominant Case Material
Coagulation Rounds – Predominant Case Material
Obstetrics & Gynecology
For the woman with pregnancy losses – is there a hypercoagulable state to explain the fetal loss(es)
Coagulation Rounds – Predominant Case Material
Coagulation Rounds – Predominant Case Material
Renal
For pre-transplant evaluation – is there a hypercoagulable state that would cause us to remove this patient from the transplant list?
Coagulation Rounds – Predominant Case Material
Coagulation Rounds – Predominant Case Material
Rheumatology
For the adult or pediatric patient with autoimmune disease – is there an antiphospholipid antibody that presents an increased thrombotic risk in this patient?
Coagulation Rounds – Predominant Case Material
Coagulation Rounds – Predominant Case Material
For Pediatrics
In the bruised child – is there any evidence of a bleeding disorder to account for the bruising or is child abuse more likely?
Coagulation Rounds Impact on Test Selection
Coagulation Rounds Impact on Test Selection
• It helps test selection by involving reflex test algorithms and panels of related tests.
• It saves dollars on lab tests and tech time when it reduces unnecessary tests – but it is impossible to know what unnecessary tests might have been ordered.
• It allows residents on the coagulation service to confer with doctors ordering tests that are likely to be uninformative, often before they are performed.
Coagulation Rounds Impact on Establishing a Diagnosis
Coagulation Rounds Impact on Establishing a Diagnosis
• It brings a subspecialist and a trainee into every case involving the special coagulation lab – without need for a consult request – simply by ordering the lab test .
• It identifies for the clinician a coagulation expert and related resident to call for a free curbside consultation, often connected to a narrative interpretation.
• It identifies a coagulation expert to provide continuing medical education in departmental seminars.
Coagulation Rounds Impact on Establishing a Diagnosis
Coagulation Rounds Impact on Establishing a Diagnosis
R. Lawrence Van Horn, Ph.D, MPH, MBAAssoc. Prof. of Economics and Management
Exec. Dir. Of Health AffairsThe Owen Graduate School of Business Administration
Director, Office of Sustainable Health Care FinanceInstitute of Medicine & Public Health
School of Medicine
Preliminary Observations on Impact of Coagulation DMT
Preliminary Observations on Impact of Coagulation DMT
“Diagnostic Latency” - I“Diagnostic Latency” - I
• Tests ordered when patient admitted on Monday.
• Results back Tuesday with several abnormal results.
• Action taken on Wednesday with further evaluation.
“Diagnostic Latency” - II“Diagnostic Latency” - II
• Diagnosis and discharge plan on Thursday. Patient gone by 3 PM.
Length of Stay: 4 days
No Diagnostic Latency - INo Diagnostic Latency - I
• Tests ordered when patient admitted on Monday.
• Results to coagulation rounds with preliminary interpretation by coagulation resident Monday at 4:00 p.m.
• Patient specific, expert driven narrative completed by 6:00 p.m. Monday and into medical record.
No Diagnostic Latency - IINo Diagnostic Latency - II
• Further evaluation Tuesday.
• Discharge on Wednesday.
Length of Stay: 3 days
Limiting factor for some evaluations: Not all assays done daily Monday-Friday, delayingnarrative and increasing length of stay.
0K 5K 10K 15K 20K 25K 30K 35K 40K 45K 50K 55K 60K 65K 70K 75K 80K 85K
TOTAL_CHARGES
0
1
2
3
4
5
6
7
8
9
los
Percent of Cases with LOSgreater or equal to 4 days
Jan - Jul (Before) 36.75%Aug - Dec (After) 12.50%Chi-sq significant at .05
Bottom Line:It appears that the changes in the median LOS aredue to truncation of the right tail.
Comparison of Length of Stay and Total Charges Pre and Post Aug 1, 2010
August 1
After
Before
MSDRG 176: PE MSDRG 176: PE
10K 20K 30K 40K 50K 60K 70K 80K 90K 100K 110K 120K 130K 140K 150K 160K
TOTAL_CHARGES
0
5
10
15
20
los
Percent of Cases with LOSgreater or equal to 10 days
Jan - Jul (Before) 14.5%Aug - Dec (After) 2.25%Chi-sq significant at .05.
Bottom line:It appears that the changes in median LOS aredue to truncation of the right tail.
Comparison of Length of Stay and Total Charges Pre and Post Aug 1, 2010
August 1
After
Before
MSDRG 65 Intracranial HemorrhageMSDRG 65 Intracranial Hemorrhage
Can diagnostic management team activity be exported to institutions that have many
barriers to implementation of such a service?
Can diagnostic management team activity be exported to institutions that have many
barriers to implementation of such a service?
“What’s in the Box” from Vanderbilt?
Test selection algorithms and test panel recommendations
Enabling software for creation of interpretations
Reliable and simple connection to Vanderbilt DMTs using Skype if possible
Billing information to collect revenue for interpretations for as long as it is available
Templates for local physician surveys of clinical benefits of the DMT service in the receiving institution – and for collection of
local data on savings from use of the diagnostic service
“What’s in the Box” from Vanderbilt?
Test selection algorithms and test panel recommendations
Enabling software for creation of interpretations
Reliable and simple connection to Vanderbilt DMTs using Skype if possible
Billing information to collect revenue for interpretations for as long as it is available
Templates for local physician surveys of clinical benefits of the DMT service in the receiving institution – and for collection of
local data on savings from use of the diagnostic service
Recommended