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LABORATORY LABORATORY UTILIZATION & QUALITY UTILIZATION & QUALITY
OUTCOMESOUTCOMES
What Are The Issues?What Are The Issues?
Impetus For Greater Control
Cost of health careCost of health care Solvency of Medicare programSolvency of Medicare program Medical necessity rulesMedical necessity rules Consumer demandsConsumer demands
Employers and patientsEmployers and patients
Failures In U.S. Health Care System
No coordination between major No coordination between major playersplayers
Vested interests drive medical Vested interests drive medical decisionsdecisions
Little interest in “whole Little interest in “whole person”, prevention and person”, prevention and wellnesswellness
Limited resourcesLimited resources No systemNo system
Dartmouth Studies
The level of physicians and hospital The level of physicians and hospital beds drive demandbeds drive demand
Physician and hospital preference, Physician and hospital preference, not patient need, drive health care not patient need, drive health care services in a communityservices in a community
The number of surgical procedures The number of surgical procedures vary geographicallyvary geographically
Likelihood of a diagnosis varies by Likelihood of a diagnosis varies by locationlocation
Support Study
Many Americans die in Many Americans die in hospitals, alone and in pain, hospitals, alone and in pain, after receiving treatment after receiving treatment regimens undertaken with regimens undertaken with knownknown unfavorable odds unfavorable odds
Regional Variations in Diagnostic Practices
There is substantial regional There is substantial regional variability in test ordering variability in test ordering practices that cannot be practices that cannot be explained by case mixexplained by case mix
Song, Y. et al. (2010). Song, Y. et al. (2010). – New England Journal of Medicine.
http://www.nejm.org/doi/pdf/10.1056/NEJMsa0910881
Diagnosis And Management Of
Polycythemia Vera In the era since the Polycythemia
Vera Study Group formulated its formulated its recommendationsrecommendations
Significant variations in diagnostic and therapeutic approach were evident by region, practice type, specialty, and clinical experience.
Streiff et al. Blood February 15, 2002 vol. 99 no. 4 1144-1149
Future Needs
Baby boomers demanding Baby boomers demanding disease preventiondisease prevention
Controversies about a variety of Controversies about a variety of environmental effects on healthenvironmental effects on health
Obsession with weight Obsession with weight Obsession with exerciseObsession with exercise Popularity of self-testingPopularity of self-testing Internet access to range of medical Internet access to range of medical
informationinformation
New Attitude
Emphasis on prevention and Emphasis on prevention and wellnesswellness
Skepticism for physicians and Skepticism for physicians and health care systemshealth care systems
Reluctantly aging population Reluctantly aging population
Primary Questions
How do we control utilization of How do we control utilization of our services?our services?– Control, not limitControl, not limit
What knowledge do healthcare What knowledge do healthcare providers need to use laboratory providers need to use laboratory services appropriately?services appropriately?
What We Know
FactsFacts AnecdotesAnecdotes StudiesStudies
Overutilization
Study in APRIL 1998 Issue of Study in APRIL 1998 Issue of American Journal of MedicineAmerican Journal of Medicine
Supported by Agency for Health Supported by Agency for Health Care Policy and ResearchCare Policy and Research
Many clinical laboratory tests Many clinical laboratory tests redundantredundant
Review of 6,000 charts looking for Review of 6,000 charts looking for 12 standard tests12 standard tests
Chart revealed no clinical need for Chart revealed no clinical need for 92% of repeats92% of repeats
Abnormal Test Results
Study in February 1996 Study in February 1996 Archives Archives Of Internal MedicineOf Internal Medicine
36% of physicians do not always 36% of physicians do not always notify patients of abnormal lab notify patients of abnormal lab resultsresults
Some wait till next visitSome wait till next visit Most don’t document Most don’t document
communicating the results to the communicating the results to the patientpatient
Abnormal Test Results
28% of physicians always notify 28% of physicians always notify patients of normal and abnormal patients of normal and abnormal resultsresults
72% let patients assume that “no 72% let patients assume that “no news is good news”news is good news”
Lack of follow-up can have a Lack of follow-up can have a negative effect on patient carenegative effect on patient care
Physician Ordering Patterns
Quest to collect dataQuest to collect data Gather information to justify Gather information to justify
decisionsdecisions Avoid criticism for not Avoid criticism for not
ordering a testordering a test Traditional ordersTraditional orders
– How they were taughtHow they were taught
Physician Ordering
Many studies to change Many studies to change behavior have been behavior have been conductedconducted
Most work during the Most work during the intervention but behavior intervention but behavior reverted after study stoppedreverted after study stopped
Benchmark Information
Many common preoperative Many common preoperative tests not of valuetests not of value
Drug utilization costs drop with Drug utilization costs drop with lab informationlab information
Cost to diagnose and treat Cost to diagnose and treat suspected MI reduced with lab suspected MI reduced with lab teststests
Benchmark Information
Lifetime expenses/diabetic Lifetime expenses/diabetic decrease with control of decrease with control of disease through close disease through close monitoring of glucose and monitoring of glucose and glycohemoglobinglycohemoglobin
PAP testing - more than 20 PAP testing - more than 20 years of data support years of data support screening benefitsscreening benefits
Benchmark Information Needed
Focus diagnosesFocus diagnoses Disease/organ specificDisease/organ specific Effectively prescribeEffectively prescribe
Direct optimal therapyDirect optimal therapy Disease progressDisease progress Drug levelsDrug levels Treatment responseTreatment response
Optimize wellnessOptimize wellness
Successful Strategies
Provide test costs at order Provide test costs at order entryentry
Change order formsChange order forms Algorithms, reflex testing, Algorithms, reflex testing,
pathways, case managementpathways, case management Financial incentivesFinancial incentives Physician Physician
education/consultationeducation/consultation
Evidence-based Medicine
Support some strategies?Support some strategies? Use current, best evidence to Use current, best evidence to
make patient care decisionsmake patient care decisions Conduct research & meta-analysesConduct research & meta-analyses Clinician must know how to Clinician must know how to
access, read and interpret valid access, read and interpret valid researchresearch
““First, payers want appropriate utilization for First, payers want appropriate utilization for expensive genetic and molecular assays,” expensive genetic and molecular assays,” observed Zubiller. observed Zubiller.
““Labs are perfectly positioned to work with Labs are perfectly positioned to work with clinicians at the time of a test order to determine clinicians at the time of a test order to determine if that genetic test is appropriate for that patient. if that genetic test is appropriate for that patient. Doing so could have a dramatic impact on the Doing so could have a dramatic impact on the follow-on care decisions. follow-on care decisions.
This will require labs to be more interactive with This will require labs to be more interactive with their client physicians, and integrated informatics their client physicians, and integrated informatics for clinical for clinical decision support is one way to deliver is one way to deliver this added value service. this added value service.
Matthew Zubiller, Vice President and Matthew Zubiller, Vice President and General Manager of General Manager of Advanced Diagnostic Management, a , a business unit of McKesson business unit of McKesson Corporation. Corporation.
That is why we see payers beginning That is why we see payers beginning to implement utilization management to implement utilization management requirements like pre-authorization requirements like pre-authorization and notifications and notifications
MuirLab is the core laboratory and outreach MuirLab is the core laboratory and outreach laboratory service of the laboratory service of the John Muir Health System..
It has implemented an evidence-based It has implemented an evidence-based automated diagnostic platform that enables it to automated diagnostic platform that enables it to collaborate in real-time with providers and payers collaborate in real-time with providers and payers and ensure that the most appropriate tests were and ensure that the most appropriate tests were being ordered by physicians at the point of care. being ordered by physicians at the point of care.
This resulted in improved utilization of clinical This resulted in improved utilization of clinical tests and increased revenues, thanks to a tests and increased revenues, thanks to a marked decrease in claims denials. marked decrease in claims denials.
CDC CDC Projects
2007 CDC Institute Integration Workgroup to focus on
better integration of laboratory medicine in the health care continuumNeed to optimize utilization of laboratory
services for better patient care Now called Clinical Laboratory
Integration into Healthcare Collaborative
(CLIHC)TM
CLIHCTM Workgroup
Co-Lead: John Hickner, MD, MScCo-Lead: John Hickner, MD, MSc University of ChicagoUniversity of Chicago
Co-Lead: Michael Laposata, MD, Co-Lead: Michael Laposata, MD, PhD PhD
Vanderbilt University HospitalVanderbilt University Hospital Paul Epner, MEd, MBAPaul Epner, MEd, MBA
Paul Epner, LLCPaul Epner, LLC
Marisa B. Marques, MDMarisa B. Marques, MD University of Alabama at Birmingham University of Alabama at Birmingham
Jim L. Meisel, MD, FACPJim L. Meisel, MD, FACP
Boston Medical CenterBoston Medical Center
Elissa Passiment, EdMElissa Passiment, EdM
American Society for Clinical American Society for Clinical Laboratory Science Laboratory Science
Brian Smith, MDBrian Smith, MD
Yale School of MedicineYale School of Medicine
CLIHCTM Workgroup Support
CDC:CDC: Diane BosseDiane Bosse MariBeth GagnonMariBeth Gagnon Maryam DaneshvarMaryam Daneshvar Anne PollockAnne Pollock Julie Taylor*Julie Taylor* Pam ThompsonPam Thompson Nancy CornishNancy Cornish
Others Participating in CLIHCOthers Participating in CLIHCTM TM ProjectsProjects
Samir Aleryani, PhDSamir Aleryani, PhDVanderbilt University Medical CenterVanderbilt University Medical Center
Julian Barth, MDJulian Barth, MDUniversity of Leeds, United Kingdom University of Leeds, United Kingdom
Allison Floyd, MDAllison Floyd, MDVanderbilt University Medical CenterVanderbilt University Medical Center
John Fontanesi, PhDJohn Fontanesi, PhDUniversity of California at San Diego University of California at San Diego
George A. Fritsma, MS MT (ASCP)George A. Fritsma, MS MT (ASCP)University of Alabama at BirminghamUniversity of Alabama at Birmingham
John A. Gerlach, PhDJohn A. Gerlach, PhD Michigan State UniversityMichigan State University
Robert D. Hoffman, MD, PhD Vanderbilt University Medical Center
Katherine Kahn, MDRand Corporation and UCLA
Mario Plebani, MDUniversity of Padua, Italy
Mitch Scott, PhDWashington University
Oxana Tcherniantchouk, MDCedars-Sinai Medical Center
CLIHCTM
Key ProjectsKey ProjectsClinician Test Selection & Clinician Test Selection & Result InterpretationResult Interpretation
– Diagnostic AlgorithmsDiagnostic Algorithms– Nomenclature ProjectNomenclature Project– Survey of Clinicians’ ChallengesSurvey of Clinicians’ Challenges– Medical Errors related to Laboratory Medical Errors related to Laboratory
TestsTestsMedical School curriculum Medical School curriculum content pertinent to laboratory content pertinent to laboratory servicesservices
The reports showing that errors in test The reports showing that errors in test selection and result interpretation can selection and result interpretation can jeopardize patient safety are on the rise jeopardize patient safety are on the rise
Allison Floyd, MD and Michael Laposata, MD, PhD, Vanderbilt University Medical Center, unpublished data
Review of the Literature
Diagnostic Algorithms
Goal:Goal: Demonstrate complexity of Demonstrate complexity of
selecting the appropriate selecting the appropriate laboratory testlaboratory test
Understand the most effective Understand the most effective testing strategiestesting strategies
Diagnostic Algorithms
Three clinical pathologists with expertise in Three clinical pathologists with expertise in coagulation created diagnostic laboratory test coagulation created diagnostic laboratory test algorithms to guide evaluation of patients with a algorithms to guide evaluation of patients with a prolonged Partial Thromboplastin Time (PTT) and a prolonged Partial Thromboplastin Time (PTT) and a normal Prothrombin Time (PT)normal Prothrombin Time (PT)
The 6 algorithms addressed: The 6 algorithms addressed: – age (adult versus newborn)age (adult versus newborn)– patient location (inpatient or outpatient)patient location (inpatient or outpatient)– symptoms (none, bleeding or thrombosis) symptoms (none, bleeding or thrombosis) – timing of the abnormal PTT result (recent versus extended timing of the abnormal PTT result (recent versus extended
period of time)period of time)
Diagnostic AlgorithmsDiagnostic Algorithms
CDC has developed an app for iPhones that physicians can use to determine what coagulation tests to order for some of the algorithms– Working on remaining ones
Need to now address algorithms for new drugs prescribed
Expect to produce 25 apps
Pathways
Originate from professional Originate from professional societies, federal & state societies, federal & state agencies and managed careagencies and managed care
28 states require guidelines 28 states require guidelines for health plans serving for health plans serving MedicaidMedicaid
Success depends on Success depends on implementation processimplementation process
Pathways
STUDY IN STUDY IN PEDIATRIC ANNALS, PEDIATRIC ANNALS, APRIL 1998APRIL 1998
Guidelines must be implemented Guidelines must be implemented with education, reminders, & with education, reminders, & incentivesincentives
Must be consistent with current Must be consistent with current practicepractice
Do not always have desired impact Do not always have desired impact on savings or improvement of careon savings or improvement of care
Nomenclature
Goal:Goal: Demonstrate the complexity of test selectionDemonstrate the complexity of test selection
– Multiplicity - Hepatitis B surface antibody Multiplicity - Hepatitis B surface antibody HBs Antibody, Hepatitis Bs Ab, HBG, Anti-HBs HBs Antibody, Hepatitis Bs Ab, HBG, Anti-HBs
– Complexity - lupus anticoagulant – not for lupusComplexity - lupus anticoagulant – not for lupus Developed a flow chart and tables Developed a flow chart and tables
demonstrating:demonstrating:– Complexity – Vitamin DComplexity – Vitamin D– Breadth – Commonly ordered testsBreadth – Commonly ordered tests
– Depth – CoagulationDepth – Coagulation
36
NomenclatureNomenclature
Test naming could be based on:Test naming could be based on:– Disease associationDisease association– Method used to perform the testMethod used to perform the test– Name of developerName of developer– Inappropriate names (i.e. no link between Inappropriate names (i.e. no link between
name and what is being tested)name and what is being tested) Multiple test name abbreviationsMultiple test name abbreviations
– Many evolved from implementing Laboratory Many evolved from implementing Laboratory Information SystemsInformation Systems
Existing nomenclature options for vitamin D Existing nomenclature options for vitamin D and its multiple formsand its multiple forms
::
Vitamin D2Vitamin D2ErgosterolErgosterolVitamin D3Vitamin D3CholecalciferolCholecalciferol25-0H vitamin D225-0H vitamin D225-0H vitamin D325-0H vitamin D325-0H vitamin D25-0H vitamin D25 hydroxy vitamin D225 hydroxy vitamin D225 hydroxy vitamin D325 hydroxy vitamin D325 hydroxy vitamin D25 hydroxy vitamin D1,25 (OH)2 vitamin D21,25 (OH)2 vitamin D21,25 (OH)2 vitamin D31,25 (OH)2 vitamin D31,25 (OH)2 vitamin D1,25 (OH)2 vitamin D1,25 dihydroxy vitamin D21,25 dihydroxy vitamin D21,25 dihydroxy vitamin D31,25 dihydroxy vitamin D31,25 dihydroxy vitamin D1,25 dihydroxy vitamin DVitamin D 25 Hydroxy D2 and Vitamin D 25 Hydroxy D2 and D3D3Vitamin D 1,25 DihydroxyVitamin 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
Article Published
Journal of General Internal Medicine Decoding Laboratory Test Names: A
Major Challenge to Appropriate Patient Care– March 2013
Article cited on the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network (PSNet)
Next StepsNext Steps
Summit to connect IT minds and Summit to connect IT minds and needs of all users of clinical needs of all users of clinical laboratory testinglaboratory testing
Working towards a Google-like Working towards a Google-like search tool to present users with search tool to present users with the correct test namesthe correct test names
Clinicians’ Challenges in Test Ordering and
Results Interpretation
Goal:Goal: Raise awareness of the challenges clinicians face Raise awareness of the challenges clinicians face
in test ordering and result interpretationin test ordering and result interpretation Phase 1 - Conduct three focus groups targeting Phase 1 - Conduct three focus groups targeting
internal, family, and general medicine internal, family, and general medicine practitionerspractitioners
Phase 2 - Using information from focus groups in Phase 2 - Using information from focus groups in Phase 1, conduct a national survey of cliniciansPhase 1, conduct a national survey of clinicians
41
To understand primary care needs and issues, To understand primary care needs and issues, three focus groups were conductedthree focus groups were conducted
The results are suggestive of actions that The results are suggestive of actions that laboratory professionals can take to improve laboratory professionals can take to improve clinician performanceclinician performance
To validate findings and gain greater insights To validate findings and gain greater insights into needs, the CDC commissioned a national into needs, the CDC commissioned a national survey of primary care physicianssurvey of primary care physicians– National sample of Family Practice and Internal National sample of Family Practice and Internal
Medicine physicians: target sample size of 1600 Medicine physicians: target sample size of 1600
– Results collected in 2011Results collected in 201142
FocusFocus GroupsGroups SummarySummary
Primary care physicians are comfortable selecting Primary care physicians are comfortable selecting from a small working repertoire of common testsfrom a small working repertoire of common tests
““Interpretation and ordering tests, I usually Interpretation and ordering tests, I usually don’t have a problem with that. For the don’t have a problem with that. For the most part I know what to order.”most part I know what to order.”
““I may order 20 tests commonly and I may I may order 20 tests commonly and I may order an additional 10-20 tests order an additional 10-20 tests [occasionally], so I may be using 40 tests [occasionally], so I may be using 40 tests that I feel comfortable that I’m not wasting that I feel comfortable that I’m not wasting time or money or resources.”time or money or resources.”
43
Challenges/ BarriersChallenges/ BarriersTest OrderingTest Ordering
Insurance and cost limitationsInsurance and cost limitations Issues with accessing and Issues with accessing and
communicating with laboratoriescommunicating with laboratories Variations in test names Variations in test names Variable and nebulous practice Variable and nebulous practice
guidelinesguidelines
44
EnablersEnablersTest OrderingTest Ordering
Electronic resourcesElectronic resources Access to peers and colleaguesAccess to peers and colleagues Access and relationships with Access and relationships with
laboratory professionalslaboratory professionals Availability of practice guidelines, Availability of practice guidelines,
algorithms, etc.algorithms, etc.
45
Challenges/ BarriersChallenges/ BarriersResult InterpretationResult Interpretation
Insurance and cost limitationsInsurance and cost limitations Varying practice guidelines and Varying practice guidelines and
methodologiesmethodologies Difficulties in accessing and Difficulties in accessing and
communicating with laboratory communicating with laboratory professionalsprofessionals
Inconsistency of laboratory test results Inconsistency of laboratory test results with clinical presentationwith clinical presentation
Inadequate laboratory reporting and Inadequate laboratory reporting and documentationdocumentation
46
EnablersEnablersResult InterpretationResult Interpretation
Access to electronic results and Access to electronic results and resourcesresources
Access to peers and colleaguesAccess to peers and colleagues Access to laboratory professionalsAccess to laboratory professionals Follow-up testing information and Follow-up testing information and
reflex testing, when appropriatereflex testing, when appropriate
47
Focus Group SummaryFocus Group Summary
Physicians are comfortable with selecting from a Physicians are comfortable with selecting from a small working repertoire of common testssmall working repertoire of common tests
When results did not fit their suspected diagnosis, When results did not fit their suspected diagnosis, physicians relied on combination of patient physicians relied on combination of patient presentation and own diagnostic instincts more presentation and own diagnostic instincts more than the laboratory resultsthan the laboratory results
Laboratory consultation was a useful resource Laboratory consultation was a useful resource when the physician had effective and consistent when the physician had effective and consistent access to laboratory services and were access to laboratory services and were comfortable with laboratory professionalscomfortable with laboratory professionals
Electronic resources are becoming more Electronic resources are becoming more important, with level of utilization dependent on important, with level of utilization dependent on ease of availability and a culture that encourages ease of availability and a culture that encourages their usetheir use
48
Focus Groups SummaryFocus Groups Summary
When results did not fit their suspected diagnosis, When results did not fit their suspected diagnosis, physicians relied on combination of patient physicians relied on combination of patient presentation and own diagnostic instincts more than presentation and own diagnostic instincts more than the laboratory resultsthe laboratory results
““Patient symptoms trump the lab Patient symptoms trump the lab results”results”
49
Focus Groups SummaryFocus Groups Summary
Laboratory consultation was a useful resource when the Laboratory consultation was a useful resource when the physician had effective and consistent access to laboratory physician had effective and consistent access to laboratory professionals but this was not commonprofessionals but this was not common
“Most of us don’t call the lab, we call a specialist”
“It hasn’t even occurred to me to call a pathologist to ask what test to order. I wouldn’t have even considered It as an option”
You’re lucky if you have someone answer you but most of the time you have a machine or they’ll put you on hold for an extended time period 50
Focus Groups SummaryFocus Groups Summary
Laboratory consultation was a useful resource when the Laboratory consultation was a useful resource when the physician had effective and consistent access to physician had effective and consistent access to laboratory professionals but this was not commonlaboratory professionals but this was not common
“Most of us don’t call the lab, we call a specialist”
“It hasn’t even occurred to me to call a pathologist to ask what test to order. I wouldn’t have even considered It as an option”
You’re lucky if you have someone answer you but most of the time you have a machine or they’ll put you on hold for an extended time period
51
Phase 2 - Clinicians’ SurveyPhase 2 - Clinicians’ Survey
Methods:Methods:– National sample of Family Practice and Internal National sample of Family Practice and Internal
Medicine physicians drawn from AMA Master Medicine physicians drawn from AMA Master FileFile
– Target sample size of 1600 Target sample size of 1600 – Survey delivered via WebSurvey delivered via Web
Status:Status:Manuscript submitted to a few journalsManuscript submitted to a few journals
52
What we don’t know
What is the prevalence of diagnostic errors What is the prevalence of diagnostic errors impacted by the testing process?impacted by the testing process?– Failure to order necessary testsFailure to order necessary tests– Ordering of unnecessary testsOrdering of unnecessary tests– Inappropriate utilization of test resultsInappropriate utilization of test results
What are effective interventions that reduce What are effective interventions that reduce diagnostic errors and could be initiated by diagnostic errors and could be initiated by laboratory professionals?laboratory professionals?– What settings are appropriate for these What settings are appropriate for these
interventions?interventions?– What limitations exist in the use of these What limitations exist in the use of these
interventions? interventions? – What new sources of errors are created by the What new sources of errors are created by the
interventions?interventions?Paul Epner, Diagnostic Errors in Medicine, October 25, 2010
Improvements in Clinicians’ Test Improvements in Clinicians’ Test Selection and Result Interpretation (ITSRI) Selection and Result Interpretation (ITSRI) Lead – Paul Epner, MEd, MBALead – Paul Epner, MEd, MBA
Goal:Goal: Demonstrate the effect of improvements in Demonstrate the effect of improvements in
laboratory test selection and result interpretation laboratory test selection and result interpretation on diagnostic errors on diagnostic errors
Methods:Methods: Develop methods to measure the effect of Develop methods to measure the effect of
laboratory test selection and result interpretation laboratory test selection and result interpretation on diagnostic errorson diagnostic errors
Conduct pilot studies to determine the effect of Conduct pilot studies to determine the effect of improvements in laboratory test selection and improvements in laboratory test selection and result interpretation on diagnostic errorsresult interpretation on diagnostic errors
Vanderbilt University Medical Vanderbilt University Medical Center Center Unpublished StudyUnpublished Study**
Reviewed one week of consultation requestsReviewed one week of consultation requests 53 cases total53 cases total
– 29 cases had appropriate test orders (55%)29 cases had appropriate test orders (55%)– 19 cases had incomplete test orders (36%)19 cases had incomplete test orders (36%)– 5 cases had inappropriate test orders (9%)5 cases had inappropriate test orders (9%)
Of 24 cases where tests were added or Of 24 cases where tests were added or deleted following consultation, the diagnosis deleted following consultation, the diagnosis was impacted in 2 cases. was impacted in 2 cases.
The timing of the diagnosis in the other cases The timing of the diagnosis in the other cases was not impacted only because of the near was not impacted only because of the near real-time addition of tests.real-time addition of tests.
*Information and analysis provided by Jennifer M. Giltnane, MD, PhD and *Information and analysis provided by Jennifer M. Giltnane, MD, PhD and Michael Laposata, MD, PhD, Vanderbilt University Medical CenterMichael Laposata, MD, PhD, Vanderbilt University Medical Center
Outcomes Vs Indicators
Outcomes require Outcomes require measurementmeasurement
Measurements, to be Measurements, to be accurate, must compare accurate, must compare large, like populations over a large, like populations over a period of timeperiod of time
Few health care plans are Few health care plans are that comparablethat comparable..
Challenges
Characteristics of population, Characteristics of population, such as age, health status, such as age, health status, comorbidities, etc. Differcomorbidities, etc. Differ
Need to follow patients five to Need to follow patients five to twenty years and few patients twenty years and few patients stay with one health plan that stay with one health plan that longlong
Challenges
Illness is rare in the general Illness is rare in the general population so the number of population so the number of individuals needed to conduct individuals needed to conduct a valid study may not be a valid study may not be available in each health planavailable in each health plan
Health informatics poor; Health informatics poor; clinical information not clinical information not capturedcaptured
Laboratory Medicine Education in U.S. Medical
Schools
Required courses in 57% (68/120) of schoolsRequired courses in 57% (68/120) of schools Few schools report no training at all (2 -4%)Few schools report no training at all (2 -4%) An ad hoc committee of The Academy of Clinical An ad hoc committee of The Academy of Clinical
Laboratory Physicians and ScientistsLaboratory Physicians and Scientists Proposed medical student laboratory medicine Proposed medical student laboratory medicine
curriculumcurriculum Developed:Developed:
Goals and objectives for trainingGoals and objectives for training Guidelines for instructional methodsGuidelines for instructional methods Examples of how outcomes can be assessedExamples of how outcomes can be assessed
Smith, Brian R, et. al.; Educating Medical Students in Laboratory Medicine A Proposed Curriculum; AJCP; 2010: Smith, Brian R, et. al.; Educating Medical Students in Laboratory Medicine A Proposed Curriculum; AJCP; 2010: 133: 533-542133: 533-542
Survey of U.S. Medical SchoolsSurvey of U.S. Medical SchoolsProject Leads –Brian Smith, MD and John Project Leads –Brian Smith, MD and John Hickner, MD, MScHickner, MD, MSc
Goal:Goal: Raise awareness to the gaps in US medical school Raise awareness to the gaps in US medical school
curricula and laboratory medicine training curricula and laboratory medicine training
Methods:Methods: Survey all 133 allopathic and 26 osteopathic U.S Survey all 133 allopathic and 26 osteopathic U.S
medical schoolsmedical schools Recruit one medical student (via AMSA) per Recruit one medical student (via AMSA) per
school to help complete the surveyschool to help complete the survey
60
Clinical Pathology Residency Education
Goal: Goal: Establish the nature and amount of clinical Establish the nature and amount of clinical
consultation education provided to clinical consultation education provided to clinical pathology residentspathology residents
Raise awareness to the gaps in, and solutions to Raise awareness to the gaps in, and solutions to improve clinical pathology residency educationimprove clinical pathology residency education
Method: Method: Conduct observational study of academic Conduct observational study of academic
institutions assessing clinical pathology resident institutions assessing clinical pathology resident training activitiestraining activities
Clinical Pathology Residency Education
Results:Results: 14 Accredited programs contacted – invited to visit 314 Accredited programs contacted – invited to visit 3 Some training programs have focal areas of consult Some training programs have focal areas of consult
activityactivity Many programs not prepared to develop meaningful Many programs not prepared to develop meaningful
consultative roles for residents in laboratory medicineconsultative roles for residents in laboratory medicine Obstacle - Limited # of doctoral level laboratory Obstacle - Limited # of doctoral level laboratory
directors to teach residentsdirectors to teach residents Need to obtain more data to substantiate the results Need to obtain more data to substantiate the results
and identify model programsand identify model programs
Successful Strategies
Physician involvementPhysician involvement Laboratory professionals Laboratory professionals
commitment and involvementcommitment and involvement Laboratory utilization Laboratory utilization
committee committee Track by physician, pathway, encounter, Track by physician, pathway, encounter,
like pharmacy and surgerylike pharmacy and surgery
The Future Is Bright
Laboratory testing provides patient-specific information necessary for the prevention, diagnosis, treatment, and management of disease or establishment of health.
Other InitiativesOther Initiatives
Development of evidence-based Development of evidence-based methods to identify and evaluate methods to identify and evaluate Best Practices in Laboratory Best Practices in Laboratory Medicine.Medicine.http://wwwn.cdc.gov/dls/bestpractices/LabBestPractice.pdf