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CCLM) Laboratory Demand Management of Repetitive Testing Time for Harmonisation and an Evidenced Based Approach

laboratory utilization

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Shaimaa Aboamer
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10 views

CCLM) Laboratory Demand Management of Repetitive Testing Time for Harmonisation and an Evidenced Based Approach

laboratory utilization

Uploaded by

Shaimaa Aboamer
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© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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DOI 10.

1515/cclm-2013-0063 Clin Chem Lab Med 2013; 51(6): 1139–1140

Editorial

Tim Lang

Laboratory demand management of repetitive


testing – time for harmonisation and an
evidenced based approach
In a time when laboratories are struggling to cope with grouped into five areas: education, rules aimed at restrict-
increasing pressures on their services, and shrinking ing test requests, redesign of request forms, computerised
budgets demand management tools and strategies provide physician order entry (CPOE) and reimbursement models
potential solutions. There are a number of areas where the [2]. Fryer and Smellie have recently published a demand
laboratory is being squeezed including increasing work- management toolbox to assist laboratories in achieving
loads, increased costs, reduced revenue, inappropriate effective workload management [3]. One solution that
tests and changes in how their services are commissioned has already showed promise and sustainability are rules
and delivered. aimed at restricting tests based on time between repeti-
The pathology workload in the UK alone is increas- tive tests [4, 5]. In this issue of the Clinical Chemistry and
ing by an average of 10% every year and must be delivered Laboratory Medicine, Janssens and Wasser discuss an
despite a 20% reduction in pathology funding [1]. Workload example of this type of intervention, calculating the finan-
has been increasing due to both increases in appropriate cial savings realised [6]. In partnership with hospital phy-
and inappropriate tests. Advances in laboratory technol- sicians “spare periods” (periods during which tests were
ogy have allowed multiple testing, more rapid turnaround barred) were produced and implemented through the
times and more choice. With the advent of the worldwide laboratory information and management system (LIMS).
web, patients are better informed and become advocates Although the savings in this example were relatively low
for their own investigations. The population is also getting in proportion to their own pathology budget and previ-
older with more patients having chronic diseases, which ously published figures, they indicated that it should
require effective long-term management. Requestors are still be continued due to the minimum effort required to
also more defensive in the way they request for fear of sustain it. A key step in such a solution is the partner-
missing a test or a medico-legal consequence. Identifying ship between the laboratory and the clinician using the
the appropriate and inappropriate test is a challenge for the service as demonstrated in this paper. What is sometimes
laboratory, but this in itself depends upon the perspective lacking is the evidence to support an intervention par-
of the individual. A standardised approach and definition ticularly when barring tests, which from a user’s perspec-
of an appropriate or inappropriate test is required to allow tive may be thought to be necessary. The provision of and
the laboratories to effectively manage each. In Australia, availability of individual tests may differ between labora-
the National Coalition of Public Pathology Report (2012) tories with different demand management rules in place
presents a matrix that can be used to ascertain whether a based on local practice and rarely published evidence or
request is appropriate or inappropriate, thereby bringing practice. To address some of the variance in practice and
some standardisation to this difficult area [2]. lack of evidence base, the Clinical Practice Section of the
Therefore, the laboratory must be proactive in effec- Association for Clinical Biochemistry (ACB) prepared a set
tively managing its workload in order to provide the best of consensus/evidence based recommendations on when
service for the patient within the defined constraints. a test should be repeated [7]. The National Minimum Re-
The ideal demand management strategy ensures that testing Interval Project used a “state of the art” approach
the right test is done on the right patient at the right time. to prepare over 100 recommendations in a number of clin-
It also provides an opportunity to harmonise processes ical areas [8]. Invited members working in small groups
and remove unnecessary waste thereby saving money. prepared recommendations, which when complete were
A number of demand management solutions are then assessed by an independent reviewer before review
available, which can assist the laboratory and can be by a panel of regional representatives. Where evidence

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1140 Lang: Laboratory demand management of repetitive testing

was lacking recommendations were prepared based on to allow identification of duplicate or inappropriate
the consensus opinion of the panel. The final recommen- requests. If a subsequent request is blocked, then it is
dations were then approved after a consultation period also important that there is real-time notification of a
by the Executive of the ACB. Establishing a set of nation- potential redundant test so that the requestor can make
ally agreed recommendations supports the work of exist- an informed choice on the clinical need of the test and
ing harmonisation programmes and provides evidence if it is required to override the rule. It is important that
for those who want to implement this type of demand there is a facility whereby the laboratory or requestor
management tool [9]. It may also be timely to propose can record the reason for blocking a request or over-
that similar terminology is used when discussing and riding the rule. The implementation of CPOE and order
implementing such initiatives. For example, the follow- communication software provides a real opportunity for
ing terms; repetitive frequency, spare period, duplicate the laboratory to effectively manage their workload and
period, repeat interval and minimal re-testing interval, meet the increasing demands of service. Janssens and
have all been used to describe the minimum time before Wasser have showed that their example of a demand
a test should be re-tested based on the properties of the management solution can be maintained with minimal
test and the clinical situation in which it is used. To assist support, but is effective in removing and reducing
with those searching for evidence to support a demand redundant testing thereby optimising the service for the
management solution, I would propose that the term patient and pathology.
minimal re-testing interval be adopted as it has already
been used by a number of organisations in laboratory
medicine [2, 7].
When implementing a demand management tool Conflict of interest statement
it is important that the system used to manage a labo-
ratory workload can correctly identify the patient and Author’s conflict of interest disclosure: The author stated that
there are no conflicts of interest regarding the publication of this
match requests with the patient’s medical record.
article.
Ideally there should be one unique identifier used (e.g., Research funding: None declared.
NHS number in the UK), which will allow the LIMS to Employment or leadership: None declared.
interrogate the patient’s previous pathology result Honorarium: None declared.

References
1. Lord Carter of Coles. Report of the second phase of the 7. Lang TF. National Minimum Re-testing Intervals Project: a final
independent review of NHS pathology services 2006. Available report detailing consensus recommendations for minimum
at: http://www.dh.gov.uk/en/Publicationsandstatistics/ re-testing intervals for use in Clinical Biochemistry 2013. London:
Publications/PublicationsPolicyAndGuidance/DH_4137606. Association for Clinical Biochemistry, 2012.
Accessed on 12 January, 2012. 8. Glaser EM. Using behavioral science strategies for
2. Encouraging quality pathology ordering in Australia’s public defining the state-of-the-art. J Appl Behavioral Sci 1980;16:
hospitals – final report (2012). Available at: www.ncopp.org.au. 79–92.
Accessed 23 January, 2013. 9. Pathology harmony working towards harmonising standards
3. Fryer AA, Smellie WS. Managing demand for laboratory tests: a in UK pathology services. Available at: http://www.pathology-
laboratory toolkit. J Clin Pathol 2013;66:62–72. harmony.co.uk. Accessed on 11 January, 2012.
4. van Walraven C, Raymond M. Population-based study of repeat
laboratory testing. Clin Chem 2003;49:1997–2005.
5. Hutton HD, Drummond HS, Fryer AA. The rise and fall of C-reactive *Corresponding author: Dr. Tim Lang FRCPath, Consultant Clinical
protein: managing demand within clinical biochemistry. Ann Clin Scientist, Clinical Biochemistry Department, University Hospital of
Biochem 2009;46:155–8. North Durham, North Road, Durham DH1 5TW, UK,
6. Janssens PM, Wasser G. Managing laboratory test ordering through Phone: +44-191-3332694, Fax: +44-191-3332115,
test frequency filtering. Clin Chem Lad Med 2013;51:1207–15. E-mail: [email protected]

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