Journal of Applied Laboratory Medicine最新文献

{"title":"Revisiting the Environmental Impact of Inappropriate Clinical Laboratory Testing: A Comprehensive Overview of Sustainability, Economic, and Quality of Care Outcomes.","authors":"Luigi Devis, Mélanie Closset, Jonathan Degosserie, Sarah Lessire, Pauline Modrie, Damien Gruson, Emmanuel J Favaloro, Giuseppe Lippi, François Mullier, Emilie Catry","doi":"10.1093/jalm/jfae087","DOIUrl":"10.1093/jalm/jfae087","url":null,"abstract":"<p><strong>Background: </strong>The use of laboratory resources has seen a substantial increase in recent years, driven by automation and emerging technologies. However, inappropriate use of laboratory testing, encompassing both overuse and underuse, poses significant challenges.</p><p><strong>Content: </strong>This review explores the complex interplay between patient safety, economic, and environmental factors-known as the \"triple bottom line\" or \"3Ps\" for people, profit, and planet-associated with inappropriate use of laboratory resources. The first part of the review outlines the impact of inappropriate laboratory testing on patient safety and economic outcomes. Then the review examines the available literature on the environmental impact of laboratory activities. Several practical solutions for mitigating the environmental impact of laboratories are discussed. Finally, this review emphasizes how decreasing unnecessary laboratory testing results in cost savings and environmental benefits, as evidenced by interventional studies, without compromising patient safety.</p><p><strong>Summary: </strong>The implementation of sustainable practices in laboratories can create a virtuous circle in which reduced testing enhances cost-efficiency, reduces the environmental footprint, and ensures patient safety, thereby benefiting the 3Ps. This review highlights the critical need for appropriate laboratory resource utilization in achieving sustainability in healthcare.</p>","PeriodicalId":46361,"journal":{"name":"Journal of Applied Laboratory Medicine","volume":" ","pages":"113-129"},"PeriodicalIF":1.8,"publicationDate":"2025-01-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142366888","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Establishing Referral Laboratory Testing Governance and Addressing \"Miscellaneous\" Test Orders across an Academic Health System.","authors":"Allison B Chambliss, Joshua L Deignan, Charlemagne Isip, Monique Trinh, William Werre, Alyssa Ziman","doi":"10.1093/jalm/jfae121","DOIUrl":"https://doi.org/10.1093/jalm/jfae121","url":null,"abstract":"<p><strong>Background: </strong>Referral (send-out) laboratories support clinical needs but may cause issues for hospitals or health systems related to regulations and governance, specimen logistics, test result availability, and cost and reimbursement. The use of a \"miscellaneous\" referral test order can increase risks of specimen collection or processing errors, result delays, and repeat testing.</p><p><strong>Methods: </strong>We established an approved referral laboratory test list and a digital form for providers to request new referral tests. We collated laboratory stewardship committee decisions over a 20-month period. Separately, we retrospectively reviewed referral tests ordered as miscellaneous across our health system over 1 year. Subject matter experts identified appropriate tests to build as discretely orderable in the electronic health record. Following targeted provider notification of the new tests, we assessed their uptake and impact on result turnaround times for the first 5 built tests over 6 months.</p><p><strong>Results: </strong>Our laboratory stewardship committee approved 16 of 27 provider requests to build new referral tests over the first 20 months following implementation of the new request process. In addition, 37 of the 100 most frequently ordered miscellaneous tests were recommended to be built as discrete orders. Uptake of the first 5 built tests (relative to providers continuing to use miscellaneous orders) averaged 64% over the first 6 months. Result turnaround times improved by an average of 1.1 days when the discrete orders were used.</p><p><strong>Conclusions: </strong>We successfully established oversight of referral laboratory testing across our health system, pivoted orders away from miscellaneous, and observed improvements in turnaround times.</p>","PeriodicalId":46361,"journal":{"name":"Journal of Applied Laboratory Medicine","volume":"10 1","pages":"4-12"},"PeriodicalIF":1.8,"publicationDate":"2025-01-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142923677","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"What Is Diagnostic Stewardship?","authors":"Kimberly C Claeys, K C Coffey, Daniel J Morgan","doi":"10.1093/jalm/jfae130","DOIUrl":"10.1093/jalm/jfae130","url":null,"abstract":"<p><strong>Background: </strong>Diagnostic stewardship is a set of clinically based changes to the ordering, processing, and reporting of diagnostic tests designed to improve patient outcomes (through decreased inappropriate testing, and reduced patient harm from wrong, delayed, or missed diagnosis). It shares a common philosophy with laboratory stewardship but has some key differences.</p><p><strong>Content: </strong>Laboratory stewardship focuses primarily on pre- and post-analytical components of the testing process. Laboratory stewardship encourages laboratorians to engage clinical partners in discussion around the impact of pre- and post-analytical components of testing. Diagnostic stewardship extends laboratory stewardship into clinical medicine as it considers the clinician's interaction and experience with the ordering system and attempts to modify clinical thinking, even before a test is ordered. Diagnostic stewardship then goes beyond the post-analytic laboratory interpretation of results to contextualize those results in evidence-based best practice recommendations. Compared to laboratory stewardship, diagnostic stewardship is clinician led vs laboratorian led, utilizes clinician-focused terminology rather than laboratory-specific language, and incorporates clinician decision support and behavioral economics to drive behavior change.</p><p><strong>Summary: </strong>There are many complementary principles and activities between laboratory and diagnostic stewardship, and collaboration allows both programs to grow and improve patient overall quality of care.</p>","PeriodicalId":46361,"journal":{"name":"Journal of Applied Laboratory Medicine","volume":"10 1","pages":"130-139"},"PeriodicalIF":1.8,"publicationDate":"2025-01-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142922078","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Survey of Laboratory Stewardship Governance at US Academic Medical Centers.","authors":"Charles S Eby, Noor Al-Hammadi, Kathy Dodds, Deepak Sunkavalli, Ann M Gronowski","doi":"10.1093/jalm/jfae136","DOIUrl":"https://doi.org/10.1093/jalm/jfae136","url":null,"abstract":"<p><strong>Background: </strong>Efforts to appropriately utilize laboratory tests have been underway for several decades. However, limited information is available regarding the status of laboratory stewardship at academic medical centers. Prior to initiating a laboratory stewardship committee, a study was initiated to gain insights from peer institutions.</p><p><strong>Methods: </strong>An online REDCap survey was created and emailed to US pathology department leaders at 94 academic medical centers.</p><p><strong>Results: </strong>Response rate was 40%. Sixty-eight percent (n = 26) of respondents indicated that they have a laboratory stewardship committee. There was variability among academic medical institutions regarding governance, committee structure and responsibilities, and assessment of laboratory stewardship committee performance. There was consensus for inclusion of: hospital administration and clinical leadership; informatics (IT) support, and a multidisciplinary clinical team combined with laboratory medicine expertise. Of the 32% (n = 12) without a committee, 4 started one but found it unsustainable, and 6 were unsuccessful at starting a program. Respondents without a current laboratory stewardship program cited lack of leadership support, insufficient management and IT resources, and unclear vision and goals as major factors. Fifty-eight percent of those without a laboratory stewardship committee predicted their hospital would establish one within the next 5 years.</p><p><strong>Conclusions: </strong>Survey results provide insights into the status of laboratory stewardship efforts at peer institutions. Awareness of the structural and leadership components critical to successful and sustained initiatives will improve the quality and value of clinical laboratory services.</p>","PeriodicalId":46361,"journal":{"name":"Journal of Applied Laboratory Medicine","volume":"10 1","pages":"13-25"},"PeriodicalIF":1.8,"publicationDate":"2025-01-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142923716","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Teaching the Laboratory's Role in Diagnostic Stewardship: Engaging Pathology Residents in a Quality Initiative to Improve Autoverification Rates.","authors":"Jack A Maggiore, Constantine E Kanakis, Anastasia Gant Kanegusuku, Stephen E Kahn","doi":"10.1093/jalm/jfae124","DOIUrl":"https://doi.org/10.1093/jalm/jfae124","url":null,"abstract":"<p><strong>Background: </strong>Our institution involves our pathology residents in departmental quality initiatives and in identifying needs for operational improvements. The solutions achieved by these projects have effects beyond the laboratory, and ultimately help to improve diagnostic stewardship by supporting the clinician's ability to obtain necessary biochemical information at the right time. A project highlighting a successful venture is described here in which our investment in new total laboratory automation was not meeting our goals for autoverification rates, resulting in less than expected improvements to turnaround times (TAT).</p><p><strong>Methods: </strong>To improve efficiency of the new laboratory automation, our third-year pathology residents examined the limitations to the verification process and current delta checks. They performed a literature review for the most updated evidence-based practices, examined clinical metrics such as TAT. The residents assessed their findings combined with the laboratory's quality goals, and contributed to updating middleware rule modifications. Several chemistry analyte software rules were revised while others were eliminated.</p><p><strong>Results: </strong>After implementation of the modifications autoverification rates improved from 78% to 89% within 2 months of rule revisions. Average TAT for STAT basic metabolic profile improved from 51 to 46 minutes.</p><p><strong>Conclusions: </strong>This study demonstrates the benefits of involving pathology residents in quality improvement initiatives. Residents are skilled resources capable of evaluating laboratory workflow processes in the context of clinical need. In this process, the residents experience the responsibilities of laboratory administration and learn the role of the laboratory in diagnostic stewardship.</p>","PeriodicalId":46361,"journal":{"name":"Journal of Applied Laboratory Medicine","volume":"10 1","pages":"66-72"},"PeriodicalIF":1.8,"publicationDate":"2025-01-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142923717","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Diagnostic Stewardship-Our Past, Our Current Status, and Future Promise.","authors":"Lee H Hilborne, Allison B Chambliss","doi":"10.1093/jalm/jfae106","DOIUrl":"https://doi.org/10.1093/jalm/jfae106","url":null,"abstract":"","PeriodicalId":46361,"journal":{"name":"Journal of Applied Laboratory Medicine","volume":"10 1","pages":"200-204"},"PeriodicalIF":1.8,"publicationDate":"2025-01-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142923656","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Building a Stewardship Committee: Technical Tips from the Trenches.","authors":"Elise A Occhipinti","doi":"10.1093/jalm/jfae119","DOIUrl":"https://doi.org/10.1093/jalm/jfae119","url":null,"abstract":"","PeriodicalId":46361,"journal":{"name":"Journal of Applied Laboratory Medicine","volume":"10 1","pages":"205-206"},"PeriodicalIF":1.8,"publicationDate":"2025-01-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142923635","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Electronic Health Record Design Impacts Clinician Ordering Behavior: An Interrupted Time Series Analysis.","authors":"Eli P Wilber, Eileen M Burd, Eric C Fitts, Jesse T Jacob, Sujit Suchindran","doi":"10.1093/jalm/jfae097","DOIUrl":"https://doi.org/10.1093/jalm/jfae097","url":null,"abstract":"<p><strong>Background: </strong>Diagnostic stewardship is the science of improving diagnostic test use. Whether electronic health record (EHR) design influences clinician diagnostic testing behavior and electronic medical record interventions can improve diagnostic stewardship outcomes are key questions. We leveraged the natural experiment of a recent change in EHR platforms to investigate if changing how 2 commonly misused tests, blood cultures for acid-fast bacilli (AFB) and fungi, are displayed affected their use.</p><p><strong>Methods: </strong>We performed a retrospective chart review of all AFB and fungal blood cultures at 4 hospitals with a shared EHR. The preintervention and postintervention periods were 52 and 26 weeks, respectively. The culture rate was standardized per 1000 patient-days and segmented into 2-week periods. Pre- and postintervention median rates were compared with the Wilcoxon rank sum test and further analyzed with an interrupted time series (ITS) analysis using a quasi-Poisson regression model.</p><p><strong>Results: </strong>The biweekly median AFB blood culture rate decreased by 41.6% in the postintervention period (0.46/1000 patient-days vs 0.79/1000 patient-days, P < 0.001). The median rate of fungal blood cultures decreased by 54.3% in the postintervention period (0.42/1000 patient-days vs 0.92/1000 patient-days, P < 0.001). In ITS analysis, the EHR change was associated with a level change in AFB (-31.8%, 95% CI: -54.6% to +2.6%) and fungal (-44.6%, 95% CI: -59.3% to -24.7%) blood culture use.</p><p><strong>Conclusions: </strong>An electronic medical record design change resulted in decreased use of 2 commonly misused diagnostic tests. This highlights the impact of EHR design on clinician behavior and diagnostic stewardship programs' potential to reduce waste.</p>","PeriodicalId":46361,"journal":{"name":"Journal of Applied Laboratory Medicine","volume":"10 1","pages":"73-78"},"PeriodicalIF":1.8,"publicationDate":"2025-01-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142923659","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is the 99th Percentile Cutoff Still Relevant? A Single-Center Assessment of Different Thresholds for Diagnosing Antiphospholipid Syndrome.","authors":"Alexis Dadelahi, Brandon S Walker, Dipanwita Banerjee, Michael Mahler, Abdulrahman Saadalla, Vijayalakshmi Nandakumar","doi":"10.1093/jalm/jfae149","DOIUrl":"https://doi.org/10.1093/jalm/jfae149","url":null,"abstract":"<p><strong>Background: </strong>The 2023 American College of Rheumatology and modified Sapporo criteria for antiphospholipid syndrome (APS) recommend ELISA to detect anticardiolipin (aCL) and anti-β2-glycoprotein I (aβ2GP1) IgG/IgM antibodies, focusing on moderate to high levels or exceeding the 99th percentile. This study aims to establish the 99th percentile threshold for anti-phospholipid (aPL) antibodies and compare the diagnostic accuracies of these thresholds with manufacturer cutoffs using 2 methodologies.</p><p><strong>Methods: </strong>The 99th percentile cutoffs for aPL antibodies from 305 healthy donors were established using Aptiva, Particle-Based Multi-Analyte Technology (PMAT), and QUANTA Lite (QL) ELISA, following nonparametric reference interval estimation. Sera from 34 APS patients and 190 APS controls were tested. Diagnostic performances were compared at the 99th percentile-, manufacturer-, receiver operating characteristic (ROC) derived optimal-, and 95% specificity-optimized cutoffs. An expanded cohort of 61 APS patients and 1299 APS controls from a 2-year retrospective review was also included.</p><p><strong>Results: </strong>For ELISA, the 99th percentile cutoffs for aCL (IgG/IgM) and aβ2GP1 (IgG) were at the assay limit of quantification. Optimal cutoffs from the ROC curves, 95% specificity-matched and manufacturer cutoffs, showed better diagnostic accuracy than the 99th percentile. On the Aptiva PMAT platform, the 99th percentile cutoffs were lower but provided comparable diagnostic accuracies to manufacturer and optimal cutoffs, although specificity was below 95%.</p><p><strong>Conclusions: </strong>The clinical utility of 99th percentile cutoffs is assay dependent. For QL, these cutoffs were unsuitable, while Aptiva showed better alignment with clinical thresholds. Manufacturer-recommended cutoffs, supported by extensive validation, offer a reliable alternative when clinical studies are infeasible.</p>","PeriodicalId":46361,"journal":{"name":"Journal of Applied Laboratory Medicine","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2024-12-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142899291","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effect of Hemolysis on Routine Blood Gas and Whole Blood Analytes.","authors":"Bernice A Agana, Brian Overton, Katherine Florendo, Claire E Knezevic","doi":"10.1093/jalm/jfae140","DOIUrl":"https://doi.org/10.1093/jalm/jfae140","url":null,"abstract":"<p><strong>Background: </strong>Hemolysis is a major pre-analytical concern for many laboratory analytes; however, instruments utilized for whole blood chemistries and blood gas measurements lack the ability to detect and measure the degree of hemolysis. This study evaluated the effect of hemolysis on 13 routine whole blood and blood gas analytes and compared visual assessments of hemolysis to measured hemolysis (H-index).</p><p><strong>Methods: </strong>Remnant whole blood samples (n = 85) were split into 2 portions and aspirated through a syringe one or more times. To induce hemolysis, a needle was affixed to the end of the syringe to provide shear stress, and a mock procedure without syringe was used as a control. Samples were analyzed on a Radiometer ABL800 series instrument, centrifuged, and the H-index of the plasma portion was measured. Two medical technologists recorded a visual categorization of the specimens as slightly, moderately, or severely hemolyzed.</p><p><strong>Results: </strong>Hemolysis had a modest effect on metabolites and most cooximetry components, with percent bias within ±5% at all levels of hemolysis. Methemoglobin exhibited a larger overall negative bias, up to 13.3%. The absolute pH bias was fairly consistent (within 0.1 pH units) across all levels of hemolysis. As expected, potassium displayed a significant positive bias with increasing hemolysis. Sodium and ionized calcium displayed overall linear trends with a significant negative bias.</p><p><strong>Conclusions: </strong>Hemolysis can falsely increase or decrease certain blood gas analytes and lead to misinterpretation of results. Therefore, hemolysis detection capabilities are crucial for mitigating this effect and ensuring accurate results for patient care.</p>","PeriodicalId":46361,"journal":{"name":"Journal of Applied Laboratory Medicine","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2024-12-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142839764","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}