Joaquín Uris

Differences in laboratory requesting patterns in emergency department in Spain

Background It is necessary to achieve a reduction in the number of requests for laboratory tests by improving the appropriateness of testing behaviour. The aim of the study was, first, to compare laboratory requiring patterns for emergency department (ED) patients in clinical laboratories of different institutions in Spain; second, to design an appropriateness pre-pre-analytical quality control report based on appropriateness indicators. Methods A call for data was posted on a website. We obtained production statistics for the year 2010 from emergency laboratories at 36 hospitals. Two types of appropriateness indicators were calculated: test request per 1000 ED admissions or related test requesting ratios. In order to explore the inter-practice variability in tests requests, the ‘index of variability’ was calculated. A pre-pre-analytical quality control report was designed, prepared and sent to each participating laboratory. The savings generated, if each Health-care Department would have achieved the appropriate indicator standard, were calculated. Results The rate of request of the stat tests ranged from 44 to 412 per 1000 ED patient admissions. There was a high and peculiar dispersion of related test requesting ratio results. If every single laboratory would have achieved the appropriate indicator, we would have saved 1,019,230 urea, 302,511 AST and 316,161 CK unnecessary tests. Conclusions There are large variations of test requesting in the emergency setting. An appropriateness pre-pre-analytical quality control report was useful for comparing requesting patterns. The study shows the need to unify demand. The key to achieve this goal will be interdepartmental cooperation between ED clinicians and laboratory professionals.

Achieving continuous improvement in laboratory organization through performance measurements: a seven-year experience

Abstract Background: Laboratory performance can be measured using a set of model key performance indicators (KPIs). The design and implementation of KPIs are important issues. KPI results from 7 years are reported and their implementation, monitoring, objectives, interventions, result reporting and delivery are analyzed. Methods: The KPIs of the entire laboratory process were obtained using Laboratory Information System (LIS) registers. These were collected automatically using a data warehouse application, spreadsheets and external quality program reports. Customer satisfaction was assessed using surveys. Nine model laboratory KPIs were proposed and measured. Results: The results of some examples of KPIs used in our laboratory are reported. Their corrective measurements or the implementation of objectives led to improvement in the associated KPIs results. Conclusions: Measurement of laboratory performance using KPIs and a data warehouse application that continuously collects registers and calculates KPIs confirmed the reliability of indicators, indicator acceptability and usability for users, and continuous process improvement. Clin Chem Lab Med 2010;48:57–61.

Towards laboratory knowledge, not data, in 70% of clinical decision-making. What “knowledge management” can add to clinical practice?

Laboratory data are involved in 70% of clinical decisions regarding diagnosis, treatment or prevention, and are thus critical to the clinical decision-making process (1). However, the future of laboratory medicine as a specialty is currently uncertain throughout the world (2–4). Why? Off hand, we would say that it is because laboratory data, not laboratory knowledge, is involved in 70% of clinical decisions. The words ‘‘data’’, ‘‘information’’ and ‘‘knowledge’’ are sometimes used interchangeably. However, it is essential to understand how ‘‘knowledge’’ differs from ‘‘data’’ and ‘‘information’’ in order to understand what ‘‘knowledge management’’ can add to clinical practice. Knowledge is a raw information input molded by experience and values. The spatial dimensions generated by knowledge serve as a framework for useful incorporation of experience. Knowledge management reflects the creative and operational dimensions of the generation and dissemination of knowledge, not only in an organization, but also among the stakeholders, in our case physicians and patients. The laboratory professional applies experience and learning to data or information to generate knowledge (5). If we want the status of laboratory medicine to change, if we want laboratory medicine to receive the attention that it deserves, then laboratories will have to provide knowledge, not just data, to be useful for clinical decision-making (6). Technological developments have vastly increased the volume of tests processed (7). Laboratories report millions of data points. However, isolated bits of data, as opposed to knowledge, can generate errors. Millions of fragments of

Potential over request in anemia laboratory tests in primary care in Spain

Abstract Objectives The aim was to study the inter-practice variability in anemia laboratory tests requested by general practitioners in Spain, to evaluate for a potential requesting inappropriateness. Methods Laboratories from diverse Spanish regions filled out the number of cell blood count, ferritin, folate, iron, transferrin, and vitamin B12 requested by general practitioners during 2012. The number of test requests per 1000 inhabitants and ratios of related tests requests were calculated. The results obtained in hospitals from different areas (urban, rural, or urban–rural), type of management (public or private), and geographic regions were compared. Results There was a high variability in the number of test requests and ratios of related tests. Cell blood count was over requested in rural areas and in hospitals with private management. Andalucía was the community with the lowest number of iron requests and the lowest folate/vitamin B12 indicator value. Conclusions Iron and transferrin seemed over requested in some areas; as were folate and ferritin when compared to vitamin B12 and cell blood count, respectively. The differences observed between areas indicate that other factors besides clinical reasons could be behind that variability and emphasize the need to accomplish interventions to improve the appropriate use of anemia laboratory tests.

Two Minutes of Monthly Monitoring Can Ensure Quality Laboratory Service Every Day of the Year

Objective: The aim of this study was to show how opportunities for improving laboratory performance can be identified by monitoring indicators. The testing process was also monitored using indicators to evaluate the impact of improvement measures on laboratory service and customer satisfaction. Methods: The process, which began with the delivery of samples to the laboratory and ended with a laboratory report, was evaluated over an 80-month study. The laboratory process was monitored before and after improvement measures were introduced using a series of indicators as transport, timely verified blood glucose requests, workload, and customer satisfaction indicators. Three improvement measures were implemented: redesign of the courier route, incorporation of automated sample distribution technology, and hiring another courier. Results: All of the improvement measures implemented led to a favorable evolution of the evaluated indicator. Conclusions: The use of simple strategies improved the efficacy of this laboratory’s testing process and customer satisfaction. * PCCs : primary care centers TAT : turnaround time LIS : laboratory information system OLAP : online analytical processing ANOVA : variance analysis

Three years of preanalytical errors: Quality specifications and improvement through implementation of statistical process control

Abstract Background: The objectives of this research were to show the most frequent preanalytical sample errors from two distinct patient populations and blood-drawing personnel, to calculate preanalytical quality specifications, and to demonstrate an improvement strategy for patients whose samples have been drawn in the primary health care center by means of a monthly preanalytical quality control report based on statistical process control (SPC). Material and methods: We collected preanalytical errors from the tests requested for hematology, coagulation, chemistry, and urine samples in both populations. To monitor an improvement strategy, we designed a set of indicators. The indicator results for 35 months were entered into the statistical software application, where they were statistically analyzed. The preanalytical quality specifications were calculated using the SPC control charts. The intervention consisted of the sending of a monthly preanalytical quality report to a pilot Decentralized Phlebotomy Center (DPC) and setting up a direct communication channel between the laboratory and the DPC. Results: Fewer errors were observed when the sample drawing was carried out by the laboratory personnel, showing distinct preanalytical quality specifications. Improvements were seen in the DPC after four months of the improvement strategy. Conclusions: We show a practical and effective methodology for the identification, monitoring, and reduction of preanalytical errors using the technology employed in daily total testing laboratory process.

A study of the differences in the request of glycated hemoglobin in primary care in Spain: A global, significant, and potentially dangerous under-request.

OBJECTIVES The study was performed to compare the variability and appropriateness in the request of glycated hemoglobin (HbA1c) in primary care in Spain. DESIGN AND METHODS 76 Spanish laboratories from diverse regions across Spain filled out the number of HbA1c tests requested by general practitioners (GPs) during the year 2012. Every patient seen at the different primary care centers was included in the study. Each participating laboratory was required to provide organizational data. The number of HbA1c requests per 1000 inhabitants was calculated and compared between regions. To investigate whether HbA1c was appropriately requested to manage and to diagnose Diabetes Mellitus (DM), the number of necessary HbA1c was calculated, according to the disease prevalence in Spain (6.9%) and the guidelines regarding DM management and diagnosis. RESULTS 17679195 patients were included in the study. A total of 1544551 HbA1c tests were ordered. No significant difference in the number of HbA1c requests per 1000 inhabitants was seen according to hospital setting (rural, urban or rural-urban). No significant differences were noticed between 3 Spanish regions, except the Valencian Community that presented higher values. Regarding the request appropriateness, 3280183 additional tests would have been necessary to manage diabetic patients and to diagnose new patients with the disease. CONCLUSION There was a high variability regarding the request of HbA1c; the test was under-requested in all the participating health departments. This emphasizes the need to accomplish interventions to improve an appropriate use.

An Evaluation of Hemoglobin A1c Test Ordering Patterns in a Primary Care Setting

Background: To evaluate the hemoglobin A1c (HbA1c) prescription patterns by primary care physicians before the International Expert Committee (IEC) guidelines and how they have changed. Materials and Methods: The number of HbA1c tests ordered from January 2002 to December 2009 was examined in a cross-sectional study. The percentage of HbA1c results <6% and <5.5% were calculated. These cutoffs were decided after consultation of the literature regarding HbA1c values that were unlikely to have diabetic patients. Repeat HbA1c orders per patient were also tabulated. Results: 95,321 HbA1c tests were ordered. The percentage of HbA1c results <6% and <5.5%, respectively, were 36.2% and 13.8%. The percentage of HbA1c tests ordered with a result of <6% differed significantly between January 2009 to July 2009 and August 2009 to December 2009 (picked specifically because of the timing of the IEC guideline). Only 16% of patients had repeat HbA1c tests in 2009. Conclusions: It is necessary to conduct studies of HbA1c testing patterns in order to establish corrective measures to ensure proper use of the tests. Type 2 diabetes mellitus is a chronic illness with a relatively high prevalence, and glycemic control has been fundamental for the management of the disease. Hemoglobin glycation was first used 30 years ago to assess glycemia in subjects with type 2 diabetes mellitus. Since then, the hemoglobin A1c (HbA1c) assay has been the standard laboratory marker of glucose control and correlates well with long-term diabetes complications.1,2 Hemoglobin A1c is now a commonly used laboratory test for monitoring glycemia and managing type 2 diabetes mellitus.3 However, there is compelling evidence that the test is used inappropriately in clinical practice.4 There is a growing interest in HbA1c testing for a diabetes …

Larger differences in utilization of rarely requested tests in primary care in Spain.

Introduction The study was performed to compare and analyze the inter-departmental variability in the request of rarely requested laboratory tests in primary care, as opposed to other more common and highly requested tests. Materials and methods Data from production statistics for the year 2012 from 76 Spanish laboratories was used. The number of antinuclear antibodies, antistreptolysin O, creatinine, cyclic citrullinated peptide antibodies, deaminated peptide gliadine IgA antibodies, glucose, protein electrophoresis, rheumatoid factor, transglutaminase IgA antibodies, urinalysis and uric acid tests requested was collected. The number of test requests per 1000 inhabitants was calculated. In order to explore the variability the coefficient of quartile dispersion was calculated. Results The smallest variation was seen for creatinine, glucose, uric acid and urinalysis; the most requested tests. The tests that were least requested showed the greatest variability. Conclusion Our study shows through a very simplified approach, in a population close to twenty million inhabitants, how in primary care, the variability in the request of laboratory tests is inversely proportional to the request rate.

Variabilidad en los errores preanalíticos del laboratorio entre centros periféricos de extracción: un reto para la seguridad del paciente

OBJECTIVE The aim of the study is to show the most frequent preanalytical sample errors from distinct decentralized phlebotomy centers. METHOD The study was conducted from May 2005 to March 2008. In this period 36,2054 requests and 2,880,742 tests were received from the 16 decentralized phlebotomy centers. When an unsuitable sample is received specific coded results are registered as test results to inform the physician that an error had occurred and a new specimen collection is recommended. We used the the request number, which is specific for each phlebotomy center to ascertain where the samples with errors had been drawn, The preanalytical errors were identified by looking for coded results and were collected automatically from the LIS using a software program based on OLAPs cube (Omnium Roche Diagnostic), obtaining number and type of preanalytical error for each sample. The errors are calculated as number per million samples requested. Analysis of data was carried out using Microsoft Excel 2003. Categorical variables were expressed as frequency and percentage. RESULTS The highest number of incidences occurred in urine samples (52%), followed by coagulation (21%), haematology (17%) and biochemistry (10%). With regard to the type of error, the largest proportion of errors was due to failures of process (62%). CONCLUSIONS The high incidence of preanalytical errors and variability between centers suggests that there is a need to standardize the drawing practice.