Laboratory Test Utilization Research Articles

Evaluating the utility of perioperative laboratory tests in primary shoulder arthroplasty

BackgroundThe rising incidence of primary total shoulder arthroplasty (TSA) predicts a $4 billion increase in cost associated with this procedure by 2030. Studies have evaluated sources of cost containment, including inpatient services, namely routine perioperative laboratory tests. This study evaluates the utility of routine perioperative complete blood count (CBC) and basic metabolic panel (BMP) in TSA and identifies predictors of abnormal postoperative laboratory results and the need for medical intervention (NMI). MethodsAll patients undergoing primary TSA from 2013 to 2020 at a single institution were included. Demographics, comorbidities, procedural details, and preoperative and postoperative CBC and BMP values were recorded. Abnormal values were identified for each laboratory parameter. NMI was defined as postoperative blood transfusion, electrolyte repletion, fluid resuscitation, and inpatient medical consultation. Univariate and multivariate analyses were performed to determine independent predictors for abnormal postoperative CBC and BMP (AbBMP) results and NMI. A P value < .05 was considered statistically significant. ResultsA total of 328 patients were included in the study, with 202 (61.6%) female patients and a median age of 70.5 years. Medical intervention was required in 115 (35.1%). There were no differences in rates of NMI based on patient demographics, comorbidities, and preoperative CBC and BMP results, although there was a significant difference in rates of NMI when comparing postoperative serum potassium (4.1 mmol/L in no NMI group; 3.9 mmol/L in NMI group; P = .039). Ultimately, there were no demographic, surgical, or laboratory factors associated with postoperative NMI on predictive modeling. Increasing body mass index (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.15, P < .03), preoperative serum glucose (OR 1.05, 95% CI 1.02-1.08, P = .003), and preoperative serum blood urea nitrogen (OR 1.12, 95% CI 1.05-1.12, P = .01) are associated with an 8.0%, 5.0%, and 12% increase in odds of an AbBMP, respectively. Preoperative potassium is inversely correlated with odds of AbBMP (OR 0.19, 95% CI 0.05-0.67, P = .01). ConclusionsAlthough postoperative laboratory tests were routinely obtained following primary shoulder arthroplasty, abnormal postoperative CBC and BMP were not associated with NMI. Postoperative BMP tests should be considered in patients with elevated body mass index, elevated preoperative serum glucose, elevated preoperative serum blood urea nitrogen, and those with preoperative serum hypokalemia. Postoperative CBC tests are likely not necessary after primary shoulder arthroplasty.

"Customers Like You Also Ordered …".

Inappropriate laboratory test utilization is a significant challenge for clinical laboratories attempting to improve patient care while minimizing waste of resources.1 Overordering of tests is a high-priority target for laboratories due to external pressures to identify and prevent unnecessary health care expenses and phlebotomy. Fortunately, it is relatively easy for laboratories to measure the volumes of tests that have been performed and to monitor changes in volume in response to initiatives designed to reduce overuse. Underordering of tests, on the other hand, is a more formidable challenge. There are fewer economic incentives to recommend additional testing, and it is more difficult to predict an event that does not happen (ie, a test that should have been performed but was not, one that may have guided clinical decision-making to improve a patient’s care . . . if only it had been ordered at the right time). In this issue of AJCP, Pearson et al2 present a quality improvement initiative at a tertiary medical center designed to facilitate the laboratory evaluation of monoclonal gammopathies (MGs) by tackling an example of underordering: serum free light chain (sFLC) testing. Current expert guidelines recommend the use of sFLC in conjunction with serum protein electrophoresis (SPEP) testing for the initial screening and diagnosis of MGs due to the superior sensitivity and prognostic value of sFLC over SPEP alone.3 Unfortunately, sFLC testing is often not ordered when indicated. The reasons for this underordering are not known, but they may include lack of awareness by ordering providers or lack of adoption by clinical services of recently published guidelines.

Laboratory Testing for Obstetrics Patients at Academic and Non-Academic Health Systems

Abstract Introduction/Objective Evaluation of obstetric clinical laboratory test utilization differences between academic and non-academic health systems would provide important benchmarking information for healthcare leaders and policy makers. Methods/Case Report Over a 3-year period (2019-2021), using the Vizient® Clinical Data Base with permission from Vizient, Inc. (All rights reserved.), we compared clinical laboratory utilization for adult obstetrics inpatients at mid-size (250-450 hospital beds) academic (N=9; 27,036 hospitalizations) and non-academic (N=17; 50,462 hospitalizations) hospitals across the US. We used Medicare Severity Diagnosis Related Groups (MSDRG), employed by the US Centers for Medicare and Medicaid Services (CMS), to identify Cesarean section (MSDRG triplet 786-788) and vaginal delivery (MSDGR triplet 805-807) patient groups. For both groups, we stratified by comorbid conditions and complications into high, moderate, and low severity subgroups. We compared the mean number of laboratory tests (CPT codes 80000-89999) per hospitalization and per hospital day. We measured aggregate Clinical Resource Intensity Weight (RIW) per hospitalization to quantify laboratory resource consumption for each encounter. The RIW is based on the CMS Ambulatory Payment Classification (APC) weights. Results (if a Case Study enter NA) Academic hospitals had a significantly (p&amp;lt;.01) higher mean number of lab tests per Cesarean section hospitalization (20.3 vs. 10.3 tests, 97.1% higher) and hospital day (4.7 vs. 3.3 tests, 42.4% higher). Laboratory RIW per case was also significantly (p&amp;lt;.01) higher at academic hospitals (4.8 vs. 3.6 RIW, 33.3% higher); however, RIW per day did not differ between academic and non-academic hospitals. Significant differences (p&amp;lt;.01) persisted after adjusting for severity level. Although differences were smaller, academic hospitals had greater lab tests per case (12.1 vs. 8.1 tests, 49.4% higher) and day (4.3 vs. 3.6 tests, 19.4% higher) for vaginal delivery hospitalizations. Laboratory RIW per case was also significantly (p&amp;lt;.01) higher at academic hospitals (3.4 vs. 2.8 RIW, 21.4% higher). Laboratory RIW per day did not differ significantly. Significant differences remained for the high and moderate severity vaginal delivery groups. Conclusion Academic hospitals have greater laboratory test utilization for obstetrics patients. This difference appears to be largely due to a longer mean length of stay as well as use of tests with higher RIW.

Clinical Lab Decision Support System for Quality Test Ordering and Utilization with Increase Reimbursement

Abstract Introduction/Objective It is estimated that at least 20% of the 5 billion lab orders submitted annually are inappropriate. Use of an appropriate laboratory test utilization management system (TUMS) can significantly overcome this. Laboratory Decision System (LDS) is the only automated TUMS to assist providers understand, select, order, and optimally utilize tests for disease diagnosis and management. This algorithm-based LDS rates and scores potential tests for any given disease and assigns an interpretable numeric score based on clinical relevance, medical necessity, and indication. Importantly, every orders using LDS will also have right CPT and ICD-10 codes assigned to meet the medical necessity and improve reimbursement. Therefore, in this study, we evaluated the performance of LDS as a testing utilization management system and its ability to improve the reimbursement. Methods/Case Report A total of 96,170 lab orders were analyzed from a reference laboratory. Of these, 814 tests were accompanied by an invalid ICD10 code and 44,671 tests or were accompanied by ICD10 that are described by Medicare as “never covered” because of inability to meet medical necessity. A total of 160,449 tests were subject to an Medicare policy review from which 112,400 tests met coverage criteria and 48,049 tests did not. These orders were then reevaluated using LDS, which can be accessed from app.medicaldatabase.com/site/api/cpoe or interfaced with EMR to determine if the system would have improved test selection and reimbursement. Results (if a Case Study enter NA) Of the original test order sample, 91.5% had an associated LDS score. Of these scored tests, 47.80% met coverage and 43.73% failed to meet coverage, according to the LDS Ranking System. Importantly, LDS provided recommendations for alternative diagnostic ICD10 codes or tests which could have aided physicians in choosing a more appropriate test or submitting a different ICD10 diagnostic code to meet medical necessity. 96.4% with an alternative ICD10 code or test with a score above 5, meeting medical necessity. 80.5% were recommended by the LDS system which would meet Medicare policies. Conclusion Use of such algorithm-based testing selection and ordering database that rates and scores potential tests for any given disease based on clinical relevance, medical necessity, and testing indication, would eventually help providers to select and order right test and reduce miss-utilization of tests.

From Sedentary Lifestyle to Exertional Rhabdomyolysis: A Case Report

It is imperative that internists and hospitalists who are the frontier of care seen by the patient are aware of the red flags associated with Rhabdomyolysis. This case report discusses the clinical evaluation of Exertional Rhabdomyolysis (ER) highlighting the utility of various laboratory tests and clinical hospital course. We here in discusses the clinical evaluation of a 44-year-old male with a sedentary lifestyle who presented with an episode of acute soreness of the proximal muscles, and a near faint in the field in the heat summer month during a basketball game. He reported a prior weightlifting and aerobic running exercise 48 hours before the event. ER was complicated with an acute kidney injury (AKI). The patient’s symptoms improved during hospital admission and labs including creatinine kinase and liver enzymes and kidney function gradually was restored close to reference ranges.

Diagnostic utility of clinical characteristics, laboratory tests, and serum ferritin in diagnosis of adult-onset Still disease.

The diagnosis of adult-onset Still disease (AOSD) is challenging with ambiguous clinical presentation and no specific serological markers. We aim to evaluate the diagnostic utility of clinical, laboratory and serum ferritin features in established AOSD patients. We included all patients >18 years who were admitted to 2 tertiary medical centers (2003–2019) with serum ferritin above 1000 ng/mL. AOSD patients and non-AOSD controls were matched in 1:4 ratio for age and sex. The primary outcomes were sensitivity, specificity, positive/negative likelihood ratio and area under the curve (AUC) using clinical and laboratory characteristics based on the Yamaguchi classification criteria, in addition to serum ferritin. We identified 2658 patients with serum ferritin above 1000 ng/m, of whom 36 diagnosed with AOSD and 144 non-AOSD matched controls. Presence of arthralgia/arthritis showed the highest sensitivity (0.74), specificity (0.93), positive likelihood ratio (10.69), negative likelihood ratio (0.27) and AUC (0.83, 95% confidence interval 0.74–0.92) to the diagnosis of AOSD. On the other hand, serum ferritin showed variation and poorer results, depends on the chosen ferritin cutoff. Joint involvement showed the best diagnostic utility to establish the diagnosis of AOSD. Although clinicians use often elevated ferritin levels as an anchor to AOSD, the final diagnosis should be based on thorough clinical evaluation.

Pursuing appropriateness of laboratory tests: a 15-year experience in an academic medical institution.

Appropriateness in Laboratory Medicine has been the object of various types of interventions. From published experiences, it is now clear that to effectively manage the laboratory test demand it is recommended to activate evidence-based preventative strategies stopping inappropriate requests before they can reach the laboratory. To guarantee appropriate laboratory test utilization, healthcare institutions should implement and optimize a computerized provider order entry (CPOE), exploiting the potential of electronic requesting as "enabling factor" for reinforcing appropriateness and sustaining its effects over time. In our academic institution, over the last 15 years, our medical laboratory has enforced various interventions to improve test appropriateness, all directly or indirectly based on CPOE use. The following types of intervention were implemented: (1) applying specific recommendations supported by monitoring by CPOE as well as a continuous consultation with clinicians (tumour markers); (2) removing outdated tests and avoiding redundant duplications (cardiac markers, pancreatic enzymes); (3) order restraints to selected wards and gating policy (procalcitonin, B-type natriuretic peptide, homocysteine); (4) reflex testing (bilirubin fractions, free prostate-specific antigen, aminotransferases, magnesium in hypocalcemia); and (5) minimum retesting interval (D-Dimer, vitamin B12, C-reactive protein, γ-glutamyltranspeptidase). In this paper, we reviewed these interventions and summarized theiroutcomes primarily related to the changes in total test volumes and cost savings, without neglecting patient safety. Our experience confirmed that laboratory professionals have an irreplaceable role as "stewards" in designing, implementing, evaluating, and maintaining interventions focused to improving test appropriateness.

Less is more: clinical utility of postoperative laboratory testing following minimally invasive hysterectomy for endometrial cancer

With the increasing rates of same-day discharge following minimally invasive surgery for endometrial cancer, the need for and value of routine postoperative testing is unclear. This study aimed to determine whether routine postoperative laboratory testing following minimally invasive hysterectomy for endometrial cancer leads to clinically significant changes in postoperative care. This was a single-institution retrospective cohort study of patients undergoing minimally invasive hysterectomy for endometrial cancer by a gynecologic oncologist between June 2014 and June 2017. Patient demographics, preoperative comorbidities, operative and postoperative data, and pathologic findings were manually extracted from the patients' medical records. The financial burden of laboratory testing was computed using hospital-level cost data. Of the 649 women included in the analysis, most (91.4%) were White, with a mean age of 61 years, and mean body mass index of 38.0 kg/m2. The most common comorbidities were diabetes mellitus (31.9%, n=207), chronic pulmonary disease (7.9%, n=51), and congestive heart failure (3.2%, n=21). Median operative time was 151 minutes (range, 61-278), and median estimated blood loss was 100 mL (range, 10-1500). Most patients (68.6%, n=445) underwent lymphadenectomy. All patients had postoperative laboratory tests ordered: 100% complete blood count, 99.7% chemistry, 62.9% magnesium, 46.8% phosphate, 37.4% calcium, and 1.2% liver function tests. Twenty-six patients (4.0%) had a change in management owing to postoperative laboratory test results. Of these 26 women, 88% experienced a change in clinical status that would have otherwise prompted testing. Only 3 (0.5% of entire cohort) were asymptomatic: 1 received a blood transfusion for asymptomatic anemia, and the other 2, who did not carry a diagnosis of diabetes mellitus, had interventions for hyperglycemia. On univariable analysis, peripheral and cerebrovascular disease, diabetes mellitus with end-organ damage, and a Charlson Comorbidity Index of ≥3 were associated with increased odds of change in management; these were not significant on multivariable analysis. Routine postoperative laboratory evaluation in this cohort increased hospital costs by $292,000. Routine postoperative laboratory tests are unlikely to lead to significant changes in management for women undergoing minimally invasive hysterectomy for endometrial cancer, and may increase cost without providing a discernible clinical benefit. In the setting of strict postoperative guidelines, laboratory tests should be ordered when clinically indicated rather than as part of routine postoperative management for women undergoing minimally invasive hysterectomy for endometrial cancer.

Utility of routine laboratory tests in the assessment of chronic venous disease progression in female patients.

Chronic venous disease (CVD) is a frequently encountered disease that progresses with age. Although the principal method of evaluation and diagnosis is Doppler ultrasound, routine laboratory tests may be an easier and more accessible way to evaluate CVD progression. The present retrospective study evaluated the laboratory results of 256 patients diagnosed with CVD. According to the Clinical, Etiological, Anatomical and Pathophysiological classification, depending on the CVD stage, patients were stratified into three groups: Group 1 (C2-C3; mild disease), Group 2 (C4; moderate to severe disease) and Group 3 (C5-C6; severe disease). The considered parameters were age, red blood cell count (RBC), white blood cell count (WBC) and platelet count (PLT), percentage of neutrophils and lymphocytes, neutrophil-to-lymphocyte ratio (NLR), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), fibrinogen, prothrombin time (in percentages and seconds), internal normalized ratio, activated partial thromboplastin time, creatine kinase (CK), CK myocardial band, alanine transaminase, aspartate transaminase, total bilirubin and urea. No significant differences among the groups were noted in RBC, WBC, PLT and coagulation factors; on the other hand, inflammatory markers exhibited differences among the groups. Several differences were observed in hepatic, metabolic and muscle tissue markers. Intraluminal thrombus formation in the case of varicose veins (thrombophlebitis) may be due to conditions of turbulent flow, stasis and endothelial inflammation, rather than hypercoagulability. The results of the present study confirmed the implication of inflammatory factors in pathophysiological modifications, including thickening of venous walls and valvular modification, as well as the appearance of intraluminal thrombi and trophic lesions. NLR, ESR, CRP and fibrinogen were increased with CVD progression and may be considered useful markers in evaluating CVD progression. Simple blood tests may provide phlebologists with additional insight for the management of those patients.

The Impact of COVID-19 on Laboratory Test Utilization at a Pediatric Medical Center.

BackgroundThe epidemiology and clinical manifestation of coronavirus disease 2019 (COVID-19) in the pediatric population is different from the adult population. The purpose of this study is to identify effects of the COVID-19 pandemic on laboratory test utilization in a pediatric hospital.MethodsWe performed retrospective analysis on test utilization data from Ann & Robert H. Lurie Children’s Hospital of Chicago, an academic pediatric medical center. Data between two 100-day periods prior to (prepandemic) and during the pandemic (mid-pandemic) were analyzed to evaluate changes in test volume, lab utilization, and test positivity rate. We also evaluated these metrics based on in- vs outpatient testing and performed modeling to determine what variables significantly impact the test positivity rate.ResultsDuring the pandemic period, there was an expected surge in COVID-19 testing, while over 84% of lab tests studied decreased in ordering volume. The average number of tests ordered per patient was not significantly different during the pandemic for any of the laboratories (adjusted P value > 0.05). Thirty-three studied tests showed significant change in positivity rate during the pandemic. Linear modeling revealed test volume and inpatient status as the key variables associated with change in test positivity rate.ConclusionsExcluding severe acute respiratory syndrome coronavirus 2 tests, the COVID-19 pandemic has generally led to decreased test ordering volume and laboratory utilization. However, at this pediatric hospital, the average number of tests performed per patient and test positivity rates were comparable between pre- and mid-pandemic periods. These results suggest that, overall, clinical test utilization at this site remained consistent during the pandemic.

The utility of laboratory testing for pediatric patients undergoing isotretinoin treatment.

Isotretinoin, the most effective treatment for severe cystic acne, involves laboratory monitoring. In this retrospective case series of 130 pediatric patients taking isotretinoin, there were significant increases in cholesterol (143.9mg/dl to 155.3mg/dl), triglycerides (81.8mg/dl to 115.2mg/dl), and low-density lipoprotein (82.0mg/dl to 98.1mg/dl), and a decrease in high-density lipoprotein (50.0mg/dl to 44.7mg/dl) from baseline to follow-up (p < .05); there were no significant changes in liver enzymes. None of the patients had clinical sequelae (triglyceride-induced pancreatitis, retinoid-induced hepatotoxicity) related to their abnormal lab values. These findings question the utility of laboratory monitoring for prevention of severe clinical sequelae in pediatric patients, and suggest testing based on individualized risk factors may be more appropriate.

The role of routine laboratory tests after unilateral total knee arthroplasty

BackgroundRecent studies suggest that routine laboratory tests are not required within 1 day after partial knee arthroplasty. In this study, we evaluated the utility of routine postoperative laboratory tests after initial unilateral total knee arthroplasty (TKA) in an Asian population. In addition, we explored risk factors associated with abnormal test results.MethodsClinical data of patients who underwent original unilateral TKA between 2015 and 2020 were retrospectively analyzed. Patient characteristics and laboratory test results were recorded. Multivariate binary logistic regression analysis was performed to identify risk factors associated with 3 abnormal laboratory results.ResultsA total of 713 patients, who underwent relevant laboratory tests within 3 days of TKA surgery, were enrolled. Among them, 8.1%, 9.9%, and 3.4% patients with anemia, hypoalbuminemia, and abnormal serum potassium levels required clinical intervention after surgery. Binary logistic regression analysis revealed that preoperative hemoglobin levels, estimated blood loss, and age were independent risk factors of postoperative blood transfusion in TKA patients. On the other hand, preoperative albumin levels, intraoperative blood loss, and operation time were risk factors associated with postoperative albumin supplementation. In addition, lower body mass index (BMI) and preoperative hypokalemia were potential risk factors of postoperative potassium supplementation.ConclusionConsidering that more than 90% of abnormal postoperative laboratory tests do not require clinical intervention, we believe that routine laboratory tests after surgery have little significance in patients with primary unilateral TKA. However, postoperative laboratory testing is necessary for patients with established risk factors.

Inequity in out-of-pocket expenditure and utilization of laboratory tests in Iran: lessons learned in human rights

Purpose This study aims to calculate the inequity in out of pocket expenditures and utilization of laboratory tests in Iran. Equal access to health services is an important part of human rights in health care. Out-of-pocket payment is a part of financial access to health care. In this study, the authors tried to find inequity in out-of-pocket payments and utilization of medical laboratory tests (MLTs) as a part of human rights in Iran in 2016. Design/methodology/approach Gini and concentration indices were calculated for this purpose, and regression models were estimated to show the relationship between different factors and utilization and out-of-pocket. Findings The average out-of-pocket payment for all of the households was US$1.56 (urban areas: 1.97 and rural areas: 1.31). Moreover, the average utilization of MLTs was 0.079 (urban areas: 0.0908 and rural areas: 0.0753). Gini and concentration indices for out-of-pocket payments were 0.522 and 0.0701, respectively. Originality/value Out-of-pocket and utilization were low in lower in less developed regions of ease and southeast regions of the country and were related to access to health insurance, income and wealth deciles.

The utility of laboratory testing for suspected hyperthyroidism in the emergency department.

Given signs and symptoms of hyperthyroidism are non-specific, thyroid studies may be completed to evaluate patients with vague complaints such as tachycardia in the emergency department (ED). We sought to determine how often a new diagnosis of hyperthyroidism was made in patients who underwent thyroid laboratory testing in the ED. The primary outcome of this study was a new diagnosis in the ED, or in the following 30 days, of hyperthyroidism or thyrotoxicosis following ED thyroid laboratory testing. This was a retrospective chart review study in a single ED of all patients who had a TSH or free T4 ordered from 2007 to 2018, or a TSH value below, or a free T4 higher than the local reference ranges. Patients with a diagnosis of hypothyroidism were excluded. 12,366 patients underwent thyroid laboratory testing, and 12,244 patients were included. Of included patients, 655(5.4%) had abnormal thyroid studies, and 95(0.8%) patients received a new diagnosis of hyperthyroidism or thyrotoxicosis. The sensitivity and specificity of tachycardia for the diagnosis of hyperthyroidism was 70%(95% CI 62% to 77%) and 62%(95% CI 61% to 63%), respectively; and the positive and negative likelihood ratios were 1.8(95% CI 1.7 to 2.0) and 0.5(95% CI 0.4 to 0.6), respectively. This study suggests that thyroid laboratory studies may be best used for a focused assessment for thyroid disorders rather than a screening tool for patients with one symptom of hyperthyroidism.

Diagnostic accuracy and clinical utility of bed side tests versus laboratory tests in the diagnosis of ocular myasthenia.

Purpose:To assess the diagnostic accuracy of forced eyelid closure test (FECT), ice pack test (IPT), repetitive nerve stimulation test (RNS), and acetylcholine receptor (AchR) antibody test in patients with suspected ocular myasthenia. To assess the clinical utility of AchR antibody test in predicting disease progression.Methods:Retrospective cohort study of patients diagnosed with ocular myasthenia at a South-Indian neuro-ophthalmology tertiary eye clinic. Baseline characteristics; ocular myasthenia symptoms; results of FECT, IPT, RNS, and AchR antibody test; and progression time to generalized myasthenia (GM) over 36 months from the time of diagnosis were recorded and analyzed using receiver operator curve analysis, multiple logistic regression, and Kaplan–Meier survival analysis.Results:FECT had a sensitivity of 96.7% (95% CI: 88.5–99.6) and a specificity of 75% (95% CI: 34.9–96.8). Combination of FECT and IPT, using the positivity of at least one test, increased the sensitivity to 98.3% (95% CI: 91–100), reducing the specificity to 50% (95% CI: 15.7–84.3), whereas using the positivity of both tests, we obtained a sensitivity of 71.7% (95% CI: 58.6–82.5) and a specificity of 100% (95% CI: 63.1–100). In the subset of patients with double negative RNS and AchR antibodies, the positive predictive value of combined FECT and IPT (double positive) was 100%. Patients who developed GM were more likely to have a positive AchR antibody test result (P = 0.001)Conclusion:Combined FECT and IPT (double positive) has high diagnostic accuracy even among patients with normal RNS and negative AchR antibodies. Despite low sensitivity, AchR-antibody test has a significant predictive value in disease progression.

Utility of Routine Clinical Laboratory Tests in COVID 19

The novel severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection leading to COVID-19 pandemic has affected many countries all over the world including India. Diagnostic laboratories play crucial role in containment of pandemic as they enable the rapid identification for isolation and treatment of COVID-19 positive cases. Gold standard test for COVID 19 detection is the reverse transcriptase Polymerase Chain Reaction (RT-PCR)-based assays performed on respiratory specimen. The role of other laboratory parameters in COVID-19 cases has not been definitely established. Clinical laboratory investigations need to be studied in larger populations to understand the pathogenesis and to understand whether these parameters are useful to triage COVID-19 suspect patients before the results of RT PCR are available. This study was aimed to analyze and compare routine clinical laboratory parameters in COVID-19 positive and negative patients at the time of presentation to our tertiary care referral center situated in western region of India from April, 2020 till November, 2020. Patients were divided into two groups based on the results of RT-PCR for COVID-19. The outcome of different laboratory parameters like CBC, CRP, AST, ALT, LDH, ferritin were evaluated in cases with positive RT-PCR and compared with negative RT-PCR group. We found no statistically significant differences between COVID-19 positive and negative group on routine clinical laboratory parameters of 4602 patients.

Risk of malignancy following emergency department Bell's palsy diagnosis in children.

To quantify the risk of malignancy following the emergency department (ED) diagnosis of Bell's Palsy (BP) using a large retrospective cohort. We performed a cohort study using the Pediatric Health Information System database. We included all children (6months - 17years) from 2011 to 2020 with an ED diagnosis of BP. We excluded children with previous neurologic chronic condition or malignancy diagnosed during or prior to the index visit. Our primary outcome was diagnosis of malignancy within 60days following the index ED visit. We compared clinical characteristics between children with and without new-onset malignancy. Of 12,272 encounters for BP, 41 had a new oncologic diagnosis within 60days (0.33%, 95% confidence interval [CI]: 0.25-0.45%). Median time to oncologic diagnosis was 22days. Primary CNS malignancy (59%) and leukemia (17.1%) were the most common diagnoses. Younger children had a higher incidence of new oncologic diagnosis compared with older children. Incidences were 0.68% (95% CI 0.36-1.3%), 0.70% (95% CI 0.38-1.3%), 0.26% (95% CI 0.15-0.47%), and 0.21% (95% CI 0.12-0.37%) for children aged <2years, 2-5years, 6-11years, and 12-17years respectively. We found a small but potentially clinically significant rate of new-onset oncologic diagnosis within 60days after BP diagnosis in the ED, especially in children younger than 5years. Further studies of the diagnostic utility of laboratory testing or neuroimaging and the risk of empiric steroids in children with BP are needed.

Laboratory Test Utilization Practices in Hamad Medical Corporation; Role of Laboratory Supervisors and Clinicians in Improper Test Utilization; a Descriptive Pilot Study.

BackgroundThe use of diagnostic laboratory tests is increasing worldwide. Improper test utilization (ITU) is a common problem for all healthcare systems as it costs substantial expenses for the health systems and impacts optimal patient care.PurposeThe present small-scale survey aims to highlight the current practice of ITU among the labs and physicians, and investigate the actions of diagnostic laboratories towards ITU, and identify the reasons affecting test ordering decisions among physicians.MethodsA cross sectional study based on two different surveys was developed and distributed from March 2017 to April 2017 to laboratory supervisors and physicians (clinicians) at Hamad Medical Corporation (HMC), Qatar. Fourteen laboratory supervisors and eighty-nine physicians were surveyed about improper test utilization practices. The overall results are descriptive data.ResultsThe overall proportion of improperly utilized tests detected by the laboratory supervisors were 50.0%, 35.7%, and 14.3% for overused, misused, and underused lab tests, respectively. Among the physicians, 91% used the electronic ordering template to select the appropriate tests. Moreover, 78.7% of the physicians used the clinical guidelines, while 73% were not employing the laboratory handbook. Furthermore, 95.5%% of the physicians preferred to get feedback about inappropriate tests, while 51.1% were not receiving any, and 40.9% were rarely receiving. Finally, 67.4% were unaware of the tests’ costs among surveyed physicians, and 63.6% showed a willingness to reduce their orders if the cost was high and unnecessary.ConclusionThe physician’s and the laboratories’ communication were inadequate and not systematized, causing ITU practices. The improvement strategy should focus on the communication between clinical labs and physicians and enhance physician implementation to order appropriate lab tests. This could be achieved by conducting legitimate educational methodologies, continuous feedback reviews, ongoing audits, executing health information technology instruments, engaging laboratory practice guidelines, and applying demand management and testing algorithms.

Current state of laboratory test utilization practices in the clinical laboratory

Appropriate laboratory test utilization is of growing interest in the face of rising healthcare costs and documented evidence of over- and under-utilization. Building from published literature, laboratory organizations have recently published guidelines for establishing laboratory utilization management programs. However, systematic reviews and meta-analyses have consistently struggled to define rigorous evidence-based best practice recommendations due to the paucity of published data or the heterogeneity of available data. We sought to gain information about utilization practices and programs currently in use and which factors contribute to their success by distributing a survey among laboratory professionals. The survey received seventy-four eligible respondents. We observed a wide range in the duration of laboratory utilization programs and the number of stewardship initiatives. In addition, there was great variety in the utilization practices used and the tests or processes targeted by programs. There was similarity in how initiatives are evaluated and who is involved with utilization programs. Finally, respondents often credited a multidisciplinary committee, support from leadership, and strong IT support/data access as important factors for their program's perceived success. Many of these factors agree with previously published literature.

Study of gonococcal and chlamydial urethritis: Old culprits with a new story.

Neisseria gonorrhoeae and Chlamydia trachomatis are the primary pathogens causing urethritis. A cross-sectional study was carried out in the Department of Microbiology in conjunction with the Department of Dermatology and STD of our hospital. The aim of the study was to detect N. gonorrhoeae and C. trachomatis among men with urethritis and to determine the anti-microbial susceptibility of the N. gonorrhoeae isolates. All cases were subjected to direct Gram's smear examination and culture of urethral discharge (N. gonorrhoeae), real-time polymerase chain reaction and direct fluorescent antibody test (C. trachomatis). All N. gonorrhoeae isolates were subjected to anti-microbial susceptibility testing and were tested for ß-lactamase production by chromogenic cephalosporin test. Data were expressed as percentages. Fisher's exact test was used to evaluate statistical significance in the case of unpaired categorical data. Agreement between the methods was assessed by using kappa statistics. Gonococcal infection was detected in 58.1% cases, and C. trachomatis was detected in 14% cases. However, both were detected in 12% cases. The sensitivity, specificity, positive predictive value, and negative predictive value of direct Gram's smear examination and culture of urethral discharge were found to be 100% when compared to culture for N. gonorrhoeae. Direct fluorescent antibody (DFA) test proved to be a valuable test aiding in the diagnosis of chlamydial urethritis with a majority of positive cases showing 20-30 elementary bodies. We detected our first gonococcal isolate with decreased susceptibility to third-generation cephalosporins, ceftriaxone, cefixime, and cefpodoxime (MIC for ceftriaxone = 0.19 mg/ml). Optimal management of urethritis and strategies to prevent its transmission depend on accurate detection of infected persons. Our study demonstrates the utility and limitations of different laboratory tests including anti-microbial sensitivity testing for N. gonorrhoeae and C. trachomatis.