Progressing towards laboratory accreditation in developing countries.

Laboratory testing is of great value in the diagnosis and management of diseases. Good quality of results is essential if test results are to be meaningful. Uniformly high standards of laboratory practice are required to ensure that physicians may consistently rely on test results. Accreditation provides a way whereby a laboratory may meet international standards and provide assurance to a hospital's administration, medical and laboratory staff and patients that the laboratory is providing high quality results. In the absence of a national accreditation program, laboratories should undertake the low-cost or no cost actions that are elements of all accreditation programs. National societies concerned with the field of laboratory medicine or clinical pathology should work together with the appropriate government agencies to establish aNational Accrediting Body. Institution of an accrediting program will raise the visibility of clinical laboratory testing and ensure enhanced quality of testing for the entire population,

Blood transfusion costs by diagnosis-related groups in 60 university hospitals in 1995.

BACKGROUND: Transfusion services are frequently challenged to initiate efforts to reduce blood transfusion costs. One approach is to analyze blood transfusion costs for individual medical and surgical Diagnosis-Related Groups (DRGs). Rank ordering of DRGs by transfusion costs and interinstitutional comparisons of these costs may lead to the selection of DRGs for further analysis of the process of blood transfusion. STUDY DESIGN AND METHODS: Common DRGs (n = 486) that were related to discharges in 1995 were analyzed from 60 university hospital members of the University HealthSystems Consortium (UHC). Cost data were tabulated by using cost-to-charge ratios reflecting all aspects of blood transfusion-related costs of participating institutions. RESULTS: Of these 486 DRGs, 471 had identifiable mean blood costs, and 34 had median blood costs, mostly for surgical conditions. Transfusion costs represented a small proportion (< or = 1%) of total hospitalization costs for most DRGS: Nonetheless, millions of dollars were spent on blood transfusion, and for the most expensive DRGs, the costs ranged from 5.0 to 8.6 percent of total hospitalization costs. Transfusion costs are more variable for the DRGs with the lowest transfusion costs than for those with the highest transfusion costs. CONCLUSION: Members of the UHC may utilize such analyses to identify surgical or medical diagnoses with transfusion costs at variance with the group norm. These DRGs could then be targeted for further evaluation of components contributing to high costs, for possible alterations in physician or clinical laboratory practices. Considering those conditions with the highest cumulative transfusion costs (e.g., BMT, liver transplant, acute leukemia, and cardiothoracic procedures), changes in transfusion practices that affect these particular patient categories may have a significant impact on global blood transfusion costs.

Interpreting and defensively responding to threat: examining appraisals and coping with acquaintance sexual aggression.

Resistance and prevention programming aimed at strengthening women's ability to protect themselves against acquaintance sexual aggression has lacked attention to the cognitive and emotional processes women engage in when encountering such threats. Building upon current theory related to cognitive appraisal and coping processes, this study applies a theoretical model of how women evaluate and respond to sexual aggression by male acquaintances. Two hundred and two college women who had been sexually victimized by male acquaintances responded to a questionnaire that assessed their cognitive appraisals of and emotional and behavioral responses to the incident, in addition to aggression characteristics. Path analytic regression analyses examined theorized relationships among primary and secondary appraisal and emotional response variables in addition to their collective prediction of behavioral responding. The hypothesized model accounted for significant variance in behavioral responding and indicated different patterns of appraisals, emotions, and aggression characteristics predicting women's assertive and diplomatic behavioral responses to their assaults. These findings are consistent with research and theory related to individuals' appraisal of and coping with threatening events. Theoretical and intervention implications for resistance and prevention efforts are discussed.

Women's perceptions of health care in prison.

Fifteen female inmates' perceptions of medical care and the manner in which treatment is provided are explored through individual interviews in a state prison. The women did not hold exclusively negative or positive views about the care and treatment they received; however, the predominant view was negative. Examples of inadequate medical care are described by 14 of the 15 women. Nonempathetic treatment, such as being treated as if undeserving of care, is described by all 15. Examples of adequate medical care and empathetic treatment are offered as well, and the overlap between positive and negative perceptions of care is explored.

Toward a checklist for reporting of studies of diagnostic accuracy of medical tests.

BACKGROUND: : "Diagnostic accuracy" refers to the ability of medical tests to provide accurate information about diagnosis, prognosis, risk of disease, and other clinical issues. Published reports on diagnostic accuracy of medical tests frequently fail to adhere to minimal clinical epidemiological standards, and such failures lead to overly optimistic assessments of evaluated tests. Our aim was to enumerate key items for inclusion in published reports on diagnostic accuracy, with a related aim of making the reports more useful for systematic reviews. METHODS: : We examined published reports on shortcomings of studies of diagnostic accuracy. We prepared an initial draft of a checklist to address common errors and presented it at a meeting of editors. After incorporation of comments from editors, we published a revised version in Clinical Chemistry in 1997 for comment from readers. One of us (E.M.) additionally circulated copies of the draft to methodologists and others interested in Evidence-Based Medicine. We updated the checklist with input from these sources. RESULTS: : The updated document lists items for inclusion in the title, abstract, methods, results, and discussion sections of published papers. Depending on the nature of the study, the total number of items for a single paper is approximately 40. We invite comments on this document, which is freely available at Clinical Chemistry Online, where it can accessed readily from the Table of Contents for the July 2000 issue at www. clinchem.org/content/vol46/issue7/. Comments (eLetters) can be posted there for general reading. CONCLUSIONS: : The suggested revisions incorporated in this report appear useful to ensure inclusion of additional information that can allow assessment of the validity of the conclusions and the applicability of the study in other settings. The list can be useful in formulating guidelines and a checklist, which will require testing by authors and study of their effect on published studies of diagnostic accuracy.

The costs of disease.

BACKGROUND: To date there have been no studies identifying and comparing the component costs to treat a large number of diseases for hospitalized inpatients. METHODS: Hospital costs were analyzed for 486 diagnosis-related groups (DRGs) relating to >1.3 million patient discharges from 60 University Hospital members of the University HealthSystems Consortium. For each DRG, length of stay, total cost, and key cost components were analyzed, including accommodation, intensive care, and surgery. RESULTS: In general, total costs of diseases classified as surgical exceeded those classified as medical. Diseases involving organ transplantation typically cost more than other diseases. However, within the studied population, the two DRGs accounting for most total healthcare dollars were percutaneous cardiovascular procedures and management of neonates with immaturity or respiratory failure. CONCLUSIONS: Considering six key cost components, as well as disease complexity and length of stay, the best predictors of total costs for medical conditions were the length of stay and accommodation (housing, meals, nursing services) costs, whereas for surgical conditions, the best predictor of total costs was laboratory costs. This analysis may be used within an individual institution to identify surgical or medical diagnoses with total or component costs at variance with the group mean. A hospital may focus its cost reduction efforts to make decisions to expand, alter, or eliminate particular clinical programs based on comparison of its own total and component costs with those from other hospitals in the database.

Laboratory costs in the context of disease.

BACKGROUND: To determine the contribution of laboratory costs to the overall costs of managing hospital patients with different diseases, we studied the costs of laboratory testing overall and in relation to the other costs incurred during hospitalization. METHODS: We used a database developed by the University HealthSystems Consortium containing >1 million patients in 60 University Hospitals with diseases included in 486 diagnosis-related groups (DRGs). Laboratory costs included in the database comprised those associated with testing in the clinical laboratory together with those incurred in point-of-care testing and anatomic pathology but not those involving blood products and their transfusion. RESULTS: The mean laboratory costs to manage surgical patients were greater than those to manage medical patients in 19 of the 25 major diagnostic categories. The median laboratory costs for patients with liver transplants exceeded $8000, and the laboratory costs to support other organ transplants were among the highest. The highest proportion of total costs attributable to the laboratory was 18.3% for acute leukemia and kidney and urinary tract signs and symptoms, both in children. Laboratory costs were <1.0% of the total costs for only 15 DRGs. The highest median daily laboratory cost, $416, was attributable to liver transplant patients. Several conditions had median laboratory costs less than $30 per day, in spite of lengths of stay that exceeded 10 days in some cases. CONCLUSIONS: Although laboratory costs generally average 6% of the total costs for surgical conditions and 9% of the total costs for medical conditions, there is considerable variability. In general, laboratory costs were relatively poorly correlated with total costs. However, observation of high daily laboratory costs for many DRGs suggests that reducing length of stay would reduce both laboratory and total costs.

Clinical applications of two-dimensional electrophoresis.

Two-dimensional electrophoresis is increasingly being used as an important tool for biological research although it continues to have few direct clinical applications. In the absence of simple systems to identify and quantify individual proteins or groups of proteins it is unlikely that clinical applications will increase. Measurement of some individual proteins, for example a single acute phase reactant, often yields as much clinically useful information as could be currently expected from quantitation of several proteins with the same physiological role. Cost-containment pressures within the clinical laboratory will prevent the technique from becoming widely used in the clinical laboratory until it can clearly demonstrate that it can produce clinically important and necessary information that can not be obtained by other means. We continue to believe that the technique's greatest potential lies in identifying a protein or proteins whose concentration can be correlated with a disease and whose concentration varies with the progress of the disease. Antibodies to such proteins can then be produced and used to quantify the disease-associated proteins by a simple procedure, such as nephelometry. In spite of our belief of the likely clinical application of the technique there appears to be no systematic use of two-dimensional electrophoresis for this purpose. With clinical specimens a few investigators still run gels of serum or urine from patients with apparently unusual disorders and compare them visually with gels from healthy individuals. Nevertheless, the technique continues to have considerable unmet promise for clinical applications.