A multi-level strategy for a long lasting reduction in unnecessary laboratory testing: A multicenter before and after study in a teaching hospital network.

BACKGROUND: Reducing unnecessary laboratory blood testing in the hospital setting represents a challenge to improve the adequacy of healthcare and a tricky task for teaching hospitals. Our hospital network actively participates in the Choosing Wisely Campaign and is engaged in avoiding unnecessary low value interventions and investigations. We aimed to study whether a multi-level approach combining educational and web-system based interventions, could be effective in reducing laboratory testing and related costs. METHODS: Multicenter, proof of concept, prospective, observational, before and after study, in a network of public hospitals in Switzerland. All patients admitted between 1 January 2015 and 31 December 2017 were analyzed. A multi-level strategy based on online continuous monitor benchmarking and educational support was applied in the internal medicine services. The primary outcome was a significant reduction in the number of laboratory tests per patient and per day during the hospital stay. Secondary outcomes were reduction in the blood sample volume taken per patient and per day in laboratory costs. RESULTS: Over the 36 months of the study, 33 309 admissions were analyzed. A significant reduction of laboratory tests per patient and per day of hospitalisation was found:-11%, P-value<0.001; -6%, P-value <0.001. The mean monthly blood volume, per patient and per day of hospital stay and laboratory costs per patient was also significantly reduced: -7%, P-value<0.05; -3%, P-value<0.01, and -17%, P-value<0.01, respectively. CONCLUSIONS: The obtained reduction in the number of laboratory tests, blood volume withdrawn and related costs, support the idea that an open web-based system, involving all health care providers, coupled with educational interventions, can be helpful in generating awareness of prescriber habits and to catalyze changes in their behaviour. The peer pressure related to the unmasked benchmarking process did probably play a determinant role.

[Choosing Wisely: from theory to practice]. / "Choosing Wisely": von der Theorie zur Praxis.

"Choosing Wisely" is an innovative approach that the Network of Southern Switzerland Public Hospitals has decided to promote. Five standard diagnostic or therapeutic procedures have been chosen to explore the potential benefit of the "Choosing Wisely" initiative: the prescription of benzodiazepines, proton pump inhibitors or antibiotics on discharge from hospital, exposure to ionising radiation in radiological imaging and the number of blood samples taken during hospitalisation. As a first step we compared these variables in the medical and surgical departments of the four major public hospitals in Ticino. We observed significant and unexpected practical differences between specialties and between the different institutions. These results were presented to all concerned healthcare stakeholders. The next steps are to develop continuous monitoring of these indicators and specific recommendations by involving patients in the consciousness-raising process.

Interference in thyroid-stimulating hormone determination.

BACKGROUND: Thyroid-stimulating hormone (TSH) measurement plays a major role in the diagnosis of thyroid disorders. Despite the good quality of immunochemical tests measuring TSH levels, the presence of interfering substances can sometimes alter the TSH results. DESIGN: We reported the case of a 79-year-old man affected by primary autoimmune hypothyroidism hospitalized for pneumonia. A TSH value > 100 mIU L(-1) (reference: 0.44 mIU L(-1)) was found at admission. No signs and symptoms of hypothyroidism were found upon clinical examination and serum concentration of the free thyroxine (FT4) was normal. RESULTS: Serum treatment in heterophile antibody blocking tubes did not change the TSH result in our assay, while normal levels were found in a different immunoassay method. An abnormal pattern was found in protein electrophoresis at admission, with IgG / j and IgM / k monoclonal bands proved in immunofixation. Interestingly, the disappearance of monoclonal bands was paralleled with a normalization of the TSH value. CONCLUSIONS: We suggest in this study that the TSH determination might be influenced by the presence of transient paraproteins.

Lack of concordance between EMIT assay and LC-MS/MS for Therapeutic Drug Monitoring of Mycophenolic Acid: Potential increased risk for graft rejection?

Therapeutic drug monitoring (TDM) of immunosuppressive drugs is crucial in organ-transplanted patients to prevent rejection or toxic effects due to inadequate dosage. Mycophenolic acid (MPA) is a commonly used immunosuppressant in this setting. Nowadays, MPA concentrations are monitored by Enzyme Multiplied Immunoassay Technology (EMIT), and Liquid Chromatography (LC)-based techniques, particularly coupled to Tandem Mass Spectrometry (LC-MS/MS). This study evaluates the concordance between TDM results for MPA obtained through CE-IVD EMIT and LC-MS/MS assays in plasma samples. LC-MS/MS quantification was based on a commercial kit and the analytical performance in terms of accuracy was tested through external proficiency tests and inter-laboratory comparison with a home-made HPLC-UV method. Both these evaluations confirmed the reliability of the LC-MS/MS method (1.6 % and 9.0 % of bias, respectively). Conversely, the comparison between EMIT and LC-MS/MS showed overestimation by EMIT of 33.5 %. This bias resulted concentration-dependent, ranging from 46.4 % in the concentration range of 1-2 mg/L, to 21.4 % over 4 mg/L. Considering the theoretical clinical impact of this overestimation, a fraction comprised between 12.4 % and 31.4 % of samples which resulted over three different minimum effective concentration values by EMIT (no indication for dose adjustment) had discordant indications by LC-MS/MS (dose adjustment needed). Concluding, this study highlights a clinically relevant systematic overestimation of MPA concentration by EMIT, supporting the switch to LC-MS/MS techniques for TDM purpose. However, further prospective studies are needed in order to evaluate the clinical impact of switching the TDM activity from EMIT to LC-MS/MS in a larger cohort in a long period.

Comparison of two non-bronchoscopic methods for evaluating inflammation in patients with acute hypoxaemic respiratory failure.

INTRODUCTION: The simple bedside method for sampling undiluted distal pulmonary edema fluid through a normal suction catheter (s-Cath) has been experimentally and clinically validated. However, there are no data comparing non-bronchoscopic bronchoalveolar lavage (mini-BAL) and s-Cath for assessing lung inflammation in acute hypoxaemic respiratory failure. We designed a prospective study in two groups of patients, those with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) and those with acute cardiogenic lung edema (ACLE), designed to investigate the clinical feasibility of these techniques and to evaluate inflammation in both groups using undiluted sampling obtained by s-Cath. To test the interchangeability of the two methods in the same patient for studying the inflammation response, we further compared mini-BAL and s-Cath for agreement of protein concentration and percentage of polymorphonuclear cells (PMNs). METHODS: Mini-BAL and s-Cath sampling was assessed in 30 mechanically ventilated patients, 21 with ALI/ARDS and 9 with ACLE. To analyse agreement between the two sampling techniques, we considered only simultaneously collected mini-BAL and s-Cath paired samples. The protein concentration and polymorphonuclear cell (PMN) count comparisons were performed using undiluted sampling. Bland-Altman plots were used for assessing the mean bias and the limits of agreement between the two sampling techniques; comparison between groups was performed by using the non-parametric Mann-Whitney-U test; continuous variables were compared by using the Student t-test, Wilcoxon signed rank test, analysis of variance or Student-Newman-Keuls test; and categorical variables were compared by using chi-square analysis or Fisher exact test. RESULTS: Using protein content and PMN percentage as parameters, we identified substantial variations between the two sampling techniques. When the protein concentration in the lung was high, the s-Cath was a more sensitive method; by contrast, as inflammation increased, both methods provided similar estimates of neutrophil percentages in the lung. The patients with ACLE showed an increased PMN count, suggesting that hydrostatic lung edema can be associated with a concomitant inflammatory process. CONCLUSIONS: There are significant differences between the s-Cath and mini-BAL sampling techniques, indicating that these procedures cannot be used interchangeably for studying the lung inflammatory response in patients with acute hypoxaemic lung injury.

Hypokalaemia in hospitalised patients.

QUESTIONS UNDER STUDY: Hypokalaemia in inpatients is common, and is associated with morbidity and mortality. Its management is risky and not always effective. We launched an educational programme with the aim of increasing the rate of potassium normalisation during hospital stay, and of reducing unmonitored cases. METHODS: The project consisted of three phases: (I) retrospective analysis on 26 471 patients hospitalised in 2012 in five acute care hospitals of southern Switzerland (Ente Ospedaliero Cantonale, EOC) with identification of improvement goals on a sample survey (588 cases of hypokalaemia); (II) revision of internal guidelines, and implementation of educational activities in one of the five hospitals (Ospedale Regionale di Locarno, ODL); (III) follow-up analysis on the 26 726 patients hospitalised in 2014 and second sampling to complete the evaluation of the efficacy of the intervention. RESULTS: Phase I, ODL vs EOC: prevalence of hypokalaemia, 21.7 vs 23.2% (p <0.05); treated 53.1 vs 56.5% (not significant); normalisation 62.4 vs 61.1% (ns); absence of monitoring 18.3 vs 21.1% (p <0.05); time to normalisation 3.0 ± 2.7 vs 2.8 ± 2.4 days (ns); secondary hyperkalaemia 1.1 vs 1.4% (ns). Length of stay hypokalaemic vs normokalaemic 11.2 ± 11.7 vs 6.6 ± 7.9 days (p <0.001); falls 3.5 vs 1.7% (p <0.001), deaths 5.1 vs 3.1% (p <0.001). The severity/performance ratio suggested inefficiency. Phase III, ODL 2012 vs ODL 2014: treated 53.1 vs 75.7% (p <0.001); normalisation 62.4 vs 69.7% (p <0.01); absence of monitoring 20.1 vs 8.7 (p <0.01); time to normalisation 3.1 ± 2.7 vs 2.4 ± 2.6 days (ns); secondary hyperkalaemia 1.1 vs 1.8% (ns). CONCLUSIONS: The management of hypokalaemia is characterised by dysfunctions; it can, however, be ameliorated by the implementation of internal guidelines and targeted educational activities. The length of hospital stay is increased in patients with hypokalaemia, shifting the expected length of hospital stay based on the Swiss Diagnosis Related Group classification.