Addressing Neisseria gonorrhoeae Treatment Resistance With the DNA Gyrase A Assay: An Economic Study, United States.

Targeted antibiotics could delay emergence of resistant Neisseria gonorrhoeae. The DNA gyrase subunit A assay predicts susceptibility to ciprofloxacin. A model found that adding a $50 gyrase subunit A test for asymptomatic patients screened for N. gonorrhoeae resulted in cost neutrality. When ciprofloxacin susceptibility was high, a $114 test resulted in savings.

Vitamin D: too much testing and treating?

There is clinical uncertainty as to the testing of serum 25--Hydroxy vitamin D (25[OH]D) concentrations and when to use high-dose supplementation. Data show that there has been a rapid increase in the number of tests performed within the Northumbria Healthcare NHS Foundation Trust over the past 8 years and an increase in high-dose supplementation over the past 5 years. We performed a retrospective analysis of the 25(OH)D test requests over the period from January to -October 2017. A total of 17,405 tests were performed in this time period. The overall average concentration was 57.5 nmol/L and this figure was similar across age groups, although a larger proportion of patients aged over 75 had a concentration <25 nmol/L. Test requests were classified into 'appropriate', 'inappropriate' and 'uncertain' categories based on current expert opinion. We found that between 70.4% and 77.5% of tests could be inappropriate, depending on whether the 'uncertain' categories of falls and osteoporosis are considered to be justified. Tiredness, fatigue or exhaustion was the reason for testing in 22.4% of requests. We suggest that a more rational approach to testing, and subsequent treating, could lead to reductions in costs to the healthcare system and patients.

Budgetary impact of diagnostic tests for visceral leishmaniasis in Brazil.

The aim of the present study was to estimate the financial costs of the incorporation and/or replacement of diagnostic tests for human visceral leishmaniasis (VL) in Brazil. The analysis was conducted from the perspective of the Brazilian Unified National Health System (SUS) over a period of three years. Six diagnostic tests were evaluated: the indirect immunofluorescence antibody test (IFAT), the IT LEISH rapid test, the parasitological examination of bone marrow aspirate, the direct agglutination test (DAT-LPC) standardized in the Clinical Research Laboratory, René Rachou Institute of the Oswaldo Cruz Foundation, the Kalazar Detect rapid test, and polymerase chain reaction (PCR). The assumptions used were the number of suspected cases of VL reported to the Brazilian Ministry of Health in 2014 and the direct cost of diagnostic tests. The costs to diagnose suspected cases of VL over three years using the IFAT and the DAT-LPC were estimated at USD 280,979.91 and USD 121,371.48, respectively. The analysis indicated that compared with the use of the IFAT, the incorporation of the DAT-LPC into the SUS would result in savings of USD 159,608.43. With regard to the budgetary impact of rapid tests, the use of IT LEISH resulted in savings of USD 21.708,72 over three years. Compared with a parasitological examination, diagnosis using PCR resulted in savings of USD 3,125,068.92 over three years. In this study, the replacement of the IFAT with the DAT-LPC proved financially advantageous. In addition, the replacement of the Kalazar Detect rapid test with the IT LEISH in 2015 was economically valuable, and the replacement of parasitological examination with PCR was indicated.

Mindfulness-Based Laboratory Reduction: Reducing Utilization Through Trainee-Led Daily 'Time Outs'.

BACKGROUND: Overuse of laboratory investigations is widely prevalent in hospitalized patients, leads to discomfort, and increases direct and indirect costs. OBJECTIVE: We implemented a simple, inexpensive, mindfulness strategy on our inpatient medical clinical teaching unit to reduce unnecessary laboratory orders through education, a forcing function, and daily structured laboratory "time outs." METHODS: On a 26-bed unit in an academic hospital center, the per-period laboratory costs per patient were compared pre- and postintervention using segmented regression analysis of an interrupted time series. RESULTS: The average cost per admitted patient decreased from $117 to $66, with an estimated savings of $50,657 over 985 admissions. After adjusting for fiscal period and the presence of our intervention, there was a significant reduction in the per-patient number of total tests, complete blood counts, and electrolyte panels performed (P <.001 for all level and time trend changes). CONCLUSION: This trainee-designed and -led intervention, centered around structured, mindfulness-based laboratory test ordering, was successful at decreasing the overuse of common daily blood work in hospitalized patients.

Budgetary impact of diagnostic tests for visceral leishmaniasis in Brazil / Impacto orçamentário dos testes diagnósticos para leishmaniose visceral no Brasil / Impacto presupuestario de las pruebas diagnósticas para la leishmaniosis visceral en Brasil

Abstract: The aim of the present study was to estimate the financial costs of the incorporation and/or replacement of diagnostic tests for human visceral leishmaniasis (VL) in Brazil. The analysis was conducted from the perspective of the Brazilian Unified National Health System (SUS) over a period of three years. Six diagnostic tests were evaluated: the indirect immunofluorescence antibody test (IFAT), the IT LEISH rapid test, the parasitological examination of bone marrow aspirate, the direct agglutination test (DAT-LPC) standardized in the Clinical Research Laboratory, René Rachou Institute of the Oswaldo Cruz Foundation, the Kalazar Detect rapid test, and polymerase chain reaction (PCR). The assumptions used were the number of suspected cases of VL reported to the Brazilian Ministry of Health in 2014 and the direct cost of diagnostic tests. The costs to diagnose suspected cases of VL over three years using the IFAT and the DAT-LPC were estimated at USD 280,979.91 and USD 121,371.48, respectively. The analysis indicated that compared with the use of the IFAT, the incorporation of the DAT-LPC into the SUS would result in savings of USD 159,608.43. With regard to the budgetary impact of rapid tests, the use of IT LEISH resulted in savings of USD 21.708,72 over three years. Compared with a parasitological examination, diagnosis using PCR resulted in savings of USD 3,125,068.92 over three years. In this study, the replacement of the IFAT with the DAT-LPC proved financially advantageous. In addition, the replacement of the Kalazar Detect rapid test with the IT LEISH in 2015 was economically valuable, and the replacement of parasitological examination with PCR was indicated.

Resumo: O estudo teve como objetivo estimar os custos financeiros da incorporação e/ou substituição dos testes diagnósticos para a leishmaniose visceral (LV) humana no Brasil. A análise foi realizada na perspectiva do Sistema Único de Saúde (SUS) ao longo de três anos. Foram avaliados seis testes diagnósticos: reação de imunofluorescência indireta (RIFI), teste rápido IT LEISH, exame parasitológico de aspirado de medula óssea, teste de aglutinação direta DAT-LPC padronizado pelo Laboratório de Pesquisas Clínicas do Instituto René Rachou, Fundação Oswaldo Cruz, teste rápido Kalazar Detect e reação em cadeia da polimerase (PCR). Os parâmetros utilizados foram o número de casos suspeitos de LV notificados ao Ministério da Saúde em 2014 e o custo direto dos testes diagnósticos. Os custos do diagnóstico de casos suspeitos de LV ao longo de três anos usando o RIFI e DAT-LPC foram estimados em USD 280.979,91 e USD 121.371,48, respectivamente. De acordo com a análise, comparado ao uso do RIFI, a incorporação do DAT-LPC pelo SUS resultaria numa economia de USD 159.608,43. Com relação ao impacto dos testes rápidos, o uso do IT LEISH resultou em economia de USD 21.708,72 ao longo de três anos. Comparado ao exame parasitológico, o diagnóstico com PCR resultou em economia de USD 3.125.068,92 ao longo de três anos. Neste estudo, a substituição do RIFI pelo DAT-LPC mostrou ser financeiramente vantajosa. Além disso, a substituição do teste rápido Kalazar Detect com o IT LEISH em 2015 foi economicamente apropriada, e a substituição do exame parasitológico pela PCR está economicamente indicada.

Resumen: El objetivo del estudio fue estimar los costes financieros de la incorporación y/o sustitución de las pruebas diagnósticas para la leishmaniasis visceral (LV) humana en Brasil. El análisis se realizó desde la perspectiva del Sistema Único de Salud (SUS) a lo largo de tres años. Se evaluaron seis pruebas diagnósticas: reacción de inmunofluorescencia indirecta (RIFI), test rápido IT LEISH, examen parasitológico de aspirado de medula ósea, test de aglutinación directa DAT-LPC, estandarizado por el Laboratorio de Investigación Clínica del Centro de Investigación René Rachou, Fundación Oswaldo Cruz, test rápido Kalazar Detect y la reacción en cadena de la polimerasa (PCR). Los parámetros utilizados fueron el número de casos sospechosos de LV notificados al Ministerio de Salud en 2014 y el coste directo de los test diagnósticos. Los costes del diagnóstico de casos sospechosos de LV a lo largo de tres años, usando el RIFI y DAT-LPC, se estimaron en USD 280.979,91 y USD 121.371,48, respectivamente. De acuerdo con el análisis, comparado con el uso del RIFI, la incorporación del DAT-LPC por el SUS resultaría en un ahorro de USD 159.608,43. En relación con el impacto de los test rápidos, el uso del IT LEISH aportaba un ahorro de USD 21.708,72 a lo largo de tres años. Comparado con el examen parasitológico, el diagnóstico con PCR suponía un ahorro de USD 3.125.068,92 a lo largo de tres años. De acuerdo con el estudio, la sustitución del RIFI con el DAT-LPC mostró ser financieramente ventajosa. Asimismo, la sustitución del test rápido Kalazar Detect con el IT LEISH en 2015 representó un ahorro económico, y los resultados favorecieron la sustitución del examen parasitológico con PCR.

Estimated cost efficacy of systemic treatments that are approved by the US Food and Drug Administration for the treatment of moderate to severe psoriasis.

BACKGROUND: Newer psoriasis treatments tout higher efficacy but are generally more expensive. OBJECTIVE: We sought to estimate the cost efficacy of systemic psoriasis treatments that have been approved by the US Food and Drug Administration (FDA). METHODS: A literature review of systemic psoriasis treatments that have been approved by the FDA was performed for the primary end point of a 75% reduction in the Psoriasis Area and Severity Index score (PASI 75). Medication cost was referenced by wholesale acquisition cost (WAC), laboratory fees were obtained from the American Medical Association, and office visit fees are standard at our university. Total expenses were standardized by calculating cost per month of treatment considering the number needed to treat (NNT) to achieve PASI 75. RESULTS: Methotrexate ($794.05-1502.51) and cyclosporine ($1410.14-1843.55) had the lowest monthly costs per NNT to achieve PASI 75. The most costly therapies were infliximab ($8704.68-15,235.52) and ustekinumab 90 mg ($12,505.26-14,256.75). Monthly costs per NNT to achieve PASI 75 for other therapies were as follows: narrowband ultraviolet B light phototherapy ($2924.73), adalimumab ($3974.61-7678.78), acitretin ($4137.71-14,148.53), ustekinumab 45 mg ($7177.89-7263.99), psoralen plus ultraviolet A light phototherapy ($7499.46-8834.98), and etanercept ($8284.71-10,674.89). LIMITATIONS: Drug rebates and incentives, potential adverse effects, comorbidity risk reduction, ambassador programs, and combination therapies were excluded. CONCLUSION: Our study provides meaningful cost efficacy data that may influence psoriasis treatment selection.

"What took you so long?" The impact of PEPFAR on the expansion of HIV testing and counseling services in Africa.

HIV testing and counseling services in Africa began in the early 1990s, with limited availability and coverage. Fears of stigma and discrimination, complex laboratory systems, and lack of available care and treatment services hampered expansion. Use of rapid point-of-care tests, introduction of services to prevent mother-to-child transmission, and increasing provision of antiretroviral drugs were key events in the late 1990s and early 2000s that facilitated the expansion of HIV testing and counseling services. Innovations in service delivery included providing HIV testing in both clinical and community sites, including mobile and home testing. Promotional campaigns were conducted in many countries, and evolutions in policies and guidance facilitated expansion and uptake. Support from President's Emergency Plan for AIDS Relief and national governments, other donors, and the Global Fund for AIDS, Tuberculosis, and Malaria contributed to significant increases in the numbers of persons tested in many countries. Quality of both testing and counseling, limited number of health care workers, uptake by couples, and effectiveness of linkages and referral systems remain challenges. Expansion of antiretroviral treatment, especially in light of the evidence that treatment contributes to prevention of transmission, will require greater yet strategic coverage of testing services, especially in clinical settings and in combination with other high-impact HIV prevention strategies. Continued support from President's Emergency Plan for AIDS Relief, governments, and other donors is required for the expansion of testing needed to achieve international targets for the scale-up of treatment and universal access to knowledge of HIV status.

Cost-effectiveness of tuberculosis diagnostic strategies to reduce early mortality among persons with advanced HIV infection initiating antiretroviral therapy.

BACKGROUND: In sub-Saharan Africa, patients with advanced HIV experience high mortality during the first few months of antiretroviral therapy (ART), largely attributable to tuberculosis (TB). We evaluated the cost-effectiveness of TB diagnostic strategies to reduce this early mortality. METHODS: We developed a decision analytic model to estimate the incremental cost, deaths averted, and cost-effectiveness of 3 TB diagnostic algorithms. The model base case represents current practice (symptoms screening, sputum smear, and chest radiography) in many resource-limited countries in sub-Saharan Africa. We compared the current practice with World Health Organization (WHO)-recommended practice with culture and WHO-recommended practice with the Xpert mycobacterium tuberculosis and resistance to rifampicin test and considered relevant medical costs from a health system perspective using the timeframe of the first 6 months of ART. We conducted univariate and probabilistic sensitivity analyses on all parameters in the model. RESULTS: When considering TB diagnosis and treatment and ART costs, the cost per patient was $850 for current practice, $809 for the algorithm with Xpert test, and $879 for the algorithm with culture. Our results showed that both WHO-recommended algorithms avert more deaths among TB cases than does the current practice. The algorithm with Xpert test was least costly at reducing early mortality compared with the current practice. Sensitivity analyses indicated that cost-effectiveness findings were stable. CONCLUSIONS: Our analysis showed that culture or Xpert were cost-effective at reducing early mortality during the first 6 months of ART compared with the current practice. Thus, our findings provide support for ongoing efforts to expand TB diagnostic capacity.

Potential for new technologies in clinical practice.

PURPOSE OF REVIEW: Cost-effective neurorehabilitation is essential owing to financial constraints on healthcare resources. Technologies have the potential to contribute but without strong clinical evidence are unlikely to be widely reimbursed. This review presents evidence of new technologies since 2008 and identifies barriers to translation of technologies into clinical practice. RECENT FINDINGS: Technology has not been shown to be superior to intensively matched existing therapies. Research has been undertaken into the development and preliminary clinical testing of novel technologies including robotics, electrical stimulation, constraint-induced movement therapy, assistive orthoses, noninvasive brain stimulation, virtual reality and gaming devices. Translation of the research into clinical practice has been impeded by a lack of robust evidence of clinical effectiveness and usability. Underlying mechanisms associated with recovery are beginning to be explored, which may lead to more targeted interventions. Improvements in function have been demonstrated beyond the normal recovery period, but few trials demonstrate lasting effects. SUMMARY: Technologies, alone or combined, may offer a cost-effective way to deliver intensive neurorehabilitation therapy in clinical and community environments, and have the potential to empower patients to take more responsibility for their rehabilitation and continue with long-term exercise.

Cost comparison of psoriasis treatments.

BACKGROUND: Knowledge of the cost of various psoriasis therapeutic options is essential to the prescribing clinician. OBJECTIVE: To compare the cost of various psoriasis treatments over a 10-year period in the province of Ontario, Canada. METHODS: We used a hypothetical patient with plaque-type psoriasis of moderate severity with a Psoriasis Area and Severity Index of 10, body surface area of 20%, and no joint involvement. The costs to treat this hypothetical patient with different therapeutic regimens were compared in this study. RESULTS: In a 60 kg patient, alefacept was the most costly form of therapy, based on two 12-week treatments per year, followed by infliximab 5 mg/kg. In a 90 kg patient, infliximab 5 mg/kg was the most costly, followed by alefacept. The least costly treatment was ultraviolet B phototherapy. CONCLUSION: With the knowledge of these data, informed prescribing by the dermatologist may reduce the financial burden to the patient, the provincial health care system, and insurance companies.

Good Laboratory Practice (GLP) status of Asian countries and its implementation in non-clinical safety studies in pharmaceutical drug development.

Non-clinical animal studies to assess the safety of compounds under development have to comply with Good Laboratory Practice (GLP). The Organization for Economic Co-operation and Development (OECD) has established the Mutual Acceptance of Data (MAD) system in OECD member countries for the mutual acceptance of non-clinical safety study data. Since 1997 non-OECD-member countries have also been able to participate in the MAD system, if the country meets the level of standardized compliance with OECD GLP. Thus, several Asian non-OECD countries are trying to develop their GLP standards in order to become official members of the MAD system. Pharmaceutical companies face significant expense in the drug-development process, including the cost of non-clinical safety studies; in response, companies in Asian countries are seeking to establish GLP facilities to provide cost-effective services for drug development. To assess the quality and cost of GLP performance in Asian countries, in this study we approached GLP facilities in a number of Asian countries to obtain price and quality information on a 'virtual compound' to be assessed in non-clinical safety studies. Also, the development status of GLP in Asian countries in terms of policy and infrastructure was analyzed. We found that, among Asian countries, India and Singapore may be candidates for participation in te MAD system in terms of their compliance with GLP, language, and costs. These findings will be beneficial to pharmaceutical companies planning GLP studies in Asian countries.

Cost analysis of a domiciliary program of supportive and palliative care for patients with hematologic malignancies.

The costs of home care (HC) programs may be tailored to the specific needs of patients with hematological malignancies. The aim of this study was to analyze the use of resources and the costs of a program of HC for four different prognostic groups of patients subdivided according to disease status. Over 2 years, 144 patients with hematological malignancies were assisted at home. Patients were subdivided according to disease status and life expectancy in the following groups: (i) terminal phase, with a life expectancy of 3 months or less; (ii) advanced phase, with a life expectancy of 6 months or less; (iii) chronic phase, with a life expectancy of more than 6 months; (iv) discharged early from the hospital with curable disease, following anticancer chemotherapy. Median mean monthly costs (MMC) in Euro (x) have been compared with the costs of hospitalization (DRG). Among the 4 groups of patients, those discharged early and in terminal phase required the highest mean monthly number of home visits (27.2 and 24.1), transfusions (6.1 and 6.8) and days of care (22.8 and 19.7) respectively. MMC were affected by the following variables: disease status and transfusion requirements. MMC for terminal patients (4,232.50x) and those discharged early (3,986.40x) were higher than those for advanced (2,303.80x) and chronic patients (1,488,30x). The cost of HC was lower than the corresponding DRG charges, but exceeded the district fares for HC of cancer patients. In hematological patients, the costs of HC differ according to disease status and transfusion requirements. For some categories of patients, costs of HC are lower than those of hospitalization, although higher than the current national fares for HC programs.

Major inequities between district health boards in referred services expenditure: a critical challenge facing the primary health care strategy.

AIMS: This study examines variation between district health boards (DHBs) in expenditure on referred services (ie, pharmaceutical and laboratory services), and compares the gap between budgets as determined by the primary care funding formula and actual expenditure on these services. It also analyses the relationship between population need factors and variation from equity. METHODS: Actual DHB referred services expenditure related to GPs for the period July to November 2001 was obtained from the Ministry of Health and compared with expected expenditure calculated from the funding formula. Percentage difference between actual and expected expenditure was calculated for each DHB. Data were also obtained relating to DHB populations (numbers with community services cards (CSCs), ethnicity, and scores by NZDep96 quintiles) and number of GPs. The data were used to calculate rates for these variables, which were then correlated with percentage variation from equity in DHB referred services expenditure. RESULTS: The analysis showed wide percentage variation from equity between DHBs, with Capital and Coast being 17.5% above and Tairawhiti 23.9% below equity. The analysis also showed a high and significant correlation between this inequity and four measures of disadvantage--population per GP, percentage with CSC, percentage of Maori, and NZDep96 scores--which, together, explained more than 50% of the total variation between DHBs. Population per GP was found to be the most significant predictor of variation. CONCLUSIONS: The inverse care law, ie, that those populations in greatest need are those least likely to receive the services they need, remains a dominant feature of New Zealand s primary care system. This is linked to the gross historical underfunding of access to primary care services. A major redistribution of primary care resources, including GPs, supported by much greater investment in better information and research and development, will be critical to the implementation of the government s Primary Health Care Strategy.

Newborn screening for cystic fibrosis: a paradigm for public health genetics policy development. Proceedings of a 1997 workshop.

Cystic fibrosis (CF) is a genetic disease that can be detected in newborn infants (i.e., those aged < or = 1 month) by immunotrypsinogen testing. The sensitivity and specificity of such testing can now be improved as a result of the recent discovery of the Cystic Fibrosis Transmembrane Conductance Regulatory (CFTR) gene. Although limited CF screening for newborns has been used since the 1980s, the clinical, social, and economic outcomes of population-based screening are controversial. During January 1997, a workshop was convened at CDC in Atlanta, Georgia to discuss the benefits and risks associated with screening newborns for CF and to develop public health policy concerning such screening. The workshop planning committee comprised representatives from CDC, the Cystic Fibrosis Foundation, the National Institutes of Health, and the University of Wisconsin. Experts in the fields of CF, public health, the screening of newborns, and economics also contributed to discussions. Workshop participants addressed a) benefits and risks, b) laboratory testing, and c) economics concerning the implementation of routine CF screening for newborns. Summaries of these discussions and the resulting workshop recommendations are presented in this report. These recommendations, developed by workshop participants, will be useful to medical and public health professionals and state policymakers who are evaluating the merits of population-based screening of newborns for CF.

The Rochester Consortium.

The laboratories of the six hospitals in Rochester, New York worked together to bid on laboratory services for local managed-care contracts. Their primary goal was to keep shrinking health-care dollars in the Rochester community while providing quality laboratory services for managed-care payers. The six laboratory providers formed a cooperative Consortium that enabled them to compete successfully with national commercial laboratories for referral laboratory testing for outpatients and nonpatients. In 1995, the Consortium was approached by a Rochester-based health maintenance organization (HMO) offering an exclusive contract opportunity based on requirements that included cost reduction and a switch from a fee schedule to a capitated payment method. The Rochester laboratories each agreed to contract terms with the HMO, then followed this success by working with a second, significantly larger HMO, agreeing to provide exclusive laboratory services under a similar, capitated arrangement. The formation and work of the Consortium may provide other hospitals facing daunting competition from large commercial laboratory enterprises with a cooperative arrangement model to provide community-wide laboratory services.

Transfer of DNA tests from research to routine laboratories: some lessons from the French experience in the case of Duchenne muscular dystrophy.

In the last few years, the activity of research laboratories has led to the emergence of new DNA diagnostic tests in France. They permit the origin of genetic diseases to be identified and provide an answer concerning the detection of carriers and prevention. Nevertheless, given this, new actors have emerged on the health care scene: the research workers who developed the tests and who work in public research laboratories. The economic question of the transfer of the test practice from research to hospital laboratories is the main topic of this paper, taking Duchenne Muscular Dystrophy (DMD) DNA diagnostic tests as the example. After a presentation of the complexity of DNA tests for DMD, the fact that financial and human constraints do not allow the actors to continue to produce the DNA tests is discussed. The financial role of the non-profit-making associations is then explained and leads to the conclusion that a more global policy on DNA tests, such as carried out in the UK and the Netherlands, should be adopted in France by the Social Security if it wants DNA testing activity to be pursued.

Laboratory diagnostics in light of massive changes in official health policies.

Virtually 100% of the German population has health insurance. Of this 100%, approximately 90% are members of the Statutory Health Insurance plan. This insurance plan assumes responsibility for practically all of the costs of treatment; self-participation by the patient in the costs is minimal. To counteract the financial deficits of the Statutory Health Insurance funds, the Health Care Reform Act was introduced in 1993, bringing with it massive economy measures for everyone involved in the health sector. For the practitioner sector, this new legislation provides for, among other things, revision of the structure and the reimbursement of laboratories. In this context, the originally agreed-upon introduction of lump-sum payments as reimbursement for laboratory tests was abandoned, in the face of vigorous resistance by the medical profession. Instead, the system of reimbursement for each individual test continues to apply. However, the number of tests is to be limited for each specific group of doctors. In addition, the laboratory fee in the practitioner sector is being reduced by 20%.

The effect of removal of profile requesting on chemical pathology requesting patterns.

We investigated the effect on pathology requesting behaviour in a metropolitan teaching hospital, following the proscription by the Health Insurance Commission of the MBA (multiple biochemical analysis) request. Our laboratory had provided a 20 test profile in response to a request for MBA until February 1991, when the MBA request was no longer accepted. During the period February to June 1991, requesting clinicians had to comply with the new requesting requirements, although they continued to receive the results of the 20 test profile because of limitations imposed by our laboratory instrumentation. After June 1991, with the installation of a new analyzer that allowed discretionary requesting, results were provided only for those tests requested. We studied requesting patterns in the 3 time periods: i.e. (1) before the MBA request was withdrawn, and after the MBA request was withdrawn, (2) firstly while results for the 20 test profile were still provided and (3) secondly when the results were provided only for the tests requested. For each of the 3 periods the average number of requests per day for MBA, group and individual tests was calculated. The effect of removal of the MBA request on the Medicare Benefits payable was estimated. We found compliance by the requesting clinicians with the new requirements and a reduction in the number of tests requested. There was a reduction from 20 to 12 in the average number of tests per request. This was associated with a 2.2% reduction in the Medicare Benefits payable.