Educational cost-effective intervention to reduce pathologist's peripheral blood smears reviews with non-contributory findings: an academic institution experience.

Peripheral blood smear (PBS) review by a pathologist is a necessary and invaluable diagnostic tool. However, innovative highly sophisticated haematology analysers that flag peripheral blood abnormalities have decreased the need for a PBS review. Ordering practices including PBS reviews lumped as part of an 'order set' or with complete blood count (CBC) constituted most PBS requests at our institution. A retrospective review of all PBS review orders from 1 April 2016 to 31 January 2017 was performed to investigate the ordering practices at our institution. A total of 2864 PBS were ordered during the above study period. In many cases, the PBS report did not add any significant clinical information beyond that acquired by the CBC and differential count. These findings inspired policy changes within our institution for pathologist PBS reviews. Within the electronic order system, all PBS orders for inpatients were linked to a pop-up window with criteria for peripheral smear review and instructions on the approval policy. Outpatient orders required clinicians to request pathology approval. This implementation reduced total number of PBS orders by 42.5% with no adverse effect on patient management. Empowering pathologists and clinicians with guidelines on PBS review orders is a beneficial educational exercise of resource utilisation. Discussion with physicians regarding clinical indications reduces non-contributory PBS reviews, provides guidance to appropriate testing, and aptly allocates pathologist and laboratory staff time and resources.

The Utility of Obtaining a Complete Blood Count After Total Knee Arthroplasty in the Era of Tranexamic Acid.

Questioning the routine use of postoperative laboratory tests is a strategy to combat rising health care costs. The goal of this study was to determine the utility and cost of routine postoperative complete blood count (CBC) testing after primary total knee arthroplasty (TKA) in the era of tranexamic acid (TXA). This retrospective chart review identified patients who underwent primary TKA performed by a single surgeon at a single private institution during a 2-year period. All patients received TXA intraoperatively. Exact tests were used to determine whether there was a significant difference in transfusion rates between patients with and without preoperative anemia. Of 628 primary TKA procedures, 390 patients (62.10%) had anemia postoperatively. However, only 1 patient (0.16%) required transfusion. A total of 956 CBC tests were performed without intervention, at a total cost of $116,804.08. In addition, 1 of 26 patients with preoperative anemia vs 0 of 602 patients without preoperative anemia required transfusion (P=.04). Healthy patients undergoing primary TKA who receive TXA do not require postoperative CBC. This change has the potential to reduce this laboratory cost by more than 97% compared with the current practice of obtaining postoperative CBC testing for every patient undergoing TKA. Only patients with preoperative anemia should undergo postoperative CBC testing to help to identify those who require transfusion. The potential health care savings associated with eliminating routine postoperative CBC testing are substantial and should be considered by arthroplasty surgeons. [Orthopedics. 2021;44(1):e26-e30.].

Cost-effectiveness evaluation of the PROPPR trial transfusion protocols.

BACKGROUND: There have been no prior investigations of the cost effectiveness of transfusion strategies for trauma resuscitation. The Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study was a Phase III multisite, randomized trial in 680 subjects comparing the efficacy of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with the 1:1:2 ratio. We hypothesized that 1:1:1 transfusion results in an acceptable incremental cost-effectiveness ratio, when estimated using patients' age-specific life expectancy and cost of care during the 30-day PROPPR trial period. STUDY DESIGN AND METHODS: International Classification of Diseases, Ninth Revision codes were prospectively collected, and subjects were matched 1:2 to subjects in the Healthcare Utilization Program State Inpatient Data to estimate cost weights. We used a decision tree analysis, combined with standard costs and estimated years of expected survival to determine the cost effectiveness of the two treatments. RESULTS: The 1:1:1 group had higher overall costs for the blood products but were more likely to achieve hemostasis and decreased hemorrhagic death by 24 hours (p = 0.006). For every 100 patients treated in the 1:1:1 group, eight more achieved hemostasis than in the 1:1:2 group. At 30 days, the total hospital cost per 100 patients was $5.6 million in the 1:1:1 group compared with $5.0 million in the 1:1:2 group. For each 100 patients, the 1:1:1 group had 218.5 more years of life expectancy. This was at a cost of $2994 per year gained. CONCLUSION: The 1:1:1 transfusion ratio in severely injured hemorrhaging trauma patients is a very cost-effective strategy for increasing hemostasis and decreasing trauma deaths.

Clinical Impact of Routine Complete Blood Counts Following Total Knee Arthroplasty.

BACKGROUND: Routine laboratory studies are generally obtained following total knee arthroplasty (TKA), and often continued daily until discharge. This study aims to investigate the utility and cost-effectiveness of complete blood count (CBC) tests following TKA. METHODS: Retrospective review identified 484 patients who underwent primary TKA under a tourniquet at a single institution. Preoperative and postoperative CBC values were collected along with demographic data, use of tranexamic acid (TXA), and transfusion rates. Logistic regression models were calculated for all variables. RESULTS: Twenty-five patients required transfusion following TKA (5.2%). Patients requiring transfusion had significantly lower preoperative hemoglobin compared to patients who did not require transfusion (11.47 vs 13.58 g/dL, P = .005). Risk of transfusion was 5.2 times higher in patients with preoperative anemia (95% confidence interval 2.90-9.35, P < .001). Without TXA, patients were 2.75 times more likely to receive transfusion (95% confidence interval 1.43-5.30, P < .001). An average of 2.9 CBC tests were collected per patient who did not receive medical intervention, costing a total of $144,773.80 in associated hospital charges ($316.10 per patient). CONCLUSION: Ensuring quality, cost-effective patient care following total joint arthroplasty is essential in the era of bundled payments. Routine postoperative CBCs do not add value for patients with normal preoperative hemoglobin who receive TXA during TKA performed under tourniquet. Patients who are anemic preoperatively or do not receive TXA should obtain a postoperative CBC test. Daily CBCs are unnecessary if the first postoperative CBC does not prompt intervention.

Variation in Diagnostic Test Use and Associated Outcomes in Staphylococcal Scalded Skin Syndrome at Children's Hospitals.

OBJECTIVES: The incidence of staphylococcal scalded skin syndrome (SSSS) is rising, but current practice variation in diagnostic test use is not well described. Our aim was to describe the variation in diagnostic test use in children hospitalized with SSSS and to determine associations with patient outcomes. METHODS: We performed a retrospective (2011-2016) cohort study of children aged 0 to 18 years from 35 children's hospitals in the Pediatric Health Information System database. Tests included blood culture, complete blood count, erythrocyte sedimentation rate, C-reactive protein level, serum chemistries, and group A streptococcal testing. K-means clustering was used to stratify hospitals into groups of high (cluster 1) and low (cluster 2) test use. Associations between clusters and patient outcomes (length of stay, cost, readmissions, and emergency department revisits) were assessed with generalized linear mixed-effects modeling. RESULTS: We included 1259 hospitalized children with SSSS; 84% were ≤4 years old. Substantial interhospital variation was seen in diagnostic testing. Blood culture was the most commonly obtained test (range 62%-100%), with the most variation seen in inflammatory markers (14%-100%). Between hospital clusters 1 and 2, respectively, there was no significant difference in adjusted length of stay (2.6 vs 2.5 days; P = .235), cost ($4752 vs $4453; P = .591), same-cause 7-day readmission rate (0.8% vs 0.4%; P = .349), or emergency department revisit rates (0.1% vs 0.6%; P = .148). CONCLUSIONS: For children hospitalized with SSSS, lower use of diagnostic tests was not associated with changes in outcomes. Hospitals with high diagnostic test use may be able to reduce testing without adversely affecting patient outcomes.

Performance of a cost-effective and automated blood counting system for resource-limited settings operated by trained and untrained users.

Current flow-based blood counting devices require expensive and centralized medical infrastructure and are not appropriate for field use. In this article we report a streamlined, easy-to-use method to count red blood cells (RBC), white blood cells (WBC), platelets (PLT) and 3-part WBC differential through a cost-effective and automated image-based blood counting system. The approach consists of using a compact, custom-built microscope with large field-of-view to record bright-field and fluorescence images of samples that are diluted with a single, stable reagent mixture and counted using automatic algorithms. Sample collection utilizes volume-controlled capillary tubes, which are then dropped into a premixed, shelf-stable solution to stain and dilute in a single step. Sample measurement and analysis are fully automated, requiring no input from the user. Cost of the system is minimized through the use of custom-designed motorized components. We compare the performance of our system, as operated by trained and untrained users, to the clinical gold standard on 120 adult blood samples, demonstrating agreement within Clinical Laboratory Improvement Amendments guidelines, with no statistical difference in performance among different operator groups. The system's cost-effectiveness, automation and performance indicate that it can be successfully translated for use in low-resource settings where central hematology laboratories are not accessible.

Multicenter study to evaluate a new enumeration method for hematopoietic stem cell collection management.

BACKGROUND: CD34 flow cytometry is the gold standard for stem cell enumeration in peripheral blood at the mobilization stage and in the final apheresis product. The new stem cell mode of the Sysmex XN Series analyzer enumerates an immature cell population in the white progenitor and pathological cell (WPC) channel, based on the cell size, internal cellular complexity, and fluorescence intensity. STUDY DESIGN AND METHODS: In this multicenter study we analyzed 147 peripheral blood samples, 22 samples during collection of stem cells, and 45 samples from the apheresis product of 18 healthy allogeneic donors and 84 autologous patients. RESULTS: In this multicenter study we demonstrate that the XN stem cell enumeration method correlates well with viable CD34+ cells determined by flow cytometry during the stem cell mobilization phase to determine apheresis start time, during apheresis for real-time monitoring and adjustment, and for quality control of the final stem cell harvest. CONCLUSION: Our data show that there is an improvement in the correlation of XN stem cells and CD34+ cells in the peripheral blood during stem cell mobilization as well as in stem cell harvests compared to SE or XE Series analyzers. The XN stem cell enumeration method has a number of advantages compared to CD34 flow cytometry: it is fast, simple, reproducible, and less expensive. CE marking for the European market has been obtained, making the stem cell count on the XN analyzer a reportable clinical variable.

Cutting costs and standardizing care: Once-per-cycle complete blood count monitoring may be safe for patients undergoing platinum-based chemotherapy.

AIM: The aim of this study was to evaluate whether frequency of complete blood count (CBC) testing during chemotherapy for gynecologic cancer impacts hospital admissions or rates of neutropenic fever. METHODS: A retrospective cohort study was performed at a single academic institution. Patients undergoing platinum-based chemotherapy for endometrial or ovarian cancer from January 2010 to December 2014 were identified from a clinical database. Patients receiving dose-dense chemotherapy or on a clinical trial were excluded. Electronic chart review collected demographic and clinical characteristics. The primary outcome was the rate of febrile neutropenia or hospital admission. RESULTS: A total of 174 patients were identified, 63 (36%) with endometrial and 111 (64%) with ovarian cancer. Fifty-four percent of patients received multiple CBC per cycle compared with 46% who only had one CBC per cycle. The majority of patients were treated with a platinum-based doublet (85%). Dose reductions, addition of granulocyte colony stimulating factor, and rates of grade 3 or 4 anemia and neutropenia were significantly associated with more frequent testing. There was no difference in rates of neutropenic fever (5.3 vs 3.8%, P = 0.45) or hospital admission (22.3 vs 21.3%, P = 0.86) for multiple versus single CBC monitoring. CONCLUSION: More frequent laboratory testing detected more cases of grade 3 or 4 hematopoietic toxicities and was associated with more interventions. There were no differences in number of hospitalizations or cases of neutropenic fever by frequency of laboratory testing, suggesting that it may be appropriate to decrease routine laboratory tests for select patients.

Toward High-Value Care: A Quality Improvement Initiative to Reduce Unnecessary Repeat Complete Blood Counts and Basic Metabolic Panels on a Pediatric Hospitalist Service.

OBJECTIVE: Achieving high-value health care is a goal of health care providers who strive to increase quality and decrease cost. Decreasing laboratory tests is a potential method to increase value. We used quality improvement methodology to decrease the percentage of unnecessary complete blood counts (CBCs) and basic metabolic panels (BMPs) obtained on a pediatric hospital medicine service from 13.5% to <5%. METHODS: A pre- and postintervention design was conducted including all patients admitted to 2 hospital medicine teams between May 2013 and December 2014. Multiple interventions linked to key drivers were tested through rapid plan-do-study-act cycles. Primary and secondary outcome measures, percent reduction of unnecessary CBCs and BMPs, and consecutive day tests were analyzed using statistical process control. Total billed charges, laboratory charges, 7-day readmission rates, and length of stay were compared pre- and postintervention. RESULTS: Primary outcome of unnecessary CBCs and BMPs was reduced from a baseline of 13.5% to 4.5%. Secondary outcome measure of consecutive day testing was reduced from 20.9% to 8.5%. Median laboratory charges decreased significantly ($842 [$256-$1863] vs $800 [$222-$1616], P = .002), with no significant differences in total billed charges, 7-day readmission rates, or length of stay. CONCLUSIONS: Rapid cycle plan-do-study-act methodology, initially focusing on the inclusion of a daily laboratory plan in progress notes, was an effective means to improve laboratory utilization and decrease laboratory charges without adversely affecting other quality measures. Spreading these efforts to different patient populations and laboratory tests could have a demonstrable effect on the value of health care.

Complete blood counts, liver function tests, and chest x-rays as routine screening in early-stage breast cancer: value added or just cost?

Current National Comprehensive Cancer Network guidelines for breast cancer staging include pre-treatment complete blood count (CBC) and liver function tests (LFT) to screen for occult metastatic disease. To date, the relevance of these tests in detecting metastatic disease in asymptomatic women with early-stage breast cancer (Stage I/II) has not been demonstrated. Although chest x-rays are no longer recommended in the NCCN guidelines, many centers continue to include this imaging as part of their screening process. We aim to determine the clinical and financial impact of these labs and x-rays in the evaluation of early-stage breast cancer patients. A single institution IRB-approved retrospective chart review was conducted of patients with biopsy-proven invasive breast cancer treated from January 1, 2005­December 31, 2009. We collected patient demographics, clinical and pathologic staging, chest x-ray, CBC, and LFT results at the time of referral. Patients were stratified according to radiographic stage at the time of diagnosis. We obtained Medicare reimbursement fees for cost analysis. From 2005 to 2009, 1609 patients with biopsy-proven invasive breast cancer were treated at our institution. Of the 1082 patients with radiographic stage I/II disease, 27.3 % of patients had abnormal CBCs. No additional testing was performed to evaluate these abnormalities. In the early-stage population, 24.7 % of patients had elevated LFTs, resulting in 84 additional imaging studies. No metastatic disease was detected. The cost of CBC, LFTs and chest x-rays was $110.20 per patient, totaling $106,410.99. Additional tests prompted by abnormal results cost $58,143.30 over the five-year period. We found that pre-treatment CBCs, LFTs, and chest x-rays did not improve detection of occult metastatic disease but resulted in additional financial costs. Avoiding routine ordering of these tests would save the US healthcare system $25.7 million annually.

Do we need 'routine' blood counts?

Performing daily blood counts has become a routine part of hospital practice but with limited thought given to the need for them. In addition, the occasional abnormalities in these tests trigger further investigations which may have not been necessary if clinical examination was given adequate importance.

Variation in charges for 10 common blood tests in California hospitals: a cross-sectional analysis.

OBJECTIVES: To determine the variation in charges for 10 common blood tests across California hospitals in 2011, and to analyse the hospital and market-level factors that may explain any observed variation. DESIGN, SETTING AND PARTICIPANTS: We conducted a cross-sectional analysis of the degree of charge variation between hospitals for 10 common blood tests using charge data reported by all non-federal California hospitals to the California Office of Statewide Health Planning and Development in 2011. OUTCOME MEASURES: Charges for 10 common blood tests at California hospitals during 2011. RESULTS: We found that charges for blood tests varied significantly between California hospitals. For example, charges for a lipid panel ranged from US$10 to US$10,169, a thousand-fold difference. Although government hospitals and teaching hospitals were found to charge significantly less than their counterparts for many blood tests, few other hospital characteristics and no market-level predictors significantly predicted charges for blood tests. Our models explained, at most, 21% of the variation between hospitals in charges for the blood test in question. CONCLUSIONS: These findings demonstrate the seemingly arbitrary nature of the charge setting process, making it difficult for patients to act as true consumers in this era of 'consumer-directed healthcare.'

Use of Six Sigma Worksheets for assessment of internal and external failure costs associated with candidate quality control rules for an ADVIA 120 hematology analyzer.

BACKGROUND: Quality control (QC) validation is an essential tool in total quality management of a veterinary clinical pathology laboratory. Cost-analysis can be a valuable technique to help identify an appropriate QC procedure for the laboratory, although this has never been reported in veterinary medicine. OBJECTIVE: The aim of this study was to determine the applicability of the Six Sigma Quality Cost Worksheets in the evaluation of possible candidate QC rules identified by QC validation. METHODS: Three months of internal QC records were analyzed. EZ Rules 3 software was used to evaluate candidate QC procedures, and the costs associated with the application of different QC rules were calculated using the Six Sigma Quality Cost Worksheets. The costs associated with the current and the candidate QC rules were compared, and the amount of cost savings was calculated. RESULTS: There was a significant saving when the candidate 1-2.5s, n = 3 rule was applied instead of the currently utilized 1-2s, n = 3 rule. The savings were 75% per year (£ 8232.5) based on re-evaluating all of the patient samples in addition to the controls, and 72% per year (£ 822.4) based on re-analyzing only the control materials. The savings were also shown to change accordingly with the number of samples analyzed and with the number of daily QC procedures performed. CONCLUSIONS: These calculations demonstrated the importance of the selection of an appropriate QC procedure, and the usefulness of the Six Sigma Costs Worksheet in determining the most cost-effective rule(s) when several candidate rules are identified by QC validation.

The practical utility of routine postpartum hemoglobin assessment.

OBJECTIVE: To evaluate a policy of routine versus selective postpartum complete blood count (CBC). STUDY DESIGN: Historic case control design with matched subjects from 1 year periods bracketing the policy change (n = 800). Our primary outcome was postpartum transfusion rate. Univariable and multivariable analyses were performed. Total hospital costs were estimated. RESULTS: Eliminating routine postpartum CBC testing was associated with decreased transfusion rates (5.5% vs 1.8%, P = .007) despite similar transfusion risks. CBC utilization decreased from 59% to 22.2% (P < .0001). No adverse bleeding outcomes occurred. Multivariable modeling suggested that the occurrence of postpartum hemorrhage was the best clinical predictors of transfusion n risk. Tachycardia, oliguria, and symptoms were also effective at identifying transfusion candidates. Elimination of routine CBC was independently associated with a reduced risk of transfusion (odds ratio, 0.30; 95% confidence interval, 0.12-0.72). Annual cost savings were estimated at $58,000. CONCLUSION: Targeted CBC testing results in fewer transfusions, lower costs and improved quality of patient care.

Patient specific or routine preoperative workup in septoplasty: which one is cost-effective?

This study aimed at determining the limits of preoperative investigation and calculate estimated cost analysis in septoplasty with and without turbinate surgery. A retrospective chart review. The study was conducted at secondary referral center. A retrospective chart review of patients who have undergone septoplasty over a 1-year period was performed. The need for routine (battery testing) versus patient specific preoperative workup of 380 septoplasty patients was evaluated. Mean age of the patients was 31.5 ± 4.6. The patients were classified into three groups according to preoperative routine laboratory testing results: (1) normal group (2) abnormal group and (3) abnormal out of action limit group. Medical records were revaluated by an anesthesiologist and ear nose throat doctor according to preoperative American Society of Anesthesiologists guidelines to calculate estimated possible costs in case of patient specific preoperative workup. Three hundred seventy-seven patients were within ASA 1 group and three patients were within ASA 2. According to preoperative battery testing results, 5.8% of the patients (n = 22) were in group 1, 93.4% (n = 355) were in group 2, 0.8% (n = 3) were in group 3. Surgery was postponed due to concomitant pathologies for about 44 days (10-180 days) in four patients (1.1%). Preoperative routine laboratory testing costs were calculated as $41.08 ± 6.69 (40.25-128.78) per patient. When medical records were reevaluated retrospectively, estimated cost per patient would be $8.91 ± 10.40 (7.18-79.91) if patient specific preoperative workup were done. Individual preoperative testing would save $12,226.78 annually and total cost would decrease from $15,612.41 to $3,385.62. (p = 0.001). Patient-specific preoperative workup is more cost effective than routine battery testing in septoplasty with and without turbinate surgery.

Routine preoperative blood testing in pediatric neurosurgery.

OBJECT: The frequency with which routine preoperative blood test results predict perioperative or postoperative complications is insignificant. The unnecessary ordering of routine tests increases the financial costs and patients' distress. The authors evaluated the effects of routine preoperative testing on patient management and the overall financial costs. METHODS: The authors retrospectively reviewed the medical records and laboratory data for 355 children admitted to the neurosurgical department for elective procedures over a 5-year period (January 2008-December 2012). They excluded all patients admitted for imaging or surgical procedures requiring local anesthesia, and they recorded the results of preoperative and previous (up to 6 months before surgery) blood tests and any abnormalities noted. RESULTS: As a result of the 3489 blood tests ordered preoperatively for 328 (94.6%) of the 355 patients, 29 abnormalities (9%) were detected. Most of these abnormal values were near the reference range, and none significantly affected the progression of scheduled procedures. For only 1 patient (0.28%) was the procedure cancelled because of an abnormality (preoperative partial thromboplastin time), which further testing showed to be a false-positive result. The cost of these tests over 5 years was 5205-10,410 euros ($6766-$13,533 US). CONCLUSIONS: Preoperative tests should be selectively requested on the basis of clinical indication.

Cost-effective and rapid blood analysis on a cell-phone.

We demonstrate a compact and cost-effective imaging cytometry platform installed on a cell-phone for the measurement of the density of red and white blood cells as well as hemoglobin concentration in human blood samples. Fluorescent and bright-field images of blood samples are captured using separate optical attachments to the cell-phone and are rapidly processed through a custom-developed smart application running on the phone for counting of blood cells and determining hemoglobin density. We evaluated the performance of this cell-phone based blood analysis platform using anonymous human blood samples and achieved comparable results to a standard bench-top hematology analyser. Test results can either be stored on the cell-phone memory or be transmitted to a central server, providing remote diagnosis opportunities even in field settings.

Tests and expenditures in the initial evaluation of peripheral neuropathy.

BACKGROUND: Peripheral neuropathy is a common disorder in which an extensive evaluation is often unrevealing. METHODS: We sought to define diagnostic practice patterns as an early step in identifying opportunities to improve efficiency of care. The 1996-2007 Health and Retirement Study Medicare claims-linked database was used to identify individuals with an incident diagnosis of peripheral neuropathy using International Classification of Diseases, Ninth Revision, codes and required no previous neuropathy diagnosis during the preceding 30 months. Focusing on 15 relevant tests, we examined the number and patterns of tests and specific test utilization 6 months before and after the incident neuropathy diagnosis. Medicare expenditures were assessed during the baseline, diagnostic, and follow-up periods. RESULTS: Of the 12, 673 patients, 1031 (8.1%) received a new International Classification of Diseases, Ninth Revision, diagnosis of neuropathy and met the study inclusion criteria. Of the 15 tests considered, a median of 4 (interquartile range, 2-5) tests were performed, with more than 400 patterns of testing. Magnetic resonance imaging of the brain or spine was ordered in 23.2% of patients, whereas a glucose tolerance test was rarely obtained (1.0%). Mean Medicare expenditures were significantly higher in the diagnostic period than in the baseline period ($14,362 vs $8067, P < .001). CONCLUSIONS: Patients diagnosed as having peripheral neuropathy typically undergo many tests, but testing patterns are highly variable. Almost one-quarter of patients receiving neuropathy diagnoses undergo high-cost, low-yield magnetic resonance imaging, whereas few receive low-cost, high-yield glucose tolerance tests. Expenditures increase substantially in the diagnostic period. More research is needed to define effective and efficient strategies for the diagnostic evaluation of peripheral neuropathy.