The benefits of a joint venture for pathology.

A merger of two foundation trusts' pathology services led to more sophisticated technology, shorter turnaround times and lower costs, as David James explains.

Gross Pathology of Routine Pediatric Tonsillectomy Specimens: Optimizing the Value of Patient Care.

OBJECTIVE: This investigation seeks to evaluate the effect of gross pathologic analysis on our management of patients undergoing routine tonsillectomy and to evaluate charges and reimbursement. STUDY DESIGN: Retrospective chart review from 2005 through 2016. SETTING: Academic medical center. SUBJECTS AND METHODS: Participants were pediatric patients aged 14 years and younger undergoing tonsillectomy for either sleep-disordered breathing or tonsillitis, with tonsillectomy specimens evaluated by pathology, and without any risk factors for pediatric malignancy. Records were reviewed for demographics, surgical indications, and pathology. Abnormal reports prompted an in-depth review of the chart. Charges and reimbursement related to both hospital and professional fees for gross tonsil analysis were evaluated. RESULTS: From 2005 to 2016, 3183 routine pediatric tonsillectomy cases were performed with corresponding specimens that were sent for gross analysis revealing no significant pathologic findings; 1841 were males and 1342 were females. Ten cases underwent microscopy by pathologist order, revealing normal tonsillar tissue. The mean charge per patient for gross analysis was $60.67 if tonsils were together as 1 specimen and $77.67 if tonsils were sent as 2 separate specimens; respective reimbursement amounts were $28.74 and $35.90. CONCLUSIONS: Gross pathologic analysis did not change our management of routine pediatric tonsillectomy patients. Foregoing the practice at our institution would eliminate $19,171.72 to $24,543.72 in charges and $9081.40 to $11,344.40 in reimbursement per year. Eliminating this test would improve the value of patient care by saving health care resources without compromising clinical outcomes.

Factors leading to overutilisation of hospital pathology testing: the junior doctor's perspective.

Objective Pathology overutilisation is a significant issue affecting the quality and cost of health care. Because junior medical officers (JMOs) order most pathology tests in the hospital setting, the aim of the present study was to identify the main reasons for hospital pathology overutilisation from the perspective of the JMO. Methods A qualitative method, using focus group methodology, was undertaken. Sixteen JMOs from two hospitals participated in three focus groups. Data were analysed using thematic analysis. Results Three major themes contributed to overutilisation: the real and perceived expectations of senior colleagues, the level of JMO clinical experience and strategies to manage JMO workload around clinical systems. Within these themes, 12 subthemes were identified. Conclusions Overutilisation of hospital pathology testing occurs when there are high social costs to JMOs for underordering, with little cost for overordering. Interventions should restore this balance through reframing overutilisation as both a costly and potentially harmful activity, promoting a supportive culture with regular senior guidance, and addressing clinical systems in which missed tests create an excessive workload. What is known about the topic? Mean overutilisation rates of pathology testing are reported to be as high as 44%. Although numerous studies have reported successful efforts to decrease hospital pathology overutilisation, no primary research was identified that examined the JMO perspective on this subject. What does this paper add? Clinical need is not the primary factor guiding the pathology-ordering decisions of junior practitioners; rather, medical team culture, limited JMO experience and systems factors have a significant role. What are the implications for practitioners? The social and behavioural determinants of pathology ordering must be considered to achieve appropriate pathology test utilisation. These include senior medical officer engagement, the guidance of JMOs and clinical workflows.

Sustainable Development of Pathology in Sub-Saharan Africa: An Example From Ghana.

CONTEXT: - Pathology services are poorly developed in Sub-Saharan Africa. Komfo Anokye Teaching Hospital in Kumasi, Ghana, asked for help from the pathology department of the University Hospital of North Norway, Tromsø. OBJECTIVE: - To reestablish surgical pathology and cytology in an African pathology department in which these functions had ceased completely, and to develop the department into a self-supporting unit of good international standard and with the capacity to train new pathologists. DESIGN: - Medical technologists from Kumasi were trained in histotechnology in Norway, they were returned to Kumasi, and they produced histologic slides that were temporarily sent to Norway for diagnosis. Two Ghanaian doctors received pathology training for 4 years in Norway. Mutual visits by pathologists and technologists from the 2 hospitals were arranged for the introduction of immunohistochemistry and cytology. Pathologists from Norway visited Kumasi for 1 month each year during 2007-2010. Microscopes and immunohistochemistry equipment were provided from Norway. Other laboratory equipment and a new building were provided by the Ghanaian hospital. RESULTS: - The Ghanaian hospital had a surgical pathology service from the first project year. At 11 years after the start of the project, the services included autopsy, surgical pathology, cytopathology, frozen sections, and limited use of immunohistochemistry, and the department had 10 residents at different levels of training. CONCLUSIONS: - A Ghanaian pathology department that performed autopsies only was developed into a self-supported department with surgical pathology, cytology, immunohistochemistry, and frozen section service, with an active residency program and the capacity for further development that is independent from assistance abroad.

[Topical problems in the organization of cytological studies in departments of pathology (the experience of a cytological center as part of the Leningrad Regional Department of Pathology)].

Cytological studies of biopsy specimens in the Center of Cytology are one of the promising lines in the activity of the Leningrad Regional Department of Pathology. For the time being, there is no standard for cytological activities. This fact adversely affects the training system of laboratory physicians and assistants, the organization of their work in health care facilities, and the testing quality system. Cytological studies are a promising method in the morphological evaluation of biopsy specimens and surgical material and they should be considered as a morphological method in morbid anatomy.

[Twenty years' experience with the information system "biopsy" used in the work of a department of morbid anatomy].

The long-term use of the information system "Biopsy" has shown its efficiency in improving the organization of the department of morbid anatomy in a large hospital. Its advantages are the availability of materials and necessary information for the shortest period. The introduction of an electronic signature and the storage of signed documents are new real steps to the creation of paper-free technology, including the so-called electronic case history base. Automated exchange of orders for tests and their results not only reduces the time of their obtaining, but also lowers costs and enhances the efficiency of work pf a biopsy laboratory.

[Results of the activity of pathoanatomical service in Kuzbass after its reorganization].

A new structure of the pathology service in the Kemerovo region which includes Kuznetsk area and its activity is considered.

Impact of a prospective review program for reference laboratory testing requests.

OBJECTIVES: To control the cost of reference laboratory testing, to ensure that its usage is medically appropriate, and to review the contribution of reference testing to patient care at our institution. METHODS: A multidisciplinary institutional committee was convened to manage the utilization of reference testing. A subset of tests was designated to be reviewed in real time by a team of clinical pathologists in consultation with clinical subject matter experts. RESULTS: Twelve percent of testing requests, accounting for approximately 18% of send-out costs, were determined to be clinically unnecessary or would not produce actionable results at that point during that patient's care and were therefore not performed. This intervention, combined with insourcing of frequently requested tests, resulted in a reduction in the costs of reference testing to less than half of that predicted by the rate of growth from 2005 to 2009. Molecular diagnostic tests displayed a higher cost per test than other forms of testing but had a similar degree of clinical impact. CONCLUSIONS: Formal prospective review of reference laboratory testing requests resulted in substantial cost containment and improved the efficiency of patient care.

A cost-effective interdisciplinary approach to microbiologic send-out test use.

CONTEXT: Use of reference laboratories for selected laboratory testing (send-out tests) represents a significant source of laboratory costs. As the use of more complex molecular analyses becomes common in the United States, strategies to reduce costs in the clinical laboratory must evolve in order to provide high-value, cost-effective medicine. OBJECTIVE: To report a strategy that employs clinical pathology house staff and key hospital clinicians in the effective use of microbiologic send-out testing. DESIGN: The George Washington University Hospital is a 370-bed academic hospital in Washington, DC. In 2012 all requisitions for microbiologic send-out tests were screened by the clinical pathology house staff prior to final dispensation. Tests with questionable utility were brought to the attention of ordering clinicians through the use of interdisciplinary rounds and direct face-to-face consultation. RESULTS: Screening resulted in a cancellation rate of 38% of send-out tests, with proportional cost savings. Nucleic acid tests represented most of the tests screened and the largest percentage of cost saved through screening. Following consultation, requested send-out tests were most often canceled because of a lack of clinical indication. CONCLUSIONS: Direct face-to-face consultation with ordering physicians is an effective, interdisciplinary approach to managing the use of send-out testing in the microbiology laboratory.

An approach to studying the cost behavior of changing utilization of a hospital laboratory.

Strategies for cost containment in the clinical laboratory have been proposed and some are being tested. An approach is described and illustrated in this article for estimating the size of a cost reduction that might be observed in response to hypothetical changes in the utilization of the clinical laboratory. The variability of laboratory costs with changing volume is reported as a function of the assumptions made.

The flexible budget process--a tool for cost containment.

This past year the authors have been using a new tool to examine and monitor their laboratory's expenditures. Called "flexible budgeting," this process has been used to analyze the cost behavior of all operating expenses, establish budget levels for different levels of activity, and monitor activity based on relative cost rather than simply the number of tests performed. The authors' experience has shown that this tool provides much more information than previous procedures. However, better methods need to be developed for monitoring expenditures so that this information can be used effectively.

Prospective study of quantitative aspects of audit in a large general histopathology laboratory.

A non-computerised method of accurate prospective analysis of the quantitative aspects of the work of a general histopathology laboratory was devised. The method entails monitoring the progress of all biopsy and cytology specimens through the laboratory during selected monthly periods of study. The data collected include details of specimen type, block/section/stain details for each specimen, and information about the timed progress through technical, medical, and secretarial stages of specimen/report handling. The results give a detailed breakdown of the biopsy and cytology workload of this department. They give information about the rate of passage of specimens through the system and identify reasons for delay in the reporting of some cases. The method is easy to operate and will allow for the analysis of specific effects--for example, staff changes--on the efficiency of the department. The data will also provide some of the information required for the costing of histopathology laboratory services, and the type of information obtained will probably become a necessary requirement for laboratory accreditation.

The Howie Code: what are the real costs?

The costs of implementing the Code of Practice for the Prevention of Infection in Clinical Laboratories appear to have been inflated in various ways. These include: alterations and improvements not required by the Code; rehabilitation of neglected buildings to conform with the requirements of the Health and Safety at Work Act; correction of poor design in recently built laboratories; suboptimal management and courses of instruction; and numerous committees.

Benefits of costing in the clinical laboratory.

This paper urges the benefits of applying more widely a method for pathology laboratory costing originally devised for a clinical chemistry department, and illustrates these with examples drawn from costing studies in three clinical laboratories. Heads of pathology departments, laboratory managers, administrators and clinicians require different kinds of costing information, each of which can be obtained by the costing procedure outlined. The method also yields valuable and sometimes surprising insights into the workings of a pathology service. Cost comparisons between different laboratories can now become more informative. Flaws in the concept of the "cost per test" are discussed and the value of this concept is questioned; for most purposes the cost per request has greater application.

Best Practice No 177: Best practice guideline: writing a business case for service development in pathology.

This guideline reviews the introduction and development of business planning in the National Health Service. A guideline for writing a business case for service development that would form part of a pathology business plan has been developed. This guideline outlines six steps that are required in the preparation of a business case. The format of the guideline has been developed largely from other national guidelines that have been published for the development of capital projects. In view of the publication of these guidelines, the scope of this guideline excludes business cases for information, management, and technology projects and large capital projects.

Benchmarking pathology services: implementing a longitudinal study.

This paper details the benchmarking process and its application to the activities of pathology laboratories participating in a benchmark pilot study [the Royal College of Pathologists of Australasian (RCPA) Benchmarking Project]. The discussion highlights the primary issues confronted in collecting, processing, analysing and comparing benchmark data. The paper outlines the benefits of engaging in a benchmarking exercise and provides a framework which can be applied across a range of public health settings. This information is then applied to a review of the development of the RCPA Benchmarking Project. Consideration is also given to the nature of the preliminary results of the project and the implications of these results to the on-going conduct of the study.

Medicare hospital outpatient services and costs: implications for prospective payment.

Medicare expenditures of hospital outpatient department (HOPD) services are growing rapidly, prompting congressional interest in a prospective payment system. In this article, the authors identify frequently provided services and examine service volume and charges in the HOPD. Relatively few services drive Medicare HOPD spending, and volume is dominated by visits, imaging and laboratory tests, whereas surgery accounts for a large proportion of charges. Hospital-level variations in charges, costs, case mix, and outliers are also explored. There is substantial variation in charges and costs across hospital types. However, after case-mix adjustment, all hospital types have average costs within 6 percent of the national average.

Quantitative analysis of cost-savings strategies in the clinical laboratory.

Various strategies for cutting costs in the hospital clinical laboratory are noted, including straight cost cutting, modifications of internal operations, degradation of functions and services, reduced utilization, shared hospital services, and reorganization. Dr Winkleman defines quantitatively, where data exist, the actual cost savings that the different options have been claimed to produce.