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Background: For individuals with chemotherapy-related anemia, the clinical effectiveness of epoetin alfa (EPO) dosed once weekly ([QW], 40,000 units per dose) has been demonstrated to be indistinguishable from that observed with thrice-weekly dosing ([TIW], 10,000 units per dose). Whether the advantage of less-frequent administration justifies the higher EPO dosage used in the weekly regimen in terms of overall cost of care is unknown., Objective: To conduct a cost-minimization analysis comparing QW and TIW EPO dosing from a societal perspective., Methods: Direct and indirect medical cost data were calculated for a 16-week period for 2 large, prospective, multicenter, community-based studies. Costs measured included EPO, transfusions, laboratory tests, office visits, and opportunity cost of patient time., Results: The average total costs in 2002 (first half) dollars were nearly equivalent across the 2 groups (QW: 9,204 dollars; 95% confidence interval [CI], 9,057 dollars-9,350 dollars. TIW: 9,265 dollars; 95% CI, 9,083 dollars-9,447 dollars. P=0.60). QW incurred mean drug acquisition costs that were 23% higher (QW: 6,725 dollars; 95% CI, 6,611 dollars-6,838 dollars. TIW: 5,474 dollars; 95% CI, 5,350 dollars-5,598 dollars. P<0.001). However, QW patients can avoid the resource use and time cost associated with 2 additional office visits incurred each week (QW: 592 dollars [583 dollars-600 dollars]; TIW: 1,709 dollars [1,678 dollars-1,740 dollars]; P<0.001). Transfusion and laboratory test costs were slightly higher in the TIW group (QW: 1,888 dollars [1,837 dollars-1,940 dollars]; TIW: 2,082 dollars [2,020 dollars-2,144 dollars]; P<0.001)., Conclusion: Total anemia treatment costs over a 16-week period with EPO QW were similar to those of TIW dosing. In the absence of cost differences between regimens, the noneconomic advantages of less-frequent dosing intervals should make weekly dosing increasingly attractive to patients, clinicians, and payers.

Objective: To compare target joint-associated costs incurred by boys with severe hemophilia A 1 year before and 1 year after development of a target joint (pre-TJ, post-TJ)., Study Design: Resource utilization data were extracted retrospectively from medical and hemophilia clinic charts and patient diaries for 16 boys attending the Hospital for Sick Children (HSC)'s comprehensive care hemophilia program. Resources examined included drugs, medical care, hospitalization, laboratory tests, therapies, and transfusions received. All costs were figured using standard price lists and were discounted using an annual rate of 3%., Results: Fifteen of the 16 boys developed at least one target joint, defined as three bleeds into any single joint within a consecutive 3-month period, at an average age of 54 months (range, 15-94 months), with ankles being most often affected, followed by elbows and knees (46% vs 28% and 23%, respectively). The total cost of treating a boy with on-demand Factor VIII (FVIII) increased by 119% after development of a target joint, from $20,091 (in 2002 Canadian dollars [$CDN]) in the year before to $43,890 in the year after target joint development. Factor VIII use accounted for 87% of the total cost in the year before target joint development and 93% in the year after., Conclusions: This study identified substantial increased costs of care associated with target joint development. This finding provides further support for more aggressive treatment aimed at reducing target joints-either more aggressive treatment of joint bleeds or institution of primary prophylactic therapy at an early age.

Objective: There is concern about an increasing incidence of kernicterus in healthy term neonates in the United States. Although the incidence of kernicterus is unknown, several potential strategies that are intended to prevent kernicterus have been proposed by experts. It is necessary to assess the costs, benefits, and risks of such strategies before widespread policy changes are made. The objective of this study was to determine the direct costs to prevent a case of kernicterus with the following 3 strategies: (1) universal follow-up in the office or at home within 1 to 2 days of early newborn discharge, (2) routine predischarge serum bilirubin with selective follow-up and laboratory testing, and (3) routine predischarge transcutaneous bilirubin with selective follow-up and laboratory testing., Methods: We performed an incremental cost-effectiveness analysis of the 3 strategies compared with current practice. We used a decision analytic model and a spreadsheet to estimate the direct costs and outcomes, including the savings resulting from prevented kernicterus, for an annual cohort of 2,800000 healthy term newborns who are eligible for early discharge. We used a modified societal perspective and 2002 US dollars. With each strategy, the test and treatment thresholds for hyperbilirubinemia are lowered compared with current practice., Results: With the base-case assumptions (current incidence of kernicterus 1:100 000 and a relative risk reduction [RRR] of 0.7 with each strategy), the cost to prevent 1 case of kernicterus was 10,321463 dollars, 5,743905 dollars, and 9,191352 dollars respectively for strategies 1, 2, and 3 listed above. The total annual incremental costs for the cohort were, respectively, 202,300671 dollars, 112,580535 dollars, and 180,150494 dollars. Sensitivity analyses showed that the cost per case is highly dependent on the population incidence of kernicterus and the RRR with each strategy, both of which are currently unknown. In our model, annual cost savings of 46,179465 dollars for the cohort would result with strategy 2, if the incidence of kernicterus is high (1:10,000 births or higher) and the RRR is high (> or =0.7). If the incidence is lower or the RRR is lower, then the cost per case prevented ranged from 4,145676 dollars to as high as 77,650240 dollars., Conclusions: Widespread implementation of these strategies is likely to increase health care costs significantly with uncertain benefits. It is premature to implement routine predischarge serum or transcutaneous bilirubin screening on a large scale. However, universal follow-up may have benefits beyond kernicterus prevention, which we did not include in our model. Research is required to determine the epidemiology, risk factors, and causes of kernicterus; to evaluate the effectiveness of strategies intended to prevent kernicterus; and to determine the cost per quality-adjusted life year with any proposed preventive strategy.

The impact of clinical liaison on therapy for positive after-hours blood cultures was evaluated. Of 223 positive blood cultures, no change in management occurred in 164 (73%) cases: 115 positive cultures were regarded as contaminants, and 49 patients were receiving appropriate therapy already. The results of microscopy or culture altered the antimicrobial management of 59 (27%) patients: therapy was altered on the basis of microscopy for 33 patients, and was altered for 26 patients when culture results were available. In total, 94 doses of inappropriate antibiotics were avoided. The main benefit of after-hours blood cultures was that laboratory results were available a day earlier, facilitating timely initiation of appropriate therapy and infection control procedures.

Our core laboratory at St. Joseph's Medical Center (SJMC) recently installed the new Beckman Coulter LH 1500 fully automated hematology workcell. Like many laboratories in North America and other parts of the world, we are under significant pressure to improve productivity, reduce costs, and improve service provision to our hospital and clinician bases. The difficulty of meeting this challenge is often further compounded by an increasing shortage of qualified technologist personnel. We recently reported on the significant productivity gains with the introduction of the LH 750 hematology system into the core laboratory, including a 23% reduction in slide review rate, automation of reticulocyte and nucleated red blood cell counts, and an 82% increase in the pass-through rate. Evolution to the next stage of automation has come much quicker than anticipated owing to a steep rise in workload and an ever increasing shortage of trained and experienced technologists to fill vacancies in the 24-hour core laboratory operation. We chose to upgrade our LH 750 analyzers to the newly introduced LH 1500 hematology workcell in order to cope with the increased workload and shortage of available experienced hematology technologists. The LH 1500 is a compact, high throughput, fully automated hematology workcell. It is designed to automate all manual process and handling steps associated with hematology analyses, including sample sorting, loading and unloading of cassettes, automatic rerun and reflex testing, sample storage, and tracking of samples. The LH 1500 is comprised of a minimum of 2, and up to 4, LH 750 instruments (with or without integrated slidemaker/stainers). The instruments are bidirectionally interfaced and linked to a fully automated conveyor track, specimen inlet and outlet stations, a sample stockyard, and a line controller. The configuration we chose at SJMC incorporates 1 LH 750 and 1 LH 755. We report that the upgrade to the LH 1500 was a relatively straightforward process and required no redesign of the core laboratory. Based on our evaluation, we estimate cost savings with the LH 1500 of between three quarters to 1 full-time equivalent, which eliminated or decreased many manual handling steps. In addition, this increase in efficiency has freed up our technologist resources to concentrate on the more difficult and clinically important samples. This is the first published report on the new LH 1500 hematology workcell. Our research indicates that the LH 1500 is the first hematology workcell to offer hematology laboratories the next level of automation and virtually eliminate preanalytical and postanalytical sample handling and sorting. For core laboratories and high-throughput hematology laboratories that face similar pressures to ours, the LH 1500 would appear as an attractive solution to maximize hematology productivity and improve service delivery.

Cation exchange high performance liquid chromatography (HPLC) is emerging as the method of choice for the initial screening of thalassemias and haemoglobinopathies and quantification of Haemoglobins (Hbs) like HbA, HbA2 and HbF. Since it is expensive, the present study was conducted to evaluate the need for HPLC in Indian laboratories and identify situations where it would be imperative. Eighty three patients suspected to have thalassemia and haemoglobinopathies were analysed. Both HPLC and alkaline gel electrophoresis detected 14 cases of HbE syndrome and 14 cases of HbS syndrome. However of the 14 cases diagnosed as HbD syndrome by alkaline electrophoresis, eight cases were diagnosed as Hb Q India, 1 case as HbD Iran and 5 cases of HbD Punjab on HPLC. Thirty-one cases were detected to have beta heterozygous thalassemia based on the high HbA2 levels (>3.9%) and eight cases were diagnosed as beta homozygous thalassemia by both HPLC and gel electrophoresis. One of them had an unknown Hb migrating in F-A region. Her mother also had same unknown Hb variant. In view of electrophoretic migration and retention time (RT) on HPLC, possibility of HbG-San Jose was considered. HPLC being an automated instrument is highly sensitive and specific, has high resolution and helps in quantification of various haemoglobins. However in a developing country like India where economical factors play a major role in planning for management of patients, the role of HPLC is limited.

Objective: To analyze the potential cost and efficacy of Down syndrome screening in the population with advanced maternal age., Methods: Three screening methods defining Down syndrome risk for women with advanced maternal age were analyzed: advanced maternal age; advanced maternal age and maternal serum triple screen; and advanced maternal age, maternal serum triple screen and genetic sonogram. Costs for all tests and procedures were estimated. Procedure-related loss for amniocentesis was assumed to be 1:200. Efficacy was defined as: number of amniocenteses performed, number of Down syndrome cases detected, procedure-related losses, Down syndrome cases detected per fetal loss, cost per Down syndrome case detected and total cost of screening., Results: In 1999 in the USA, there were 530,610 women with advanced maternal age at 16 weeks' gestation carrying an estimated 4,043 fetuses with Down syndrome. Screening by maternal age alone would result in the 100% detection of Down syndrome cases, but would require over 530,000 amniocenteses and result in 2,653 procedure-related losses. Combining age with serum screen and genetic sonogram would detect 97.6% of Down syndrome cases, but would require only 119,791 amniocenteses and result in 599 procedure-related losses. The projected cost per Down syndrome case detected using age screening is 219,109 dollars versus 155,992 dollars using serum screen and genetic sonogram., Conclusions: The combination of advanced maternal age, maternal serum screen and genetic sonogram would result in the fewest procedure-related losses and lowest cost per Down syndrome case detected.

The Coulter AcT 5 diff autoloader (AL) hematology analyzer (Beckman Coulter, Fullerton, CA, USA) was evaluated at the Charlevoix Area Hospital, a small rural community hospital. The analyzer was compared to the laboratory's current instrument, a Cell-Dyn 3200 (Abbott Laboratories, Abbott Park, IL, USA). The study included comparisons of precision, efficiency and productivity, and reliability. The 5-part white blood cell differentials on both instruments were compared, and the clinical utility and flagging performance of both analyzers were confirmed by manual differential counts. The AcT 5 diff AL was shown to have excellent precision and accuracy. The addition of the autoloader to the AcT 5 diff provides a low-volume system with the added benefits of a "load and leave" analyzer normally available only to larger laboratories.

Purpose: Our organ procurement organization (OPO) evaluated the clinical and financial efficacy of point-of-care testing (POCT) in management of our deceased organ donors., Methods: Before we implemented point-of care testing with the i-STAT into routine clinical donor management, we compared the i-STAT result with the result from the respective donor hospital lab (DHL) for certain analytes on 15 consecutive donors in our OPO from 26 March to 14 May 2001. The financial impact was studied by reviewing 77 donors from July 2001 to March 2002., Results: There was a strong correlation for each analyte between the POC and DHL test results with r-values as follows: pH 0.86; PCO2 = 0.96; PO2 = 0.98; sodium = 0.98; potassium = 0.95; chloride = 0.94; BUN = 0.98; glucose = 0.92; haematocrit = 0.87 and creatinine = 0.95. Since our OPO coordinators began using i-STAT in their routine clinical management of organ donors, they can now more quickly maximize oxygenation and fluid management of the donor and make extra-renal placement calls sooner. Finally, since we are no longer being billed for the testing performed on the i-STAT, average financial savings to our OPO are US dollars 733 per case., Conclusions: Point-of-care testing in management of our OPO donors provides a result that is equivalent to that of the donor hospital lab, has quicker turn-around time than the donor hospital laboratory, allowing more immediate clinical management decisions to be made so that extra-renal offers may begin sooner.

In order to determine the value of routine pre-operative screening investigations, the medical notes of 100 patients undergoing elective surgical procedures under general anaesthesia were subject to prospective audit. Pre-operative screening investigations (full blood count, urea and electrolytes and random glucose) were analysed in terms of frequency of abnormalities and whether or not the peri-operative management was changed when the result was abnormal. The frequency of results being present in the note at the time of operation and the costing of the tests was also examined. A total of 773 tests was performed of which 70 (9.1%) were abnormal. Peri-operative management was altered as a result of only two abnormal results (0.2%). Eight complications arose, none of which could have been predicted by the pre-operative screening tests. In only 57% of cases were the results present in the medical notes at the time of surgery. It is conservatively estimated that a saving of pound 50 000 per year could be made in our hospital alone by selective ordering of tests.

Hematologic and hemostatic tests are important and indispensable for diagnosing any kind of hematologic disease. Recent advances in hematologic tests are seen in automation of the blood cell counts and morphological analyses that are required for diagnosing hematologic diseases, and in the accumulation and availability of genetic and chromosomal examinations related to their diagnosis. Although hemostatic tests used to be mainly aimed at checking bleeding tendency, they are now being directed toward diagnosing thrombotic tendency. Medical expenses have hardly been increased in past revisions of reimbursement schedules for medical services, which has driven hospital management into an even tighter corner. In the field of laboratory examination, test fees were heavily slashed and calculated on an all-inclusive basis, forcing budgetary restrictions on the management of test laboratories. I discuss the medical reimbursement for hematologic and hemostatic tests, focusing on the fiscal 2002 revision of the medical service fee schedule implemented in April.

Major changes in the healthcare environment have increasingly forced hospitals to reconsider their operative structures to maintain cost competitiveness. These changes have included restructuring and numerous hospital mergers, and they have forced hospitals to examine ways to improve operational efficiency. Nowhere in the hospital is this truer than in the critical care areas, where costs are highest, and one of the places where process improvements can be made is in the laboratory analysis. Data indicate that laboratory analysis comprises about 43% of the data used by critical care clinicians to make clinical decisions. The more quickly these data can be provided to the clinicians, the more likely they are to have an impact on the patient's care.Point-of-care testing (POCT) in critical care is one way of simplifying the laboratory analysis process so that laboratory data are more readily available to clinicians. A close collaborative relationship with the clinical laboratory can allow a robust POCT to be implemented in critical care that meets the needs of both the clinical laboratory and the critical care areas. When implemented appropriately, a POCT program in critical care can provide rapid and accurate test results, can be fairly simple to maintain, and can be cost effective. However, successful implementation requires a new set of skills for critical care nurses including knowledge of the laboratory regulatory issues, a commitment to training, recertification, and a quality improvement program related specifically to POCT. Several studies have shown that laboratory turnaround time can be reduced through the implementation of a POCT program. However, at this writing, no studies have linked this decrease in turnaround time to improved patient outcomes, although there are some data to support a decrease in iatrogenic blood loss with the use of POCT. Although the use of POCT in critical care has some distinct benefits, clearly, outcome studies need to be conducted to assess the true impact of POCT on the care of patients who are critically ill.

A hypothetical model using a base case and sensitivity analyses compared averted and incurred costs of in-line monitoring with neonatal intensive care unit satellite laboratory testing. Data were obtained retrospectively for 1 year from 50 consecutive critically ill premature neonates weighing less than 1,000 g at birth whose blood tests were performed in-line and processed at the satellite laboratory. Averted costs included phlebotomies, satellite blood testing, and transfusions; incurred costs included in-line monitor rental, nursing time, and daily monitor validation. In-line monitoring led to cost savings of $324 per neonate and a benefit/cost ratio (BCR) of 1.23 in our base case. Sensitivity and scenario analyses addressed uncertainty and led to a BCR variation of 0.41 to 2.48. Compared with satellite laboratory testing, in-line monitoring of critically ill neonates may generate cost savings through reduced laboratory analysis expense, less phlebotomy loss, and fewer blood transfusions for hospitals with high laboratory cost structures. Because most cost savings result from offsetting indirect costs (eg, building space and hospital overhead) that are of a longer term nature, short-run cost savings are less likely to be realized.

Background: The cost of out of hours services makes up a considerable proportion of the total laboratory budget and this has encouraged haematologists to examine workload patterns and the organisation and cost of out of hours services., Aim: To review current levels of out of hours workload and examine the organisation and cost of the service in the South Thames region., Method: Data collection was by questionnaire and data analysis by Microsoft Excel., Results: A variety of methods of organising and financing out of hours services were identified. There was a large variation in workload between different centres. There has been a rise in total workload and out of hours workload over a three year period. The most common tests to take place outside routine hours are full blood counts and clotting screens. The method of providing out of hours services did not affect total numbers of out of hours tests. There were considerable costs associated with time off in lieu for on call staff., Conclusions: The variation and increase in out of hours tests is not related to the way that out of hours services are provided, but is more likely to result from changes in medical practice. There are pronounced differences between centres in the numbers of different types of tests performed out of hours, which are not related to the numbers of acute beds. There is no single model of out of hours service provision that suits all situations.

During a 4-year period, 9465 specimens for blood culture were obtained from 11,911 highly febrile, otherwise healthy young children. Of these specimens, 87 (0.9%) yielded nonpathogens and were considered to be false-positive blood culture results (FPBCRs). Seventy-two of the patients who provided these specimens were treated on an outpatient basis (resulting in $10,821 in treatment charges), and 7 were admitted to the hospital (resulting in $16,200 in charges) as a result of the FPBCRs. Studies performed during follow-up included a second blood culture (21 patients), complete blood cell count (11), urine analysis and culture (5), lumbar puncture (3), and chest radiography (3). Only a small minority of patients were hospitalized or underwent invasive procedures. The charges associated with FPBCRs are very small in comparison to the initial charges of culturing specimens obtained from children considered to be at risk. Concern about the consequences of FPBCRs should not deter clinicians from performing indicated cultures for children who potentially have bacteremia.

Point-of-care testing technology rapidly is changing the way physicians practice medicine by facilitating the availability of biochemical parameters immediately or almost immediately. The constant evolution and developments in [figure: see text] microchemistry and computer technology will make this area a dynamic part of medicine with the constant emergence of improved and newer technologies. Clinicians must not forget, however, that the best analyzer and monitor is the physician, nurse, or other health care worker in direct contact with the patient, constantly reassessing, re-examining, and integrating all of the physiologic and biochemical data in the context of the history and physical examination. If POC testing is implemented, its goal should be to improve and assist in patient care.

This paper reports the chest X-rays, Heaf tests and haematology findings on a population of Gurkha wives and their children who arrived in the UK to accompany their husbands on an army base in 1997-8. The conclusions from this study are that there is no benefit from performing chest X-rays, but that screening for rubella and iron deficiency anaemia should continue.

Objectives: The aim of our study was to evaluate the prevalence of antithrombin, protein C and protein S deficiencies in consecutive ischemic stroke patients under 45., Material and Methods: We studied 127 consecutive patients with a mean age of 34.4 years admitted for an ischemic stroke, over a 2-year period, after exclusion of those with arterial dissection. Antithrombin, protein C and protein S levels were measured in all patients at the acute stage of the ischemic stroke and measurements were repeated in case of abnormality., Results: We found abnormal levels in 9 patients. Seven had an acquired cause of deficiency (pregnancy, oestrogen, acute inflammation). Two had no obvious acquired cause of deficiency but further controls were normal., Conclusions: Hereditary deficiencies of coagulation inhibitors are rare in ischemic stroke patients under 45 and their systematic detection seems to be of poor interest.

Objective: To measure trends in recorded incidence and mortality rates of prostate cancer in Western Australia from 1985 to 1996 and to relate these to prostate-specific antigen (PSA) testing for prostate cancer., Design: Descriptive study based on data from the Western Australian Cancer Registry, the Australian Bureau of Statistics and the Health Insurance Commission., Data: All newly diagnosed cases of prostate cancer and all deaths from prostate cancer in Western Australia from 1985 to 1996., Main Outcome Measures: Recorded incidences and mortality rates for prostate cancer., Results: After increasing steadily from 42 per 100,000 person-years in 1985 to 61 in 1992, the recorded incidence more than doubled to 134 per 100,000 person-years in 1994, then fell sharply to 87 in 1996. Among men aged 50 years or more, those aged 50-54 years had the largest annual increases: 14% (95% confidence interval [CI], 10%-19%) from 1985 to 1992 and 108% (95% CI, 84%-134%) from 1992 to 1994. They also had the smallest annual decline between 1994 and 1996 (8%; 95% CI, 1% increase to 16% decrease). The mortality rate showed no sudden increases or decreases. In men aged 60 years or older, the mortality rate increased annually by 2.9% (95% CI, 2%-4%) from 1985 to 1996. The number of Medicare reimbursements for PSA tests increased until May 1995, then fell. There was a significant correlation between the monthly number of PSA tests and new cases of prostate cancer (P < 0.01)., Conclusions: Following a period of steady increase, the recorded incidence of prostate cancer increased dramatically in 1992 because of screening by PSA testing. From 1994, these incidence figures declined almost as sharply, partly because of reductions in testing. The mortality rate has not shown any systematic deviation from its long-term trend.

Objective: To describe patterns and trends in prostate-specific antigen (PSA) testing in Australia and assess its role in the increasing incidence of prostate cancer., Design: Descriptive analysis of (i) Medicare records of PSA testing in Australia, and (ii) prostate cancer recorded incidence in New South Wales., Data: (i) Medicare data for all males who received a Medicare-reimbursed PSA test between August 1989 and December 1996. (ii) NSW Central Cancer Registry data for all males in NSW with prostate cancer diagnosed between 1988 and 1995., Main Outcome Measures: (i) Number of PSA tests, age-standardised rates of PSA tests by State and Territory, and proportions of males who had a PSA test. (ii) Recorded incidence of prostate cancer in NSW., Results: (i) More than 2.2 million PSA tests were done on more than 1.1 million Australians between 1989 and 1996. The annual number of males tested increased fivefold in this period and peaked in 1995. Twenty-seven per cent of Australian men aged 50 years or over had at least one PSA test in 1995 or 1996; 33% of men aged 60-69 years had a test in this period. (ii) In NSW the number of PSA tests per quarter was highly correlated with the number of new cases of prostate cancer (R2 = 0.92)., Conclusions: Although no organised program for prostate cancer screening exists, and despite repeated advice against it, opportunistic screening has been occurring at high rates. There was a high correlation between PSA testing and prostate cancer incidence between 1990 and 1995 in NSW.

Background: Pediatric cardiac care is costly and requires extensive resources. We studied the effect of clinical pathways on practice patterns and patient care outcomes in infants and children hospitalized for cardiac surgery., Methods: In consecutive patients admitted for selected cardiac surgical procedures before (n = 69) and after (n = 173) implementation of clinical pathways, outcomes including hospital length of stay, days in the ICU, time to extubation, ordering of blood studies, costs, and readmissions were compared. Data were analyzed for each of five cardiac surgical procedures: repair of an atrial septal defect, repair of a ventricular septal defect, division of a patent ductus arteriosus, repair of tetralogy of Fallot, and neonatal arterial switch operation to correct transposition of the great arteries., Results: A significant reduction in length of hospital stay, including days in the ICU (decreased 1 to 2 days per admission), was achieved after the clinical pathway was implemented. Reductions in average duration of mechanical ventilation ranged from 28% for repair of a ventricular septal defect to 63% for repair of tetralogy of Fallot. The number of blood studies ordered decreased 20% to 30%. A significant reduction in hospital costs for each procedure, ranging from 16% to 29%, was also achieved with no adverse effects on patients' outcomes., Conclusions: Use of clinical pathways with children hospitalized for cardiac surgery can shorten length of stay in the hospital, reduce use of resources, and improve cost-effectiveness with beneficial outcomes for patients.

In 1996 a project was undertaken to determine the clinical impact of blood cultures taken in the emergency department. It found that 1.6% of all blood cultures taken resulted in changes in patient management. In response to these findings, guidelines were developed for more appropriate utilisation of blood cultures. It was predicted that the guidelines would result in a reduction in test ordering of approximately 40% and an annual saving of approximately $18,000. The guidelines were implemented in mid-1997. An audit of test ordering for the months of January to August 1998 shows a 53% reduction in the ordering of blood cultures.

The impact of developing guidelines for laboratory testing in an Intensive Care Unit (ICU) was examined. Targeted blood tests were recorded on fifty cardiac surgery and fifty general intensive care patients retrospectively. Following the introduction of guidelines, the study was repeated with prospective data collection. Comparison of the samples before and after the intervention showed a 25.9% reduction in all blood tests and a 17.1% reduction in arterial blood gases in the post cardiac surgery group. In general ICU patients, the drop in all tests was 16.6% and in arterial blood gases 21.9%. The cost saving from the cardiac surgery sample was N.Z.$3,637 and general ICU N.Z.$3,166, giving a sum total of N.Z.$6,803 in 100 patients. The potential cost savings for the annual admissions of 1,200 patients is N.Z.$81,636. This study shows that written guidelines can bring about major cost reduction in the short-term.

The rising costs of health care and the movement for health care reform have focused attention on methods of cost containment. Of routine laboratory and radiologic procedures, complete blood cell count (CBC) and determination of serum electrolyte values rank as high as 2nd and 9th in overall cost. We retrospectively studied use of the clinical laboratory to aid diagnosis of an acute infectious event in a pediatric emergency department population. For 5 months, we reviewed medical records of pediatric patients younger than 15 years brought to the emergency department because of a febrile episode. Of 155 cases reviewed, electrolyte concentrations were determined in 108 patients and CBC in 155. In all patients, either culture or rapid test for streptococcal organisms was performed. In addition, 838 pediatric patients with similar symptoms but who did not undergo laboratory testing were monitored for 100 days. Measures of effectiveness including sensitivity, specificity, positive and negative predictive values, and likelihood ratio were used to correlate specific laboratory findings with antibiotic therapy, serious bacterial disease, and culture positivity. Electrolyte abnormalities were found largely to be dismissed clinically, with the major clinical response consisting of parental education about hydration. The CBC profile was evaluated, with white blood cell count (WBC) indicator limits of > 10,000, > 10,000 but < 15,000, and > 15,000/mm3, and differentiated into absolute neutrophil count, neutrophil percent, and band cell percent. Temperature was evaluated as an independent variable. Insofar as serious bacterial disease and culture positivity, sensitivity was uniformly low (70%), and specificity was only marginably acceptable for WBC > 15,000 (77%). Both positive predictive values and likelihood ratio were low with respect to predicting either serious bacterial disease or culture positivity, emphasizing the limited usefulness of these clinical laboratory measurements. The best hematologic predictors of serious bacterial disease or culture positivity were obtained with automated hematologic analyzers and exceeded manual differential measurement of neutrophil percent and band cell percent. In addition, we correlated the administration of antibiotics with the various hematologic parameters and discovered that WBC > 15,000, regardless of cause, almost uniformly resulted in treatment (positive predictive value, 93.5%; likelihood ratio, 5.60). These findings support the use of automated hematology analyzer-derived measurements and question the use of manual differential counts, unless specific issues are to be addressed. Furthermore, the findings seem to support more reliance on clinical impression and less on laboratory values.

Objective: Rheumatoid arthritis (RA) is a disease that often requires multiple drug treatment for long periods of time. The purpose of this study was to assess the direct costs of medical care for RA patients seen in a tertiary care center in Mexico City., Methods: The clinical cases of 3 patients attending our Institution were studied. These represented: (i) one with a disease easily controlled with a disease modifying anti-rheumatic drug (DMARD) (mild disease), (ii) one adequately controlled with 2 or more DMARDs (moderate disease), and (iii) one poorly controlled in spite of multiple DMARDs (severe disease). The costs of the medical visits and of all laboratory and routine examinations during the last year were estimated according to local tabulators, considering the options of highest, intermediate and lowest costs. The costs of the prescribed medications were calculated from current price lists obtained from four drugstores near the Institution., Results: Medical care to an RA patient costs between US $19 and US $221.70 monthly (US $228.08 and US $2,661.40 per year) depending on the socio-economic status of the patient and on variables related to the activity and severity of the disease in our setting. The number of medical visits represented 0.1% to 12.7% of the total costs, laboratory and routine examinations 0.1% to 7.1%, and medications 81.8% to 99.8%. For reference the minimum wage in Mexico is US $90.40 per month., Conclusions: The direct costs of medical care to RA patients in our setting can be high, and greatly depends on the prescribed medications.

Background: Fertile-aged women are a population group at special risk for developing ferropenia. In the periodic health care examinations, hemogram, among other tests, are included to detect the most advanced state of iron deficity, ferropenic anemia. Likewise, preanemic ferropenia presents a certain morbidity. The aim of this study was to analyze the cost-effectiveness of screening serum ferritin determination in health care examinations of fertile-aged women., Subjects and Methods: An observational transversal study was carried out in 322 women in whom hemogram and serum ferritin were determined. The effects of serum ferritin determination were simulated in a hypothetical cohort of 20-year old women annually examined up to the age of 50 years (mean age of menopause)., Results: The prevalence of preanemic ferropenia (serum ferritin < or = ng/ml) was 44.1% and that of ferropenic anemica (Hb < 120 g/l and serum ferritin < or = 25 ng/ml) was 3.4%. Hemogram sensitivity for detection of ferropenia was 7.2% (3.6-12.5). By means of the screening program with serum ferritin avoiding of one year with ferropenia costs 2,428 pesetas. Prolonging the program to longer than 35 years largely increases the marginal cost. Cost-effectiveness analysis is specially sensitive to the cost of the diagnostic tests and disease prevalence., Conclusions: Ferropenia in fertile-aged women is a frequent disorder. Avoiding ferropenia by early diagnosis may be performed at a relatively low cost.

Objective: Routine admission laboratory test protocols in injured patients are costly and involve excessive phlebotomy and turnaround time. The purpose of this prospective study was to evaluate the utility of (1) a microanalyzer, NOVA-SP5 (which provides rapid results on minimal blood volume), and (2) each component of our standard laboratory test battery., Methods: Laboratory test results for 200 consecutive injured patients admitted to a level I trauma center were evaluated by paired sample analysis. Our standard battery [60 mL: ($348): type and screen, complete blood count, PT/PTT, electrolytes, BUN, creatinine, glucose, calcium, amylase, ethanol level, and arterial blood gas] run "stat" in the central laboratory was compared to the microanalyzer profile [< 1 mL: ($182): hemoglobin, hematocrit, electrolytes, glucose, Ca2+, and arterial blood gas] run by the trauma team in the resuscitation area. Patient data and laboratory turnaround time (from time of admission to time results obtained) were recorded. Data were analyzed by linear regression., Results: Components of the paired samples correlated well (r2 0.78 to 0.99). Turnaround times were 64 (+/- 3) and 6 (+/- 1) minutes for standard analysis and microanalysis, respectively. Only two of the 26 patients requiring emergent surgical procedures had standard results available preoperatively. These patients had twice as many laboratory abnormalities as the remainder. Minimal diagnosis or intervention resulted from those values exclusive to standard analysis (white blood count, amylase, ethanol level, BUN, creatinine, platelet count, PT, and PTT). Six of ten abnormal BUN or creatinine results normalized, including two values in patients who received contrast for portable intravenous pyelography, and in all patients without a history of hypertension or diabetes. Platelet count and PT/PTT were normal in 85% of non-head-injured patients, compared with 58% of those with GCS score < or = 8., Conclusions: Microanalysis is accurate, expedient, conserves blood, and is sufficient for evaluation of most trauma patients. Those with hypertension, diabetes, or severe head trauma may require additional testing. Routine use of this technique could reduce cost substantially ($16,000/100 patients). The role of microanalysis in follow-up laboratory evaluation of injured patients remains to be elucidated.

Costs and benefits of the testing protocol for screening donated blood for the HIV-1 virus are evaluated. Estimates are made of the number of HIV-1 infections and cases of AIDS prevented in a year by blood testing, as well as the costs of providing this risk reduction. The risk reduction provided by alternative tests such as the HIV-1 antigen test is also discussed. The value of the risk reduction provided by blood testing is generated utilizing willingness-to-pay value-of-life estimates. The findings indicate that the present testing protocol is cost beneficial and support the FDA decision not to recommend the HIV-1 antigen test for use in donor testing. Policy decisions concerning present and future testing protocols are discussed, and implications for broadening our model to include indirect benefits of donor testing are evaluated.

A large number of laboratory tests are often ordered in the management of acutely burned patients. Administration of large volumes of fluid and frequent ventilator changes prompt many facilities to utilize ordering protocols. Forty-five consecutive acutely burned pediatric patients with burns measuring 25% or more of total body surface area (TBSA) sustained within 24 hours before admission were reviewed. Laboratory determinations were made at each shift and as indicated by changes in condition. Abnormal or critical values during the first 5 postinjury days were identified for electrolytes, renal function indices, complete blood counts (CBCs), glucose, and arterial blood gas (ABG) levels. Blood drawn for the laboratory tests was also measured. In the first 5 days postburn a total of 8303 laboratory determinations were made. Of these, 186 produced abnormal values. Four were critical values that were not expected from previous determinations. Of the four unexpected critical values obtained, two would have been picked up by our present standard noninvasive monitors. Six percent of estimated blood volume was used to perform laboratory tests. These results demonstrate that significant abnormal laboratory values are uncommon even in severely injured pediatric burn patients and that the ordering of these tests should be individualized based on patient examination and the use of noninvasive monitoring.

Our objective was to determine the extent to which Intensive Care Unit (ICU) physicians are aware of charges for commonly used blood tests. We also wished to ascertain ICU physicians' perception of their motivation for, and appropriateness of, test ordering. Attending physicians and Internal Medicine residents in four university-affiliated ICUs in Hamilton were surveyed using a self-administered questionnaire. The response rate for the questionnaire was 91%. Physicians varied widely in their estimates of charges for ten laboratory tests. On average, residents tended to underestimate charges, while attending physicians sometimes underestimated, and sometimes overestimated. When all ten tests were considered, the mean estimates of the housestaff were lower than the ICU attending physicians (p < 0.001). Overall, attending estimates were 29.5% higher. Over 85% of physicians felt that too many blood tests were being performed. Physicians perceived that they pay insufficient attention to the risk of anemia and to issue of cost. Their feeling that test ordering in the ICU is excessive suggests that they may be open to modifying their practice. Given the large proportion of hospital resources allocated to the intensive care unit, interventions to decrease test ordering are warranted.

We have used the step up allocation accounting method to determine the actual costs of complete blood count, urinalysis, chest radiograph and electrocardiogram. We found that the actual costs were quite different from the price set up by the hospital. The actual cost were much higher than the price for the complete blood count and urinalysis and much lower for the chest radiographs and especially for electrocardiogram. We propose that in performing economic analysis involving all these investigations, the actual cost should be used instead of the price.