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Objective: Determine if routine ordering of postoperative day 1 (POD 1) serum laboratory tests after elective colorectal surgery are clinically warranted and valuable given the associated costs of these lab tests., Summary of Background Data: Routine postoperative serum laboratory tests are a part of many colorectal surgery order sets. Whether these protocolized lab tests represent cost-effective care is unknown., Methods: Patients undergoing elective colorectal surgery between January 1, 2015 and December 31, 2017 at our institution were identified. The protocolized POD 1 lab tests obtained as part of the postoperative order set were reviewed to determine the rate of abnormal values and any intervention in response. Costs associated with protocolized laboratory testing were calculated using dollar amounts representing 2017 outpatient Medicare reimbursement., Results: A total of 2252 patients were identified with 8205 total lab test values. Of these, only 4% were abnormal (3% of hemoglobin values, 6% of creatinine values, 3% of potassium of values, and 3% of glucose values), and only 1% were actively intervened upon. The total aggregate cost of the protocolized POD 1 laboratory tests in these years was $64,000 based on Medicare outpatient reimbursement dollars., Conclusions: Routine POD 1 lab tests after elective colorectal surgery are rarely abnormal, and they even less frequently require active intervention beyond rechecking. This results in increased resource utilization and cost of care without appreciable impact on clinical care, and is not cost-effective. Protocolized POD 1 laboratory testing should be replaced with clinically-based criteria to trigger serum laboratory investigations., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Aims: To validate a set of indicators for monitoring the quality of care of patients with diabetes in 'real-life' practice through its relationship with measurable clinical outcomes and healthcare costs., Methods and Results: A population-based cohort study was carried out by including the 20,635 patients, residents in the Lombardy Region (Italy), who in the year 2012 were newly taken-in-care for diabetes. Adherence with clinical recommendations (i.e., controls for glycated haemoglobin, lipid profile, urine albumin excretion and serum creatinine) was recorded during the first year after the patient was taken-in-care, and categorized according whether he/she complied with none or almost none (0 or 1), just some (2) or all or almost all (3 or 4) the recommendations, respectively denoted as poor, intermediate and high adherence. Short- and long-term complications of diabetes, and healthcare cost incurred by the National Health Service, were assessed during follow-up. Compared with patients with poor adherence, those with intermediate and high adherence respectively showed (i) a delay in outcome occurrence of 13 days (95% CI, -2 to 27) and 23 days (9-38), and (ii) a lower healthcare cost of 54 € and 77 €. In average, a gain of 18 Euros and 15 Euros for each day free from diabetic complication by increasing adherence respectively from poor to intermediate and from poor to high were observed., Conclusion: Close control of patients with diabetes through regular clinical examinations must be considered the cornerstone of national guidance, national audits, and quality improvement incentive schemes., Competing Interests: Declaration of competing interest Giovanni Corrao received research support from the European Community (EC), the Italian Agency of Drug (AIFA), and the Italian Ministry of Education, University and Research (MIUR). He took part to a variety of projects that were funded by pharmaceutical companies (i.e., Novartis, GSK, Roche, AMGEN and BMS). He also received honoraria as member of Advisory Board from Roche. Giuseppe Mancia received honoraria for participation as speaker/chairman in national/international meetings from Bayer, Boehringer Ingelheim, CVRx, Daiichi Sankyo, Ferrer, Medtronic, Menarini Int., Merck, Novartis, Recordati and Servier. Other authors declare that they have no conflict of interest to disclose., (Copyright © 2021 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

Objective: To investigate whether utilizing a LDL-direct laboratory test rather than a lipid panel to determine LDL-C as part of the inpatient stroke and TIA workup is more cost-effective to the patient and hospital system. A retrospective analysis was conducted on all patients admitted to UCSD La Jolla and Hillcrest Hospital and discharged with a final diagnosis of ischemic stroke or transient ischemic attack between 7/2016 and 6/2019. A cost-analysis was extrapolated based on the current cost of each test as provided by the UCSD hospital billing department as of June 2020. Patients started on a statin, who were not on one prior to admission, were also analyzed to highlight the importance of an accurate LDL-C on management of dyslipidemia., Results: A total of 1245 patients were included in the study with 87% representing Ischemic strokes and 13% transient ischemic attacks. Over the three-year period, a total savings of $77,545 would be achieved if LDL-direct were used in place of a lipid-panel, representing an overall cost savings of 33%. Over the same time-frame, 536 (43%) patients were started on a statin that were not previously on one., Conclusions: Ordering a LDL-direct test should be considered over a lipid panel to evaluate LDL-C as it may prove to be the most cost effective approach to both the patient and Healthcare system., (Copyright © 2020 Elsevier Inc. All rights reserved.)

This work presents the development and validation of a simple, rapid, and cost-effective spectrophotometric method for quantitative analysis of uric acid in biological samples. The method relies upon uric acid-led reduction of Fe(III) to Fe(II) of sample/standard solutions which stoichiometrically engages ferrozine to form a magenta-colored complex. Different parameters including pH, metal and chelator concentrations, temperature, etc., were optimized for the maximum intensity and stability of the complex. The uric acid concentrations of synthetic/plasma solutions were determined by comparing the color intensity of Fe(ferrozine) 3 2+ complex produced by test solution with the standard curve formed by known uric acid concentrations. The method was validated in accordance with ICH guidelines and subjected to human plasma analysis. The results obtained were compared with a reference (enzymatic) method which revealed that there was no significant difference between the two methods at 95% confidence level. The method is highly specific, precise, linear, accurate, and robust.

Objectives : The most cost-effective newborn screening strategy for cystic fibrosis (CF) for Flanders, Belgium, is unknown. The aim of this study was to assess the cost-effectiveness of four existing newborn screening strategies for CF: IRT-DNA (immunoreactive trypsinogen, cystic fibrosis transmembrane conductance regulator ( CFTR ) gene mutation analysis), IRT-PAP (pancreatitis-associated protein), IRT-PAP-DNA, and IRT-PAP-DNA-EGA (extended CFTR gene analysis). Methods : Using data from published literature, the cost-effectiveness of the screening strategies was calculated for a hypothetical cohort of 65,606 newborns in Flanders, Belgium. A healthcare payer perspective was used, and the direct medical costs associated with screening were taken into account. The robustness of the model outcomes was assessed in sensitivity analyses. Results : The IRT-PAP strategy was the most cost-effective strategy in terms of costs per CF case detected (€9314 per CF case detected). The IRT-DNA strategy was more costly (€13,966 per CF case detected), but with an expected sensitivity of 93.4% also the most effective strategy, and was expected to detect 2.2 more cases of CF than the IRT-PAP strategy. The incremental cost-effectiveness ratio of IRT-DNA vs. IRT-PAP was €54,180/extra CF case detected. The IRT-PAP-DNA strategy and the IRT-PAP-DNA-EGA strategy were both strongly dominated by the IRT-PAP strategy. Conclusion : The IRT-PAP strategy was the most cost-effective strategy in terms of costs per CF case detected. However, the strategy did not fulfil the European Cystic Fibrosis Society guidelines for sensitivity and positive predictive value. Therefore, the more costly and more effective IRT-DNA strategy may be the most appropriate newborn screening strategy for Flanders.

Clinical pathology results are only as good as the quality of samples and accompanying information submitted to the diagnostic laboratory. The frustration of nondiagnostic or equivocal test results can often be avoided by taking the time to follow sample handling and submission guidelines. This article discusses preanalytical errors that commonly affect the accuracy of hematology, chemistry, and cytology testing, and offers practical tips for preventing these errors and maximizing diagnostic yield., Competing Interests: Disclosure The author has nothing to disclose., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim: Hypertension is a public health problem managed according to therapeutic strategies published in France by the Hauteautoritéde santé (HAS - French Health Authorities). For patients with resistant hypertension, related or not to a non-adherence, prescribers need to be sure the exposure is high enough to achieve the tensional target. Quantitative analysis of antihypertensive drugs in different biological matrices (blood/urine) is one possible solution. However, this involves determining the concentrations observed at standard doses and knowing how to interpret the measured concentrations. It is also necessary to identify medical laboratories that can assay antihypertensive drugs. This was the aim of our work., Methods: The main antihypertensive drugs recommended by the HAS have been listed. For each of them, we looked for published steady-state plasma/serum concentrations and quantities excreted in the urine at usual dosages. In addition, the elimination half-life and linear pharmacokinetic profile were specified for each antihypertensive agent measured in plasma/serum. Pharmacology-Toxicology laboratories in France likely to carry out assays were identified. The time taken to report the result and the cost of the analysis were also specified., Results: All of the afore-mentioned information has been collected and presented in a table. This can then be used to compare the plasma/serum concentration or the quantity measured in a patient's urine with the values reported in the literature. In cases where the blood sampling times differ between those of the patient and the published data, the patient's measured value is compared to the estimated value based on the published concentrations and pharmacokinetics., Conclusion: Interpretation of the plasma/serum/urinary value measured or estimated for an antihypertensive drug is a particularly interesting approach to determine if drug exposure is enough and a possible non-adherence. However, this activity is mostly carried out in hospital centres., (Copyright © 2019. Published by Elsevier Masson SAS.)

Non-specific symptoms, as well as the lack of a cost-effective test to triage patients in primary care, has resulted in increased time-to-diagnosis and a poor prognosis for brain cancer patients. A rapid, cost-effective, triage test could significantly improve this patient pathway. A blood test using attenuated total reflection (ATR)-Fourier transform infrared (FTIR) spectroscopy for the detection of brain cancer, alongside machine learning technology, is advancing towards clinical translation. However, whilst the methodology is simple and does not require extensive sample preparation, the throughput of such an approach is limited. Here we describe the development of instrumentation for the analysis of serum that is able to differentiate cancer and control patients at a sensitivity and specificity of 93.2% and 92.8%. Furthermore, preliminary data from the first prospective clinical validation study of its kind are presented, demonstrating how this innovative technology can triage patients and allow rapid access to imaging.

Background and Aim: The increase of the carbohydrate-deficient transferrin (CDT) as results of an heavy intake of alcohol for at least two weeks, is a well-known biochemical modification since the middle '70s. Notwithstanding the first commercial kit for the diagnosis of chronic alcohol abuse based on this biomarker was commercially accessible already thirty years ago, only expensive analytical methods are currently available for its determination. The present paper shows a new approach intrinsically sensitive and specific, based on a specific derivatization of transferrin, and not requiring sophisticated instrumentation., Methods: The proposed procedure is based on a selective chelation of terbium (III) by transferrin followed by detection using an characteristic Fluorescence Resonance Transfer Energy (FRET) phenomenon (ex 298 nm - em 550 nm)., Results: The proposed procedure showed a limit of detection of 2.5 pmol/mL and a reproducibility intra-day and inter-days <15% and 20%, respectively. The results obtained analyzing 40 serum samples using the developed method, were compared with those obtained with HPLC-Vis and an R 2  = 0.8854 was found., Conclusions: Considering its main features (low-cost, ease of operation, minimum need of instrumentation) the present method is suitable for application in screening contexts and in non-strictly regulated environments (e.g. clinical diagnosis) as well as in developing countries or remote areas., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Introduction: Hokianga Hospital is a small rural hospital in the far north of New Zealand serving a predominantly Maori population of 6500. The hospital, an integral part of a comprehensive primary healthcare service, provides continuous acute in-hospital and emergency care. Point-of-care (POC) biochemistry has been available at the hospital since 2010 but there is no onsite laboratory. This study looked at the impact of introducing a POC haematology benchtop analyser at Hokianga Hospital., Methods: This was a mixed methods study conducted at Hokianga Hospital over 4 months in 2016. Quantitative and qualitative components and a cost-benefit analysis were combined using an integrative process. Part I: Doctors working at Hokianga Hospital completed a form before and after POC haematology testing, recording test indication, differential diagnosis, planned patient disposition and impact on patient treatment. Part II: Focus group interviews were conducted with Hokianga Hospital doctors, nurses and a cultural advisor. Part III: An analysis of cost versus tangible benefits was conducted., Results: Part I: A total of 97 POC haematology tests were included in the study. Of these, 97% were undertaken in the setting of the acute clinical presentation and 72% were performed out of hours. The average number of differential diagnoses reduced from 2.43 pre-test to 1.7 post-test, (χ2 tests p<0.05). There was a significant reduction in the number of patients transferred and an increase in the number of patients discharged home (χ2 tests p<0.05). Part II: Three main themes were identified: impact on patient management, challenges and the commitment to 'make it work'. POC haematology had a positive impact on patient management and clinician confidence mainly by increasing diagnostic certainty. The main challenges related to the hidden costs of implementing the analyser and its associated quality assurance program in a remote-from-laboratory setting. Part III: Tangible cost-benefit analysis showed a clear cost saving to the health system as a whole., Conclusions: This is the first published study evaluating the impact of haematology POC testing on acute clinical care in a rural hospital with no onsite laboratory. Timely access to a full blood count POC improves clinical care and addresses inequity. There was an overall reduction in healthcare costs. The study highlighted the hidden costs of implementing POC systems and their associated quality assurance programs in a remote-from-laboratory context.

Background: Alkaline phosphatase isoenzyme analysis is an expensive and time-consuming laboratory test. We evaluated the effect of a locally derived screening algorithm for alkaline phosphatase isoenzyme requests on the number of alkaline phosphatase isoenzyme analyses performed, laboratory cost and patient care., Method: A total of 110 alkaline phosphatase isoenzyme analysis requests from the year 2015 were reviewed and subsequent alkaline phosphatase concentrations were monitored over a two-year period, to determine if the decision of performing/not performing alkaline phosphatase isoenzyme analysis, based on the algorithm, had an impact on patient care and laboratory cost. All alkaline phosphatase isoenzyme analysis requests with two consecutive elevated alkaline phosphatase concentrations (>upper limit of reference interval) were screened and, subject to the gamma glutamyl transferase being within the reference interval, either Bone alkaline phosphatase or 25 hydroxyvitamin D was measured depending on the age of the patient., Results: Compliance with this algorithm led to the normalization of subsequent serum alkaline phosphatase in 97% of patients without requiring alkaline phosphatase isoenzyme analysis. The cost of performing Bone alkaline phosphatase and 25 hydroxyvitamin D in-house was £778.50, while the cost of performing alkaline phosphatase isoenzyme analysis would have been £3040. This resulted in a laboratory saving of £2261.50., Conclusions: Implementation of this algorithm led to a significant reduction in alkaline phosphatase isoenzyme analysis, without compromising patient care. Total savings could be increased if 25 hydroxyvitamin D was used as a first-line test, for all patients with an elevated alkaline phosphatase and a normal gamma glutamyl transferase regardless of age. This algorithm is cost-effective and can be implemented in laboratories with 25 hydroxyvitamin D assay.

In this study, a new extraction medium based on a quite bio-compatible and bio-degradable deep eutectic solvent comprising choline chloride and phenylethanol (ChCl: Ph-ETOH) was simply and cheaply synthesized at room temperature. At the next step, it was effectively utilized at the service of air agitated-emulsification microextraction (AA-EME) of two major amphetamine-type stimulants (ATSs) in human plasma and pharmaceutical wastewater pursued by high performance liquid chromatography-ultraviolet detection (HPLC-UV). This safe, effective, and rapid enrichment process based on the new low-density DES was easily practicable via a homemade extraction cell possessing a narrow neck and with no extra demand the emulsifier intermediates. Statistical study of main parameters effects using central composite design (CCD) combined with desirability function (DF) demonstrated that pH 12, 250 μL of extraction solvent, 8 air agitation cycles, and 5% of salt amount resulted in maximum extraction efficiencies (63-66%) with DF value close to 0.98. Under optimal conditions, wide linear dynamic ranges (LDRs) of 15.0-2000 and 8.0-3000 ng mL -1 with the determination coefficients (R 2 s) close to 0.99 were obtainable for amphetamine and methamphetamine, respectively. Low limits of detection (LODs) as well as relative standard deviations (%RSDs, n = 3) were found to be 2.0-5.0 ng mL -1 and 5.7-7.8%, respectively. Also, enrichment factors (EFs) were quantitative in the span of 47-50. On the other hand, satisfactory and accurate assessment at low levels close to therapeutic and toxic domains in human plasma sample and pharmaceutical wastewater was successfully obtained., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Blood glucose (BG) testing is the most widely performed point-of-care (POC) test in a hospital setting. Multiple adverse events reported to the Food and Drug Administration (FDA) revealed that treatment decisions may be affected by information displayed on the POC glucometer's results screen. A randomized, crossover simulation study was conducted to compare two results screen configurations for ACCU-CHEK Inform II, a POC glucometer., Methods: Prior to the study, a heuristic evaluation of the results screen configurations and a pilot study were conducted to select the two results screen configurations for comparison. At two multicampus medical centers, 66 nurse participants experienced two computer-based simulation scenarios that asked them to interpret glucometer readings and make treatment decisions for simulated patients with 32 mg/dL BG levels and subtle symptoms of hypoglycemia. One scenario displayed a numeric value ("32 mg/dL"), and the other displayed a range abbreviation, such as "RR LO" (out of reportable range; low). Treatment errors were recorded when the participant did not treat the hypoglycemic patient with glucose or when they administered insulin., Results: When ACCU-CHEK Inform II displayed an "RR LO" reading, 10.6% of participants made a treatment error, including 6.7% of participants with prior training on the meaning of an "RR LO" reading. None of the participants made a treatment error when ACCU-CHEK Inform II displayed a "32 mg/dL" reading., Conclusion: Displaying a numeric BG reading eliminated potentially life-threating treatment errors caused by confusing range abbreviations. Manufacturers should consider these findings during future research and development of POC glucometers., (Published by Elsevier Inc.)

The determination of ethanol intoxication in whole blood samples may open the opportunity for a precise and quick point-of-measurement in the ambit of medical emergency or law enforcement. In contrast with traditional techniques based on breath sampling, direct blood measurements present greater immunity to errors specially in case of unconscious or non-collaborative patients. In this context, a portable, sensitive and easy-to-use instrument is highly desirable. In the current work we present a smartphone-based µPotentiostat which combines a novel circuital technique for sensor readout digitalization with a reusable lab-on-a-chip (LoC) concept. Such system allows both chronoamperometric and cyclic voltammetry measurements with a reduced number of electronic components on a very compact PCB (38.5 × 22.5 mm 2 ). Power, data-link and user interface are provided in combination with a standard smartphone, enabling cost-effectiveness and reconfigurability without sacrificing precision. The readout platform discussed in this work has been coupled to a LoC for point-of-care combining Pt electrodes microfabricated on silicon substrate for electrochemical measurement and a microfluidic structure of methacrylate for fluid management. Biosensing is enabled by in situ electrodeposition of a calcium alginate hydrogel containing horseradish peroxidase (HPR) and alcohol oxidase (AOx) for selective ethanol detection. Alginate membrane electrodeposition has been here optimized for rapid generation (2 min) and to retain the cellular fraction, thus allowing the measurement in whole blood samples. The µPotentiostat features a sensitivity of 36 nA/g L -1 to ethanol concentration in blood in the 0-1.25 g;L -1 range, with a limit of quantification (LoQ) of 4.5 nA, which is a suitable response for discerning the legal, illegal, severely illegal thresholds in a 40 µL sample of blood., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Fever is a frequent reason for consultation in pediatric emergency departments and raises the question of biological and radiological examinations. Rapidly obtaining the result of C-reactive protein (CRP) level is essential in front of the steady increase of the number of visits. We carried out a prospective study within the pediatric emergency department of the University Hospital of Clermont-Ferrand from January to April 2017, in order to evaluate the interest of the capillary CRP in point of care (POCT). In two periods, 68 patients (28 controls without and 40 cases with capillary CRP assayed on a Afinion ® AS100) with naked fever greater than 48 hours were included. After a study of the analytical performances of Afinion ® and a verification of the homogeneity and the comparability of the two groups on clinical criteria (age, sex, duration of the fever, antibiotics treatment) and biological (values of CRP), the interest of the CRP in POCT was evaluated. In the POCT group, a significant drop in the median of the emergency room consultation time (60 (IQR 33-125) versus 180 (IQR 158-208) minutes), the number of biological acts by patient (1 (IQR 1-3) versus 7 (IQR 3-8)), the global cost of biological and radiological examinations per patient (5.4 (IQR 5.4-32.6) versus 153.8 (IQR 46.9-180.4) euros), and the cost of reagents spent by the laboratory per patient (5.2 (IQR 5.2-6.4) versus 33.2 (IQR 2.3-34.2) euros). Thus, in the context of a clinical-biological partnership, the use of CRP in POCT present a practical and an economic interest.

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., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Background and Aims: Familial hypercholesterolaemia (FH) is widely underdiagnosed. Cascade testing (CT) of relatives has been shown to be feasible, acceptable and cost-effective in the UK, but requires a supply of index cases. Feasibility of universal screening (US) at age 1-2 years was recently demonstrated. We examined whether this would be a cost-effective adjunct to CT in the UK, given the current and plausible future undiagnosed FH prevalence., Methods: Seven cholesterol and/or mutation-based US ± reverse cascade testing (RCT) alternatives were compared with no US in an incremental analysis with a healthcare perspective. A decision model was used to estimate costs and outcomes for cohorts exposed to the US component of each strategy. RCT case ascertainment was modelled using recent UK CT data, and probabilistic Markov models estimated lifetime costs and health outcomes for the cohorts screened under each alternative. 1000 Monte Carlo simulations were run for each model, and average outcomes reported. Further uncertainty was explored deterministically. Threshold analysis investigated the association between undiagnosed FH prevalence and cost-effectiveness., Results: A strategy involving cholesterol screening followed by diagnostic genetic testing and RCT was the most cost-effective modelled (incremental cost-effectiveness ratio (ICER) versus no US £12,480/quality adjusted life year (QALY); probability of cost-effectiveness 96·8% at £20,000/QALY threshold). Cost-effectiveness was robust to both deterministic sensitivity analyses and threshold analyses that modelled ongoing case ascertainment at theoretical maximum levels., Conclusions: These findings support implementation of universal cholesterol screening followed by diagnostic genetic testing and RCT for FH, under a UK conventional willingness-to-pay threshold., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Aim: To study the regional variability of requests for anaemia chemistry tests in primary care in Spain and the associated economic costs of potential over-requesting., Methods: Requests for anaemia tests were examined in a cross-sectional study. Clinical laboratories from different autonomous communities (AACCs) were invited to report on primary care anaemia chemistry tests requested during 2014. Demand for iron, ferritin, vitamin B12 and folate tests per 1000 inhabitants and the ratios of the folate/vitamin B12 and transferrin/ferritin requests were compared between AACCs. We also calculated reagent costs and the number of iron, transferrin and folate tests and the economic saving if every AACC had obtained the results achieved by the AACC with best practice., Results: 110 laboratories participated (59.8% of the Spanish population). More than 12 million tests were requested, resulting in reagent costs exceeding €16.5 million. The serum iron test was the most often requested, and the ferritin test was the most costly (over €7 million). Close to €4.5 million could potentially have been saved if iron, transferrin and folate had been appropriately requested (€6 million when extrapolated to the whole Spanish population)., Conclusions: The demand for and expenditure on anaemia chemistry tests in primary care in Spain is high, with significant regional differences between different AACCs., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Aim: Legacy methods with complex testing scheme for characterization of anti-idursulfase antibodies (ADA) were simplified and optimized in order to meet current regulatory guidance and provide more timely and cost-effective support for routine patient care., Results: To compare the performance of the original and updated methods, patient samples receiving commercially prescribed Elaprase treatment were analyzed by both test methods. The ADA and neutralizing antibody results obtained by both methods were highly correlated and the updated method had an overall higher ADA and neutralizing antibody positive rates and higher ADA titers., Conclusion: The updated methods and test schemes are much simpler, more sensitive, but are also highly comparable with the original methods for the measurement of total and neutralizing ADA.

Blood tests are ordered on a daily basis in intensive care units (ICU). There are no widely accepted guidelines for testing requirements. This study investigated the impact on ICU laboratory test costs of a multi-strategy change in practice involving routine blood testing. A single centre, prospective, interventional study using historical controls was undertaken to investigate the impact of ICU specialist authorisation of high-volume routine tests on ICU laboratory test costs. Prior to commencement of the study, ICU nursing and junior ICU doctors were able to order tests. During the six-month intervention period, the ICU specialists authorised routine blood tests. Adverse events related to not performing blood tests were also recorded. Overall ICU laboratory test costs decreased by 12.3% over the six months ( P =0.0022 versus historical control) with a mean compliance of 51% with the test authorisation protocol. The costs of frequently ordered tests (classified as high-volume) decreased by 20% ( P =0.0022 versus historical control). These accounted for an average of 54 ± 3% of the overall ICU blood test costs (blood gas analyses 17%, simple chemistry tests consisting of electrolytes, liver function, calcium, phosphate, magnesium 14%, coagulation 12% and full blood count 11%). Two protocol-related adverse events were recorded and judged as minor and were resolved by ordering tests during the day. No adverse patient outcomes resulted from these two events. Blood testing authorisation by an ICU specialist was associated with significant cost savings in ICU and no adverse patient outcomes.

Therapeutic drug monitoring (TDM) is one of the most important services of clinical laboratories. Two main techniques are commonly used: the immunoassay and chromatography method. We have developed a cost-effective system of two-dimensional liquid chromatography with ultraviolet detection (2D-LC-UV) for high-throughput determination of vancomycin in human plasma that combines the automation and low start-up costs of the immunoassay with the high selectivity and sensitivity of the liquid chromatography coupled with mass spectrometric detection without incurring their disadvantages, achieving high cost-effectiveness. This 2D-LC system offers a large volume injection to provide sufficient sensitivity and uses simulated gradient peak compression technology to control peak broadening and to improve peak shape. A middle column was added to reduce the analysis cycle time and make it suitable for high-throughput routine clinical assays. The analysis cycle time was 4min and the peak width was 0.8min. Compared with other chromatographic methods that have been developed, the analysis cycle time and peak width for vancomycin was reduced significantly. The lower limit of quantification was 0.20μg/mL for vancomycin, which is the same as certain LC-MS/MS methods that have been recently developed and validated. The method is rapid, automated, and low-cost and has high selectivity and sensitivity for the quantification of vancomycin in human plasma, thus making it well-suited for use in hospital clinical laboratories., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Introduction: Type 2 diabetes presents with numerous macrovascular and microvascular impairments, which in turn lead to various co-morbidities. Vascular co-morbidities can be seen when examining arterial stiffness (AS), which is a predictor for endothelial health and cardiovascular disease risk. Pulse wave analysis (PWA) and pulse wave velocity (PWV) are two tests that are commonly used to measure AS. Currently, disease states and progression are tracked via blood biochemistry. These gold standards in monitoring diabetes are expensive and need optimization., Research Question: To investigate which biophysical and biochemical parameters correlated best with AS, which may reduce the number of biochemical tests and biophysical parameter measurements needed to track disease progression., Methods: Data from 42 subjects with type 2 diabetes mellitus for ≤10 years, aged 40-70 years, were analyzed at a single time point. We investigated various blood biochemistry, body composition, and AS parameters., Results: A combination of fat mass and fat-free mass was most associated with PWA over any other parameters. Leptin and high-sensitivity C-reactive protein seem to be the next two parameters that correlate with augmentation index. No other parameters had strong correlations to either PWA or PWV values., Conclusions: Body composition methods seemed to be better predictors of type 2 diabetes mellitus patient's vascular disease progression. Our study indicates that body composition measurements may help replace expensive tests. This may have public health and health surveillance implications in countries facing financial challenges.

Background: Despite recommendations, many middle-age adults neglect to check their blood cholesterol levels. Short message service (SMS, also known as texting) has been seldom studied for preventive education. We estimated how SMS can be a cost-effective method in encouraging people to check their blood cholesterol levels., Methods: In a field trial, 3600 cell phone users (age > 30) were randomly assigned to the intervention (N: 1200) and the control groups (N: 2400). An SMS was sent to the intervention group for five rounds every two weeks, which targeted the cognitive and affective learning and finally advised the blood cholesterol level to be checked, if not checked during the past twelve months. Two weeks after the last round, both groups were asked for the time/level of their latest blood cholesterol, family history of early cardiac death and having a family member with coronary heart disease (CHD), and to report their attitude about whether annual blood sampling is worth the cost and time to prevent CHD. Moreover, the intervention group was asked if they remembered the SMS content. The cost-effectiveness was evaluated by estimating the "number needed to treat" (NNT) and calculating the cost of sending SMS to that number of people., Results: In the intervention group, 629 individuals (72.0%) recalled the SMS content. The factors associated with cholesterol screening during the past two years were older age, diabetes, family history of coronary disease, higher education, female gender and being non-smoker. In both groups, women were significantly more aware of their blood cholesterol level (68.7% vs. 53.6%). The relative frequency of respondents who believed it was not worth checking their cholesterol annually was significantly lower in the intervention group (P < 0.001). The intervention group was significantly more likely to check its blood cholesterol levels (OR:1.22) after adjustment for age, diabetes, family history of CHD and smoking. The NNT was estimated ≈ 25 for the general population and ≈ 11 for those who received SMS and had a family member with CHD., Conclusions: We would postulate that SMS could affect people's adherence to preventive programs. Relatives of patients admitted with a diagnosis of CHD should be prioritized for superior cost-effectiveness and logistical feasibility.

Background/objectives: Most bariatric guidelines recommend frequent lab monitoring of patients to detect nutrient and vitamin deficiencies as early as possible. The aim of this study was to optimize the cost effectiveness of the nutrient panel, by developing an algorithm, which detects nutrient deficiencies at lower costs., Subjects/methods: In this retrospective study, 2055 patients who had undergone Laparoscopic Roux-Y Gastric Bypass (LRYGB) and Laparoscopic Sleeve Gastrectomy (LSG) surgery at Catharina Hospital Eindhoven between January 2009 and December 2013 were included. Perioperative biochemical measurements (7 days before and 127 days after surgery) and measurements >549 days before surgery were excluded. For analysis, the most recent preoperative and postoperative measurements were selected for each biochemical parameter separately. First, the amount of moderate and severe deficiencies were calculated. Second, we investigated whether each variable (vitamins A, B 1 , B 6 , B 12 , D, folate, ferritin, zinc and magnesium) could predict the presence of deficiency., Results: In total, 561 (LRYGB) and 831 (LSG) patients had at least preoperative and postoperative values of vitamin A, B 1 , B 6 , B 12 , D, folate, ferritin, zinc or magnesium. The algorithm reduces vitamin D, B 12 , B 6 , B 1 and ferritin examinations by 15, 11, 28, 28 and 38%, respectively, without missing clinically relevant deficiencies. The corresponding potential cost savings was 14%., Conclusions: This study identified substantial cost savings in laboratory test for both LRYGB and LSG procedures. The potential cost reduction of 14% might even be increased to 42% when less frequent moderate deficiencies are not screened anymore, whereas >99.0 of moderate deficiencies will be detected.

Background: Unnecessary blood tests are estimated to contribute to 25% of wastage in the National Health Service. The aim of this study was to assess the financial implication of clinical need-focused blood tests guided by a senior clinician in a district general hospital., Methods: We conducted an observational longitudinal study over six months with pre- and postanalysis of a vetting intervention. A colorectal firm (Team A) implemented a vetting system that required a registrar or consultant to discuss which blood tests needed to be requested for each in-patient with junior doctors. Another colorectal firm (Team B) with a similar caseload was blinded to the study and was used as a control., Results: The vetting initiative demonstrated a reduction of 33% of blood test requests, translating to a cost-saving of £2406 over three months. Following the intervention, the median number of tests requested per patient per day by Team A for C-reactive protein reduced from 0.8 to 0.63 (P = 0.0074), full blood counts reduced from 0.8 to 0.67 (P = 0.0138), liver function tests decreased from 0.8 to 0.6 (P = 0.0021) and urea and electrolytes fell from 0.8 to 0.63 (P = 0.0083). The number of tests per patient per day after the intervention was significantly less than the control group (P < 0.001). The length of hospital stay and admission to critical care were not adversely affected in the group that had less blood tests, P = 0.808 and P = 0.58, respectively., Conclusion: The direction, by a senior clinician, of the requesting of blood tests by junior doctors to ensure that requests were based on clinical need, reduced the number of inappropriate blood tests and resulted in some reduction in laboratory costs., (© The Author(s) 2016.)

Aim: To assess the cost-effectiveness of two population-based hepatocellular carcinoma (HCC) screening programs, two-stage biomarker-ultrasound method and mass screening using abdominal ultrasonography (AUS)., Methods: In this study, we applied a Markov decision model with a societal perspective and a lifetime horizon for the general population-based cohorts in an area with high HCC incidence, such as Taiwan. The accuracy of biomarkers and ultrasonography was estimated from published meta-analyses. The costs of surveillance, diagnosis, and treatment were based on a combination of published literature, Medicare payments, and medical expenditure at the National Taiwan University Hospital. The main outcome measure was cost per life-year gained with a 3% annual discount rate., Results: The results show that the mass screening using AUS was associated with an incremental cost-effectiveness ratio of USD39825 per life-year gained, whereas two-stage screening was associated with an incremental cost-effectiveness ratio of USD49733 per life-year gained, as compared with no screening. Screening programs with an initial screening age of 50 years old and biennial screening interval were the most cost-effective. These findings were sensitive to the costs of screening tools and the specificity of biomarker screening., Conclusion: Mass screening using AUS is more cost effective than two-stage biomarker-ultrasound screening. The most optimal strategy is an initial screening age at 50 years old with a 2-year inter-screening interval.

The assessment of the fibrotic evolution of chronic hepatitis has always been a challenge for the clinical hepatologist. Over the past decade, various non-invasive methods have been proposed to detect the presence of fibrosis, including the elastometric measure of stiffness, panels of clinical and biochemical parameters, and combinations of both methods. The aim of this review is to analyse the most recent data on non-invasive techniques for the evaluation of hepatic fibrosis with particular attention to cost-effectiveness. We searched for relevant studies published in English using the PubMed database from 2009 to the present. A large number of studies have suggested that elastography and serum markers are useful techniques for diagnosing severe fibrosis and cirrhosis and for excluding significant fibrosis in hepatitis C virus patients. In addition, hepatic stiffness may also help to prognosticate treatment response to antiviral therapy. It has also been shown that magnetic resonance elastography has a high accuracy for staging and differentiating liver fibrosis. Finally, studies have shown that non-invasive methods are becoming increasingly precise in either positively identifying or excluding liver fibrosis, thus reducing the need for liver biopsy. However, both serum markers and transient elastography still have "grey area" values of lower accuracy. In this case, liver biopsy is still required to properly assess liver fibrosis. Recently, the guidelines produced by the World Health Organization have suggested that the AST-to-platelet ratio index or FIB-4 test could be utilised for the evaluation of liver fibrosis rather than other, more expensive non-invasive tests, such as elastography or FibroTest.

Objective: In order to reduce invasive testing in newborns prior to discharge, we tested the direction of the correlation between transcutaneous bilirubin (TcB) and total serum bilirubin (TSB), the likelihood of missing high TSBs with a raised threshold for confirmatory testing, and also calculated potential cost savings from fewer laboratory testing., Methods: We performed a cross-sectional analysis of single paired TcB and TSB results measured at 36 ± 2 h of life in neonates ≥37 weeks admitted only to the Level 1 nursery. TcB was measured using the BiliChek® meter., Results: Of the 552 infants, 512 (92.8%) had TSB levels below TcB values. Correlation between TcB and TSB was 0.69. If TSB confirmation was to be performed at 11.7 mg/dL (medium risk threshold for phototherapy), the negative predictive value was 99.4%, with a potential cost savings of $6555.00 ($1500.00 per 100 patients). Of the 495 infants with TcB <11.7 mg/dL, only 3 had TSB levels higher than 11.7 mg/dL, and none met phototherapy threshold for low risk infants., Conclusions: TcB screening at our institution has a high negative predictive value, and can be used as a stand-alone test until values are close to phototherapy threshold, thus reducing invasive testing and cost.

Background: Primary aldosteronism (PA) is a common and underdiagnosed disease with significant morbidity potentially cured by surgery. We aim to assess if the long-term cardiovascular benefits of identifying and treating surgically correctable PA outweigh the upfront increased costs in patients at the time patients are diagnosed with resistant hypertension (RH)., Methods and Results: A decision-analytic model compares aggregate costs and systolic blood pressure changes of 6 recommended or implemented diagnostic strategies for PA in a simulated population of at-risk RH patients. We also evaluate a 7th "treat all" strategy wherein all patients with RH are treated with a mineralocorticoid-receptor antagonist without further testing at RH diagnosis. Changes in systolic blood pressure are subsequently converted into gains in quality-adjusted life years (QALYs) by applying National Health and Nutrition Examination Survey data on concomitant risk factors to an existing cardiovascular disease simulation model. QALYs and lifetime costs were then used to calculate incremental cost-effectiveness ratios for the competing strategies. The incremental cost-effectiveness ratio for the strategy of computerized tomography (CT) followed by adrenal venous sampling (AVS) was $82,000/QALY compared with treat all. Incremental cost-effectiveness ratios for CT alone and AVS alone were $200,000/QALY and $492,000/QALY; the other strategies were more costly and less effective. Integrating differential patient-reported health-related quality of life adjustments for patients with PA, and incremental cost-effectiveness ratios for screening patients with CT followed by AVS, CT alone, and AVS alone were $52,000/QALY, $114,000/QALY, and $269,000/QALY gained., Conclusions: CT scanning followed by AVS was a cost-effective strategy to screen for PA among patients with RH., (© 2015 American Heart Association, Inc.)

Cardiac natriuretic peptides (BNP, NT-proBNP) play a pivotal role in cardiovascular homeostasis, mainly due to their roles in vasodilatation, natriuresis, diuresis and due to their antiproliferative properties. Proper measurement of the natriuretic peptide levels may help differentiate between respiratory and cardiac forms of dyspnea, diagnose early forms of heart failure, evaluate severity of heart failure (prognosis) and monitor the efficacy of therapy. In many countries natriuretic peptide levels are being used as one of the earliest diagnostics tools to evaluate the involvement of the heart. Current theoretical and clinical data confirm the importance of natriuretic peptides in routine healthcare. These roles are clearly described in international recommendations and guidelines. In the current review the authors discuss the problems of the measurement of natriuretic peptides in Hungary, including several aspects related to laboratory medicine, cardiology and health economy.

Background & Aims: Trace elements (TE) are involved in the immune and antioxidant defences which are of particular importance during critical illness. Determining plasma TE levels is costly. The present quality control study aimed at assessing the economic impact of a computer reminded blood sampling versus a risk guided on-demand monitoring of plasma concentrations of selenium, copper, and zinc., Methods: Retrospective analysis of 2 cohorts of patients admitted during 6 months periods in 2006 and 2009 to the ICU of a University hospital., Inclusion Criteria: to receive intravenous micronutrient supplements and/or to have a TE sampling during ICU stay. The TE samplings were triggered by computerized reminder in 2006 versus guided by nutritionists in 2009., Results: During the 2 periods 636 patients met the inclusion criteria out of 2406 consecutive admissions, representing 29.7% and 24.9% respectively of the periods' admissions. The 2009 patients had higher SAPS2 scores (p = 0.02) and lower BMI compared to 2006 (p = 0.007). The number of laboratory determinations was drastically reduced in 2009, particularly during the first week, despite the higher severity of the cohort, resulting in à 55% cost reduction., Conclusions: The monitoring of TE concentrations guided by a nutritionist resulted in a reduction of the sampling frequency, and targeting on the sickest high risk patients, requiring a nutritional prescription adaptation. This control leads to cost reduction compared to an automated sampling prescription., (Copyright © 2014. Published by Elsevier Ltd.)

Introduction: Arterial blood gas analysis is relevant in chronic obstructive pulmonary disease (COPD) management. The aim of this study was to evaluate whether the use of a blood gas analyzer in pulmonology departments improves the clinical, operational and economic outcomes when compared with clinical laboratory measurements., Patients and Methods: It is an observational prospective study. 112 patients were selected. After specimen collection, the measurement was performed both in pulmonology office as point-of-care and in laboratory. We evaluated clinical outcomes (modification of the indication of long-term oxygen therapy (LTOT) according to results, changes in blood gas analysis results, relationship of the partial pressure of oxygen (PaO2) obtained in the medical visit and velocity of change of the PaO2, influence of total haemoglobin concentration and the change in PaO2), operational outcomes (turnaround time (TAT) from specimen collection to receiving the blood gas analysis report) and economic outcomes (overall cost per process of patient care)., Results: There were discrepancies in the indication of LTOT in 13.4% of patients. All parameters showed changes. PaO2 levels showed changes in 2 ways, though they frequently increase over time. The correlation was not good in the other two clinical outcomes. The median TATs in pulmonology office were 1 min versus 79 in laboratory, with 52 min for specimen preparation and transport and 17 min for TAT intralaboratory. The overall cost for the 112 patients in pulmonology office and laboratory was 16,769.89€ and 22,260.97€ respectively., Conclusions: The use of a blood gas analyzer in a pulmonology office improves clinical, operational and economic outcomes when compared with clinical laboratory., (Copyright © 2014 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.)

Background: Whether or not antibiotic stewardship protocols based on procalcitonin levels results in cost savings remains unclear. Herein, our objective was to assess the economic impact of adopting procalcitonin testing among patients with suspected acute respiratory tract infection (ARI) from the perspective of a typical US integrated delivery network (IDN) with a 1,000,000 member catchment area or enrollment., Methods: To conduct an economic evaluation of procalcitonin testing versus usual care we built a cost-impact model based on patient-level meta-analysis data of randomized trials. The meta-analytic data was adapted to the US setting by applying the meta-analytic results to US lengths of stay, costs, and practice patterns. We estimated the annual ARI visit rate for the one million member cohort, by setting (inpatient, ICU, outpatient) and ARI diagnosis., Results: In the inpatient setting, the costs of procalcitonin-guided compared to usual care for the one million member cohort was $2,083,545, compared to $2,780,322, resulting in net savings of nearly $700,000 to the IDN for 2014. In the ICU and outpatient settings, savings were $73,326 and $5,329,824, respectively, summing up to overall net savings of $6,099,927 for the cohort. RESULTS were robust for all ARI diagnoses. For the whole US insured population, procalcitonin-guided care would result in $1.6 billion in savings annually., Conclusions: Our results show substantial savings associated with procalcitonin protocols of ARI across common US treatment settings mainly by direct reduction in unnecessary antibiotic utilization. These results are robust to changes in key parameters, and the savings can be achieved without any negative impact on treatment outcomes.

Analytical techniques used to quantify neurosteroids in biological samples are often compromised by non-specificity and limited dynamic range which can result in erroneous results. A relatively rapid and inexpensive gas chromatography-mass spectrometry (GC-MS) was developed to simultaneously measure nine neurosteroids, including allopregnanolone, estradiol, and progesterone, as well as 25-hydroxy-vitamin D3 in plasma samples collected from adult women subjects during and after pregnancy. Sample preparation involved solid-phase extraction and derivatization, followed by automated injection on a GC equipped with a mass selective detector (MSD) operated in single ion monitoring (SIM) mode to yield a run time of less than 11min. Method detection limits for all neurosteroids ranged from 30 to 200pg/mL (parts per trillion), with coefficients of variation that ranged from 3% to 5% based on intra-assay comparisons run in triplicate. Although concentrations of estradiol measured by chemiluminescent immunoassay (CIA) were consistent with values determined by GC-MS values, CIA yielded considerable higher values of progesterone, suggesting antibody cross reactions resulting from low specificity. Mean neurosteroid levels and representative time-course data demonstrate the ability of the method to quantify changes in multiple neurosteroids during pregnancy, including rapid declines in neurosteroid levels associated with delivery. This simplified GC-MS method holds particular promise for research and clinical laboratories that require simultaneous quantification of multiple neurosteroids, but lack the resources and expertise to support advanced liquid chromatography-tandem mass spectrometry facilities., (Copyright © 2015. Published by Elsevier Inc.)

Introduction: Since Canada began fortifying grain products with folic acid in 1998, the rate of folate deficiency in outpatients has decreased substantially. Limited data exist on the prevalence of folate deficiency in Canadian hospital inpatients., Methods: The electronic patient record at a large urban academic institution was reviewed for all red blood cell folate and vitamin B12 level tests performed on inpatients between January 1 and December 31, 2010. Chart reviews were performed on patients found to have folate deficiency to determine the indication for folate testing and the etiology of deficiency., Results: There were 2563 red blood cell folate and 3154 vitamin B12 level tests performed in 2010. Of these, only 4 (0.16%) red blood cell folate levels were in the deficient range (<254 nmol/L), compared with 98 (3.1%) and 426 (13.5%) vitamin B12 levels that were in the deficient (<138 pmol/L) and intermediate (138-221 pmol/L) range, respectively. Of the 4 patients with folate deficiency, the etiology appeared to be alcohol abuse in one, a malabsorption syndrome in the second, decreased oral intake due to schizophrenia in the third, with the final low folate level appearing to be spurious. At a cost of $12.54 per test, $32,140 could be saved each year at this institution if red blood cell folate testing on inpatients was restricted., Conclusion: Folate deficiency in inpatients is nearly nonexistent, while an appreciable number of patients have low/intermediate vitamin B12 levels. Significant savings could be achieved by eliminating folate testing on inpatients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background and Objective: Hypomagnesemia, defined as a serum magnesium (Mg) level<1.5 mg/dL (0.62 mmol/L), is often asymptomatic. The goals of this study were to determine the incidence of clinically significant abnormal Mg levels in the inpatient setting and to identify diagnoses for which testing would be diagnostically helpful., Methods: We obtained data from 2010 through 2011 on charges for serum Mg levels and Mg supplementation for all non-ICU inpatients from the 43 tertiary care children's hospitals in the Pediatric Health Information System database. A manual chart review was performed for all patients at our institution with charges for both Mg levels and Mg supplementation., Results: A median of 13.5% (interquartile range: 7.7-22.1) of non-ICU inpatients from Pediatric Health Information System centers had charges for Mg levels, at a total charge of $41 million in the 2010-2011 period. At our institution, 19.1% of non-ICU inpatients had charges for Mg levels, at a charge of $67.32/patient-day. Of the 4608 patients with Mg laboratory charges at our institution, 171 (3.7%) had an intervention, defined as addition or modification of an Mg supplement dose in response to a serum Mg level. The 4 most common groups of diagnoses (oncologic, abdominal surgery requiring total parenteral nutrition, solid organ transplant, and short bowel syndrome) accounted for 143 (83.6%) of these interventions., Conclusions: Serum Mg levels were frequently ordered in non-ICU inpatients, but levels were seldom abnormal and rarely resulted in changes in clinical management. These findings raise concerns about resource overutilization and provide a target for more judicious laboratory ordering practices., (Copyright © 2015 by the American Academy of Pediatrics.)

Unlabelled: Falls and fractures constitute a major cause of morbidity and mortality among older adults. Although falls and fractures share similar risk factors, there is no integrated approach to identifying secondary causes of both entities. We report a cost-effective approach to identify metabolic causes of falls and fractures in the clinical setting., Purpose: Falls and fractures are a major cause of morbidity and mortality among older adults. Metabolic disorders contributing to the combined risk of falls and fractures are frequent but often go undetected. The most efficient and cost-effective laboratory screening strategy to unmask these disorders remains unknown. The purpose of this study was to identify the most cost-effective laboratory tests to detect undiagnosed metabolic contributors and to decide treatment of these disorders in older persons., Methods: This is a cross-sectional study design, which included all participants attending the Falls & Fractures Clinic, Nepean Hospital (Penrith, Australia) between 2008 and 2013. Chemistry profile included 25(OH) vitamin D, parathyroid hormone (PTH), albumin, creatinine, calcium, phosphate, vitamin B-12, folate, and thyroid-stimulating hormone (TSH) for all patients, and serum testosterone in men. The number of new diagnoses identified and their cost-effectiveness (cost in US$ per patient screened and cost per new diagnosis) were calculated., Results: A total of 739 participants (mean age 79, 71 % female) were assessed. Among 233 participants with complete laboratory tests, previously undiagnosed disorders were identified in 148 (63.5 %). Vitamin D deficiency (27 %) and hyperparathyroidism (21.5 %) were the most frequent diagnoses. A testing strategy including serum vitamin D, calcium, PTH, creatinine/estimated glomerular filtration rate (eGFR), and TSH for all patients and serum testosterone in men would have been sufficient to identify secondary causes of falls and fractures in 94 % of patients at an estimated cost of $190.19 per patient screened and $257.64 per diagnosis., Conclusions: The minimum cost-effective battery for occult metabolic disorders in older adults at risk of falls and fractures should include serum vitamin D, PTH, TSH, creatinine/eGFR, testosterone (in men), and calcium.

Background: Early notification of critical values by the clinical laboratory to the treating physician is a requirement for accreditation and is essential for effective patient management. Many laboratories automatically repeat a critical value before reporting it to prevent possible misdiagnosis. Given today's advanced instrumentation and quality assurance practices, we questioned the validity of this approach. We performed an audit of repeat-testing in our laboratory to assess for significant differences between initial and repeated test results, estimate the delay caused by repeat-testing and to quantify the cost of repeating these assays., Methods: A retrospective audit of repeat-tests for sodium, potassium, calcium and magnesium in the first quarter of 2013 at Tygerberg Academic Laboratory was conducted. Data on the initial and repeat-test values and the time that they were performed was extracted from our laboratory information system. The Clinical Laboratory Improvement Amendment criteria for allowable error were employed to assess for significant difference between results., Results: A total of 2308 repeated tests were studied. There was no significant difference in 2291 (99.3%) of the samples. The average delay ranged from 35 min for magnesium to 42 min for sodium and calcium. At least 2.9% of laboratory running costs for the analytes was spent on repeating them., Conclusions: The practice of repeating a critical test result appears unnecessary as it yields similar results, delays notification to the treating clinician and increases laboratory running costs.

Noncommunicable diseases (NCDs), including cardiovascular diseases and diabetes, have emerged as an underappreciated health threat with enormous economic and public health implications for populations in low-resource settings. In order to address these diseases, devices that are to be used in low-resource settings have to conform to requirements that are generally more challenging than those developed for traditional markets. Characteristics and issues that must be considered when working in low- and middle-income countries (LMICs) include challenging environmental conditions, a complex supply chain, sometimes inadequate operator training, and cost. Somewhat counterintuitively, devices for low-resource setting (LRS) markets need to be of at least as high quality and reliability as those for developed countries to be setting-appropriate and achieve impact. Finally, the devices need to be designed and tested for the populations in which they are to be used in order to achieve the performance that is needed. In this review, we focus on technologies for primary and secondary health-care settings and group them according to the continuum of care from prevention to treatment.