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Background: Blood-based biomarker tests can potentially change the landscape of colorectal cancer (CRC) screening. We characterize the conditions under which blood test screening would be as effective and cost-effective as annual fecal immunochemical testing or decennial colonoscopy., Methods: We used the 3 Cancer Information and Surveillance Modeling Network-Colon models to compare scenarios of no screening, annual fecal immunochemical testing, decennial colonoscopy, and a blood test meeting Centers for Medicare & Medicaid (CMS) coverage criteria (74% CRC sensitivity and 90% specificity). We varied the sensitivity to detect CRC (74%-92%), advanced adenomas (10%-50%), screening interval (1-3 years), and test cost ($25-$500). Primary outcomes included quality-adjusted life-years (QALY) gained from screening and costs for a US average-risk cohort of individuals aged 45 years., Results: Annual fecal immunochemical testing yielded 125-163 QALY gained per 1000 at a cost of $3811-$5384 per person, whereas colonoscopy yielded 132-177 QALY gained at a cost of $5375-$7031 per person. A blood test with 92% CRC sensitivity and 50% advanced adenoma sensitivity yielded 117-162 QALY gained if used every 3 years and 133-173 QALY gained if used every year but would not be cost-effective if priced above $125 per test. If used every 3 years, a $500 blood test only meeting CMS coverage criteria yielded 83-116 QALY gained at a cost of $8559-$9413 per person., Conclusion: Blood tests that only meet CMS coverage requirements should not be recommended to patients who would otherwise undergo screening by colonoscopy or fecal immunochemical testing because of lower benefit. Blood tests need higher advanced adenoma sensitivity (above 40%) and lower costs (below $125) to be cost-effective., (© The Author(s) 2024. Published by Oxford University Press.)

Background: Diagnostic blood tests have the potential to identify lung cancer in people at high risk. We assessed the cost-effectiveness of a lung cancer screening intervention, using the EarlyCDT ® -Lung Test (ECLS) with subsequent X-ray and low-dose chest CT scans (LDCT) for patients with a positive test result, compared to both usual care and LDCT screening for the target population., Methods: We conducted a model-based lifetime analysis from a UK NHS and personal social services perspective. We estimated incremental net monetary benefit (NMB) for the ECLS intervention compared to no screening and to LDCT screening., Results: The incremental NMB of ECLS intervention compared to no screening was GBP 33,179 (95% CI: -GBP 81,396, GBP 147,180) and GBP 140,609 (95% CI: -GBP 36,255, GBP 316,612), respectively, for a cost-effectiveness threshold of GBP 20,000 and GBP 30,000 per quality-adjusted life year. The same figures compared with LDCT screening were GBP 162,095 (95% CI: GBP 52,698, GBP 271,735) and GBP 52,185 (95% CI: -GBP 115,152, GBP 219,711)., Conclusions: The ECLS intervention is the most cost-effective screening alternative, with the highest probability of being cost-effective, when compared to no screening or LDCT screening. This result may change with modifications of the parameters, suggesting that the three alternatives considered in the main analysis are potentially cost-effective., Competing Interests: All authors report grants from Oncimmune Ltd., and grants from the Scottish Government Health & Social Care Directorate of the Chief Scientist Office (CSO), during the conduct of the study.

Background: Hemoglobin (Hgb) levels are frequently checked through venipuncture [invasive hemoglobin (iHgb)] in pediatric orthopaedic patients after high blood loss procedures. This needlestick may causes further anxiety and fear in hospitalized children. Noninvasive hemoglobin (nHgb) monitoring has been effectively utilized in the adult intensive care and postoperative total joint arthroplasty setting. nHgb monitoring has not yet been validated in children for routine postoperative Hgb assessment in pediatric orthopaedics., Methods: In this prospective study, 46 pediatric orthopaedic patients were enrolled who were undergoing surgery and postoperative standard of care iHgb testing. On postoperative day 1, Hgb levels were obtained through venipuncture and nHgb monitor (Pronto-7; Masimo) within a 2-hour period. Patient preferences, iHgb and nHgb values, time to result, and provider preferences were recorded. Cost data were estimated based on the standard Medicare payment rates for lab services versus the cost of nHgb probe., Results: nHgb results were obtained after 1 attempt in 38 patients (83%), after multiple attempts in 7 patients (15%), and could not be obtained in 1 patient. The mean time to obtain nHgb value was significantly shorter than that to obtain iHgb results (1.3±1.5 vs. 40±18.1 min; P <0.0001). The mean nHgb value was significantly higher than the mean iHgb value (11.7±1.5 vs. 10.6±1.1 g/dL, P <0.0001). nHgb exceeded iHgb by 2 g/dL or more in 12 (26%) patients (2.64±0.9 vs. 0.54±0.84 g/dL; P <0.0001). The concordance correlation coefficient between the 2 Hgb methods was 0.59, indicating moderate agreement. Forty-three (93%) of our patients and 34 (74%) of the care providers preferred nHgb over iHgb if results were equivalent. At our institution, the cost per iHgb monitoring is approximately $28 per blood draw as compared with $5 for nHgb monitoring. Interestingly, no patients required postoperative transfusion during the study period, as asymptomatic patients with no cardiac disease are typically observed unless the Hgb is <6., Conclusions: nHgb monitoring in postoperative pediatric patients overestimated Hgb levels compared with the standard of care methods; however, nHgb had high patient and provider satisfaction and had moderate agreement with iHgb. As no patients required transfusion, postoperative Hgb checks could likely be discontinued in some portion of our population., Level of Evidence: Level Ib-Diagnostic study., Competing Interests: Outside of the study, T.A.M. reports consulting activities with Orthopediatrics, Medtronic, Zimmer, and stock ownership in Viking Scientific. A.N.L. reports consulting activities with Orthopediatrics, Medtronic, Zimmer, and Globus. The remaining authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To discuss the clinical significance of HCV-cAg testing in the diagnosis, activity determination, and monitoring of therapeutic effectiveness of HCV infection and its advantages compared with HCV-RNA and anti-HCV antibodies detection., Methods: By summarizing the published literature, the advantages and significance of HCV core antigen detection were sought., Results: The expression of HCV-cAg is highly consistent with that of HCV-RNA, but compared with HCV-RNA, detection of HCV-cAg is easy to operate, time saving, and low cost. HCV-cAg can be detected within 12~15 days after infection, and the window period can be shortened by5~7 weeks. HCV-cAg is a serological indicator of virus replication, which can distinguish previous infection of HCV or current infection. HCV-cAg detection is more suitable for immunocompromised, hemodialysis, organ transplant patients. HCV-cAg also can be used to monitor antiviral efficacy and predict sustained virological response (SVR)., Conclusion: HCV core antigen has similar clinical sensitivity to NAT and can be used as a substitute for HCV-RNA in the diagnosis of virus infection. Combined detection of HCV-cAg and antibody serology can help doctors detect HCV infection earlier, accurately diagnose different stages of HCV infection, and evaluate the therapeutic effect of antiviral drugs, which are beneficial in the prevention and treatment of hepatitis C., (© 2021 The Authors. Journal of Clinical Laboratory Analysis published by Wiley Periodicals LLC.)

Background: Laboratory testing forms an important part of diagnostic investigation in modern medicine; however, the overuse of 'routine blood tests' can result in significant potential harm and financial cost to the patient and the healthcare system. In 2018, a new protocol targeting the ordering of investigations was implemented within the General Surgical Teams of Wollongong Hospital in New South Wales, an Australian tertiary referral hospital, to reduce the number of 'routine blood tests' as a quality improvement initiative., Objective: To identify whether there was a reduction in the number of 'routine blood tests' and associated costs following implementation of the new protocol., Methods: The protocol involved regular review of the laboratory investigations being ordered for the following day with a senior team member. The medical records of all patients admitted under the general surgery service at Wollongong Hospital were retrospectively reviewed over two 10-week periods in 2017 and 2018 (control and study, respectively). The casemix was categorized into Minor, Intermediate, Major or Unscored, depending on case complexity coding., Results: A total of 838 patients were identified during the control period (2017) and 805 patients were identified during the study period (2018). Ten thousand and thirty tests were included in the control period, compared to 8610 over the study period, resulting in a 16% (or greater) reduction in 'routine blood tests' per patient, per day of admission and a 6% reduction in costs in the study group (P < 0.001)., Conclusion: Targeted ordering of investigations with personalized education and feedback to junior staff during review of clinical status of each patient as a part of normal workflow can reduce inappropriate ordering of 'routine blood tests' and associated costs to the patient and the healthcare system., (© The Author(s) 2021. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and Aims: COVID-19 pandemic has strained the health infrastructure globally, providing an opportunity to identify cost-effective biomarkers. We aimed to identify simple hematological prognostic markers in hospitalized severe COVID-19 patients with and without diabetes., Methods: Retrospective study of RT-PCR confirmed hospitalized severe COVID-19 patients (total: n = 154 patients, including diabetic subset n = 57) were analyzed. Clinically applicable cut-offs were derived using receiver operating characteristic (ROC) curve analysis for total leucocyte count (TLC), absolute neutrophil count (ANC), neutrophil lymphocyte ratio (NLR), and derived neutrophil lymphocyte ratio (dNLR) in order to prognosticate the outcome., Results: Among 154 severe COVID-19 patients, significant association with mortality was seen with respect to TLC(p < 0.001), ANC (p < 0.001), NLR(p < 0.001) and dNLR(p < 0.001). In the total cohort, applicable cut-offs based on ROC curve in predicting outcome were, for TLC 8950 cells/mm 3 (area under curve (AUC)-0.764, odds ratio (OR)-7.53), ANC 7679 cells/mm 3 (AUC-0.789, OR-8.14), NLR 5.13 (AUC-0.741, OR-4.77), dNLR 3.44 (AUC -0.741, OR-4.43) respectively.In diabetic subset, the cut-offs for TLC was 8950 cells/mm 3 (AUC -0.762, OR-14.9), ANC 6510 cells/mm 3 (AUC -0.773, OR-16.8), NLR 5.13(AUC -0.678, OR-6) and dNLR 3.25(AUC -0.685, OR-4.7) respectively., Conclusions: In severe COVID-19 patients irrespective of diabetes, a simple, applicable total leucocyte count cut-off, 8950 cells/mm 3 , together with easily derived cut-offs for ANC, NLR, dNLR may serve as cost-effective prognosticators of clinical outcome. A normal TLC may be misleading in the intensive care and the above applicable cut-off for TLC serves as an early warning tool for high-risk identification and better in-hospital management. Even with similar or lower cut-offs, diabetics had a higher mortality., (Copyright © 2021 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Aims: In Malaysia, majority anti-HCV positive haemodialysis patients do not undergo hepatitis C confirmation due to the high cost of HCV RNA. HCV Core Antigen might be a cost-effective diagnostic test to identify HD patients who have active HCV infection eligible for Direct Acting Anti-viral therapy., Methods: A cross-sectional study was conducted to assess the correlation between HCV Ag and HCV RNA and the cost implications of different diagnostic algorithms to diagnose active HCV infection using Anti-HCV, HCV Ag, and HCV RNA. Pre-dialysis blood was tested for both HCV Ag and HCV RNA. HCV Ag was tested with Abbott ARCHITECT HCV Ag test., Results: Two-hundred twenty-seven haemodialysis patients were recruited from 20 centres with mean age of 57.68 ± 12.48 years, and male constitutes 56.8% (129) of the study population. HCV Ag correlated well with HCV RNA (Spearman test coefficient 0.943, p < .001) with sensitivity of 93.9%, specificity 99.3%, and the accuracy was 97.36%. Cost analysis indicated that a sequential test involving Anti-HCV antibody as initial screening, followed by HCV Ag on Anti-HCV positive and HCV RNA on HCV Ag negative cases translated to a modest cost-saving algorithm compared to standard diagnostic algorithm., Conclusion: HCV Ag correlated well with HCV RNA and can potentially be fused in an alternative diagnostic algorithm to generate cost savings methods to diagnose active HCV infection among haemodialysis patients. This alternative algorithm is especially relevant in low to middle-income countries such as Malaysia to optimize the use of the healthcare resource and gains in clinical outcomes., (© 2021 Asian Pacific Society of Nephrology.)

Background : Hospitalists at our institution have taken on most non-intensive care unit (ICU) coronavirus disease 2019 (COVID-19) care. Based on sparse research, our institution developed a protocol for ordering labs for this patient population, including routine admission labs in addition to eight COVID-19-specific daily labs. The study goal is to determine if COVID-19-specific admission labs have any prognostic value beyond that provided by routine admission labs and vitals, and costs of labs with no prognostic value. Methods : We retrospectively reviewed adult patients admitted with COVID-19 from 3/2020 to 7/2020. Outcomes were mortality, ICU stay, and length of hospitalization. Multivariable logistic and linear regression were used to determine if COVID-19-specific admission labs have any prognostic value beyond that provided by vitals and routine admission labs. COVID-19-specific labs were d-Dimer, fibrinogen, ferritin, LDH, CK, pro-BNP, troponin, and CRP. Multivariable models included all routine admission labs and vitals. COVID-19-specific admission labs were included in the multivariable models if the p-value was <0.05 in the univariable analysis. Results : 331 patients met study criteria, inpatient mortality was 13.0%, 52.4% of patients required ICU stays and the average length of hospitalization was 8.9 days. COVID-19-specific labs showed no additional prognostic value for mortality. CRP, LDH, and d-Dimer provided additional prognostic information for ICU stay. CRP≥100 mg/dL and LDH≥900 U/L were associated with increased length of hospitalization. Conclusion : Only 3 of 8 admission COVID-19-specific labs recommended by our institution's protocol had additional prognostic value beyond that provided by routine labs and vitals. The total cost of non-prognostic COVID-19-specific labs during the study period was $75,874.

Objectives: There is a need to improve efficiency in healthcare delivery without compromising quality of care. One approach is the development and evaluation of behavioural strategies to reduce unnecessary use of common tests. However, there is an absence of evidence on patient attitudes to the use of such approaches in the delivery of care. Our objective was to explore patient acceptability of a nudge-type intervention that aimed to modify blood test requests by hospital doctors., Study Design: Single-centre qualitative study., Methods: The financial costs of common blood tests were presented to hospital doctors on results reports for 1 year at a hospital. Focus group discussions were conducted with recent inpatients at the hospital using a semi-structured question schedule. Discussions were transcribed and analysed using qualitative content analysis to identify and prioritise common themes explaining attitudes to the intervention approach., Results: Three focus groups involving 17 participants were conducted. Patients were generally apprehensive about the provision of blood test cost feedback to doctors. Attitudes were organised around themes representing beliefs about blood tests, the impact on doctors and their autonomy, and beliefs about unnecessary testing. Patients thought that blood tests were important, powerful and inexpensive, and cost information could place doctors under additional pressure., Conclusion: The findings identify predominantly positive beliefs about testing and negative attitudes to the use of financial costs in the decision-making of hospital doctors. Public discussion and education about the possible overuse of common tests may allow more resources to be allocated to evidence-based healthcare, by reducing the perception that such strategies to improve healthcare efficiency negatively impact on quality of care., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background-Aim: Measurement of serum thyrotropin is currently the recommended test for the screening of thyroid dysfunction, while serum free thyroxine is kept as a reflex test. In our laboratory, the strategy followed in adult individuals from Primary Care includes a 'safety margin' for requests with a thyrotropin ≤1.0 or ≥4.0 mIU/L (normal: 0.35-4.95 mIU/L). Our aim was to optimize the thyrotropin cut-off values for the addition of free thyroxine and, based on these cut-offs, to retrospectively analyze avoidable free thyroxine measurements and possible adverse clinical consequences., Methods: Retrospective observational study performed in a tertiary care hospital between 2013 and 2018. We considered all laboratory requests for screening of thyroid dysfunction (TD) in adult patients from Primary Care. Requests from patients with a previous diagnosis of thyroid disease or pregnant women were excluded. Different receiver operating characteristic (ROC) curves were performed and the obtained thyrotropin cut-off values were compared. Economic savings were assessed considering the current cost of free thyroxin assays in our laboratory., Results: From a total of 554,529 TD protocols included, 119,504 requests had free thyroxine added. From the ROC curve that enables ≥95% of abnormal free thyroxine results to be detected, the thyrotropin values obtained were ≥4.58 mIU/L and ≤0.94 mIU/L. These thyrotropin cut-off values would lead to a saving of 22.7% of annual free thyroxine measurements without adverse clinical consequences., Discussion: Setting optimized thyrotropin cutoffs for reflex testing of free thyroxine would reduce the need for this test. Clinical laboratories need to offer not only true results, but also become the cornerstone in the optimization of resources., Competing Interests: Declaration of Competing Interest All authors declare no conflicts of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Alopecia areata (AA) is a chronic inflammatory disease characterized by non-cicatricial hair loss. The cause of the disease is still unknown. It can appear at any age and occurs in 0.2% of the general population. Red cell distribution width (RDW), mean platelet volume (MPV), plateletcrit (PCT), the ratio of neutrophils to lymphocytes (NLR), and the ratio of platelets to lymphocytes (PLR) have all been reported as inflammatory markers in recent studies. However, these parameters have not been investigated in AA patients., Aim: We investigated the haematological and inflammatory parameters of AA and considered their association with disease severity., Patients/methods: One hundred and five patients with AA and 108 healthy controls were enrolled in the study. RDW, MPV, PCT, NLR, PLR, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were studied retrospectively. Disease severity was evaluated by using the Severity of Alopecia Tool (SALT) score., Results: There were no statistically significant differences between RDW, MPV, PCT, NLR, and PLR levels in AA patients and in healthy controls. Only the CRP values were significantly higher in the AA group., Conclusion: Complete blood count (CBC) parameters are low-cost tests that can be used to define inflammation levels in inflammatory diseases. Our study shows that CRP can be used as a marker in diagnosing AA., (© 2019 Wiley Periodicals, Inc.)

Tuberculosis remains one of the deadliest infectious diseases worldwide. Only 5-15% of people infected with Mycobacterium tuberculosis develop active TB disease (ATB), while others remain latently infected (LTBI) during their lifetime, which has a completely different clinical treatment schedule. However, most current clinical diagnostic methods are based on the immune response of M. tuberculosis infections and cannot distinguish ATB from LTBIs. Thus, the rapid diagnosis of active or latent tuberculosis infections remains a serious challenge for clinicians. In this work, based on the test data of a total of 478 patients, 36 blood biochemical data were specially included with T-SPOT.TB detection results which are all from routine clinical practice as commercially available. Then a discrimination method to detect ATB infections was successfully developed based on these data by the random forest algorithm. This method presents a robust classification performance with AUC as 0.9256 and 0.8731 for the cross-validation set and the external validation set, respectively. This work suggests an innovative strategy for identification of ATB disease from a single drop of blood with advantages of being timely, efficient, and economical. It also provides valuable information for the comprehensive understanding of TB with deep associations between TB infection and routine blood test data. The web server of this identification method, called ATBdiscrimination, is now available online at http://lishuyan.lzu.edu.cn/ATB/ATBdiscrimination.html .

Study Design: Retrospective comparative study., Objectives: We aimed to characterize the frequency of perioperative laboratory tests for posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and to assess whether test results affected clinical management., Summary of Background Data: Perioperative laboratory tests for PSF including complete blood count, coagulation laboratory tests, basic metabolic panels (BMPs), and type and screen, are commonly ordered based on providers' discretion or existing order sets. Studies have shown unnecessary laboratory tests as financially and physically costly in adults; however, no studies have examined the necessity of common perioperative laboratory tests in pediatric spinal deformity surgery., Methods: Retrospective review of patients aged 10-18 years who underwent PSF for AIS at our center in the past three years. The clinical utility of perioperative laboratory tests was assessed based on detected incidence of anemia, blood transfusions, hematology/endocrinology/nephrology consultations, insulin administration, and postponed/canceled surgeries., Results: A total of 234 patients were included (mean age 14.4 ± 1.8 years, 75% female). Of 105 (44.9%) patients with preoperative coagulation laboratory tests, 21 (20%) had abnormal results; however, none had subsequent hematology consultations or canceled/postponed surgeries. Postoperatively, only 5 (2.1%) patients and 30 (12.8%) patients had hemoglobin values less than 8 g/dL on postoperative day (POD) 1 and 2, respectively. Multivariate analysis identified POD1 hemoglobin ≤9.35 g/dL as the only predictor of hemoglobin <8 g/dL on POD2. Overall, there were 8 (3.4%) indicated blood transfusions postoperatively. Costs of unnecessary laboratory tests averaged $95.27 (range $49.72 to $240.27) per patient., Conclusions: Many perioperative laboratory orders may be unnecessary in pediatric spinal deformity surgery, subjecting patients to extraneous costs and needlesticks. In particular, preoperative coagulation laboratory tests, perioperative BMPs, and additional postoperative CBCs for those with hemoglobin >9.35 on POD1 may not be warranted., Level of Evidence: Level III, retrospective cohort study., (Copyright © 2019 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Objective: Rheumatoid factor (RF) testing is used in primary care in the diagnosis of rheumatoid arthritis (RA); however a positive RF may occur without RA. Incorrect use of RF testing may lead to increased costs and delayed diagnoses. The aim was to assess the performance of RF as a test for RA and to estimate the costs associated with its use in a primary care setting., Material and Methods: A retrospective cohort study using the Information System for the Development of Research in Primary Care database (contains primary care records and laboratory results of >80% of the Catalonian population, Spain). Participants were patients ≥18 years with ≥1 RF test performed between 01/01/2006 and 31/12/2011, without a pre-existing diagnosis of RA. Outcome measures were an incident diagnosis of RA within 1 year of testing, and the cost of testing per case of RA., Results: 495,434/4,796,498 (10.3%) patients were tested at least once. 107,362 (21.7%) of those tested were sero-positive of which 2768 (2.6%) were diagnosed with RA within 1 year as were 1141/388,072 (0.3%) sero-negative participants. The sensitivity of RF was 70.8% (95% CI 69.4-72.2), specificity 78.7% (78.6-78.8), and positive and negative predictive values 2.6% (2.5-2.7) and 99.7% (99.6-99.7) respectively. Approximately €3,963,472 was spent, with a cost of €1432 per true positive case., Conclusions: Although 10% of patients were tested for RF, most did not have RA. Limiting testing to patients with a higher pre-test probability would significantly reduce the cost of testing., (Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.)

Background: Sickle cell disease (SCD) is a neglected burden of growing importance. >312,000 births are affected annually by sickle cell anaemia (SCA). Early interventions such as newborn screening, penicillin prophylaxis and hydroxyurea can substantially reduce the mortality and morbidity associated with SCD. Nevertheless, their implementation in African countries has been mostly limited to pilot projects. Recent development of low-cost point-of-care testing (POCT) devices for sickle haemoglobin (HbS) could greatly facilitate the diagnosis of those affected., Methods: We conducted the first multi-centre, real-world assessment of a low-cost POCT device, HemoTypeSC, in a low-income country. Between September and November 2017, we screened 1121 babies using both HemoTypeSC and HPLC and confirmed discordant samples by molecular diagnosis., Findings: We found that, in optimal field conditions, the sensitivity and specificity of the test for SCA were 93.4% and 99.9%, respectively. All 14 carriers of haemoglobin C were successfully identified. Our study reveals an overall accuracy of 99.1%, but also highlights the importance of rigorous data collection, staff training and accurate confirmatory testing. It suggests that HPLC results might not be as reliable in a resource-poor setting as usually considered., Interpretation: The use of such a POCT device can be scaled up and routinely used across multiple healthcare centres in sub-Saharan Africa, which would offer great potential for the identification and management of vast numbers of individuals affected by SCD who are currently undiagnosed., Funding Us: Imperial College London's Wellcome Trust Centre for Global Health Research (grant #WMNP P43370)., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Femoral shaft fractures are a common cause for hospital admission and surgery in pediatric patients, and laboratory studies are often ordered for historical concerns of excessive bleeding. Recent literature has challenged these assumptions, and unnecessary testing causes undue pain and costs in children. No previous studies have offered evidence-based recommendations for perioperative laboratories in isolated pediatric femoral shaft fractures., Methods: We retrospectively reviewed all patients presenting with femoral shaft fractures at our pediatric trauma center between 2013 and 2017. Patients with multitrauma injuries, metabolic/neuromuscular diseases, or intensive care unit stays were excluded. Necessity of laboratory tests was determined by rates of anemia, blood transfusions, specialist consultations, and delayed surgeries. Ordering patterns were recorded, with cost estimation based on Healthcare Bluebook., Results: We reviewed 95 patients (mean age, 7.9±4.8 y; 70 males). Treatments included elastic nails (33/95, 34.7%), reamed intramedullary nails (24/95, 25.3%), plates/screws (12/95, 12.6%), and spica casting (26/95, 27.4%). Of 32 patients with preoperative coagulation laboratories, 11 were abnormal; however none resulted in hematology consultations or procedure delays. Seventy-five patients (78.9%) and 15 patients (15.8%) had complete blood counts preoperatively and postoperative day 1, respectively. Four patients (4.2%) had hemoglobin<8 g/dL postoperatively, however, there were no perioperative blood transfusions. Of these 4, 3 underwent either reamed intramedullary nails or open reduction internal fixation with plates/screws. Twenty-six patients (27.4%) had preoperative basic metabolic panels that did not alter medical care. On the basis of our criteria, over 72% of laboratories appeared unnecessary, with a total potential cost of $8567. Over 80% of orders were from the emergency department by residents or attending physicians., Conclusions: Perioperative laboratory orders may be unnecessary in most isolated pediatric femoral shaft fractures, subjecting patients to extraneous costs, and associated pain. However, laboratories may be justified based on clinical circumstances or for older patients treated with reamed nails or plates/screws. Evidence-based recommendations for perioperative laboratory orders offer the potential to improve quality and value and minimize harm in pediatric orthopaedic trauma., Level of Evidence: Level III-retrospective comparative study (therapeutic).

Background and Objectives: Currently, HTLV screening is not performed in South Africa (SA). This report describes an economic assessment (budget impact and cost-effectiveness) of implementing different HTLV screening strategies., Methods: A modified version of the Alliance of Blood Operators risk-based decision-making framework was used to assess the risk and consequences of HTLV in the blood supply in SA. We developed a deterministic model of the cost and consequences of four screening strategies: none, universal, all donors once and first time donors only assuming a transfusion-transmission (TT) efficiency of 10% and a manifestation of clinical disease of 6%., Results: Unscreened blood results in 3·55 symptomatic TT-HTLV cases and a total healthcare cost of Rand (R)3 446 950 (US Dollars (USD)229 800) annually. Universal screening would cost R24 000 000 (USD1 600 000) per annum and prevent 3·54 (99·8%) symptomatic TT-HTLV cases in the first year and 0·55 (98·4%) symptomatic TT-HTLV cases in the second year at a cost per TT-HTLV prevented of R6 780 000 (USD450 000) in year one and R43 254 000 (USD2 890 000) in year two. Screening all donors once would cost R16,200,000 (USD1 080 000) or R4 600 000 (USD306 000) per symptomatic TT-HTLV infection prevented in year one. Total costs decrease to R5 100 000 (USD340 000) in year 2 but the cost per TT-HTLV prevented increases to R10 700 000 (USD713 333)., Conclusion: This analysis contributed to the decision not to implement HTLV screening as the healthcare budget and particularly the budget for blood transfusion in SA is insufficient to provide appropriate treatment. Arguably, available resources can be more efficiently utilized in other healthcare programs., (© 2019 International Society of Blood Transfusion.)

Objective: To compare the enzyme activity of different presentations of papain solution to validate in-house preparations., Methods: Two papain solutions were prepared, and the third presentation was a commercial solution. Tests were carried out with samples of red cells typed as weak RhD., Results: In-house prepared papain solutions showed similar enzyme reactivity, and statistically no differences compared to the enzyme activity of the commercial solution., Conclusion: Evaluating the cost-benefit ratio, the in-house prepared papain solutions present more economic advantages, and can be incorporated into immunohematological routines as a way to cope with periods of financial crisis and cost-containment policies.

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.

Introduction: Determination of circulating prostate specific antigen (PSA) is commonly used in the diagnosis and treatment monitoring of prostate cancer [1]. Presently, PSA testing is performed in centralized laboratories, which is associated with prolonged time between venipuncture and the PSA value being available. In this prospective study, we present a new and rapid test system for the quantitative determination of PSA levels from finger-stick blood., Methods: The Claros1 ® analyzer is a rapid microfluidics-based point-of-care system for quantitative PSA analysis from 10-µl finger-stick blood that requires only 10 min for testing. Total PSA concentrations by the Claros system in 100 consecutive asymptomatic men (median age 57 years, range 44-81 years) were compared with two commercially available, commonly used PSA assays (Abbott and Elecsys by Roche) performed by a reference laboratory., Results: Eighty-six percent of finger-stick blood-borne probes from 100 men were evaluable for PSA testing by the Claros1 ® analyzer system. In 13/14 cases the expiry date of the microfluid cassettes of the Claros system was exceeded and one blood puncture was performed inadequately. The correlations between the Claros results and OPKO-Abbott and OPKO-Roche assay results were high, with R 2 values of 0.982 and 0.985, respectively. The R 2 value for the Roche-Abbott correlation was 0.991 with a slope value of 1.160. Prostate cancer was diagnosed in seven cases, with a median PSA of 1.8 ng/ml in the Claros group compared to 1.75 ng/ml and 2.1 ng/ml in the Abbott and Roche groups, respectively., Conclusion: The Claros1 ® PSA assay combines the advantages of rapid, accurate detection with a low required sample volume, allowing the analysis to be performed using finger-stick blood. Provided that further analysis proves the reproducibility of the test, it may help to reduce the number of office visits, thus decreasing costs to the health care system.

Blood tests provide crucial diagnostic information regarding several diseases. A key factor that affects the precision and accuracy of blood tests is the interference of red blood cells; however, the conventional methods of blood separation are often complicated and time consuming. In this study, we devised a simple but high-efficiency blood separation system on a self-strained microfluidic device that separates 99.7 ± 0.3% of the plasma in only 6 min. Parameters, such as flow rate, design of the filter trench, and the relative positions of the filter trench and channel, were optimized through microscopic monitoring. Moreover, this air-difference-driven device uses a cost-effective and easy-to-use heater device that creates a low-pressure environment in the microchannel within minutes. With the aforementioned advantages, this blood separation device could be another platform choice for point-of-care testing., Competing Interests: The authors have declared that no competing interests exist.

Background: Routine immediate postoperative laboratory studies, including metabolic panels and hematologic profiles, are commonly ordered after arthroplasty procedures. However, their values only occasionally influence management. This study investigated the clinical utility and value of these tests., Methods: A large retrospective cohort study of 18,935 patients spanning a 6-year period from 2008 to 2013 from a single high-volume institution was evaluated. Only immediate postoperative labs drawn on postoperative day 0 in the recovery room were included in the study. Complete blood counts (CBC) and basic metabolic panels (BMP) were reviewed, and ranges of abnormal were set for each lab test based on values significant enough to impact patient management. Cost effectiveness calculations were made based on current cost of the laboratory tests., Results: Actionably low hemoglobin values ( < 8 g/dL) were found in 1.44% of the overall cohort. Unilateral primary total knee arthroplasty was associated with the fewest hemoglobin abnormalities at 0.59%. Primary unilateral total hip arthroplasty was associated with abnormal hemoglobin values in 1.81% of cases. Significant electrolyte abnormalities were far less common, with hyperkalemia (> 6.5 mEq/L) in 0.19%, hyponatremia ( < 120 mEq/L) in 0.01% and elevated creatinine (> 2.0 mg/dL) was found in 0.25%. Hemoglobin values were calculated at a cost of $1,710 to detect a single significantly abnormal result. The cost to detect a single actionably abnormal BMP value was $1,000., Conclusions: Routine immediate postoperative laboratory tests represent a high institutional cost and are seldom abnormal enough to warrant a change in patient management. The routine use of these tests can likely be safely eliminated in uncomplicated primary unilateral arthroplasty procedures.

The US blood supply has never been safer. This level of safety depends on a multifaceted approach including blood donor screening, sensitive infectious disease testing, and good manufacturing practice. However, risks remain for transfusion-transmitted infections due to bacterial contamination of platelets and emerging diseases. Thus, ongoing improvements in screening and testing are required. Newer pathogen reduction technologies have shown promise in further ameliorating the safety of the blood supply.

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.)

Introduction: Routine laboratory studies are often obtained daily after total joint arthroplasty (TJA) regardless of medical management. The purpose of this study was to investigate the utility of routine basic metabolic panel (BMP) tests after TJA. Furthermore, the goal was to identify factors that may predispose patients to abnormal laboratory values that require medical intervention., Methods: A retrospective review was performed on 767 patients who underwent primary TJA at a single institution. Preoperative and postoperative potassium, sodium, creatinine, and glucose values were collected along with demographic data, comorbidities, and procedural characteristics. Multivariable logistic regression models were used to determine independent risk factors for abnormal postoperative laboratory values., Results: Diabetes was associated with abnormal glucose (odds ratio [OR] 23.4, 95% confidence interval [CI] 10.7-51.0, P < .001), while chronic kidney disease was associated with abnormal creatinine (OR 3.1, 95% CI 1.7-5.8, P < .001) and potassium (OR 1.8, 95% CI 1.1-2.8, P = .014) requiring medical intervention. An abnormal preoperative laboratory value was also associated with medical treatment for each of sodium, potassium, and creatinine (all P < .001). Average number of BMP tests collected for patients who did not receive medical intervention was 2.8. This equated to $472,372.56 in total hospital charges., Conclusion: Cost containment while maintaining high-quality patient care is critical. Routine postoperative BMP tests in patients with normal preoperative values without major medical comorbidities do not contribute to actionable information. Patients with diabetes, chronic kidney disease, or with abnormal preoperative values should obtain a BMP after TJA., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To determine the potential costs and health benefits of a serum-based spectroscopic triage tool for brain tumours, which could be developed to reduce diagnostic delays in the current clinical pathway., Design: A model-based health pre-trial economic assessment. Decision tree models were constructed based on simplified diagnostic pathways. Models were populated with parameters identified from rapid reviews of the literature and clinical expert opinion., Setting: Explored as a test in both primary and secondary care (neuroimaging) in the UK health service, as well as application to the USA., Participants: Calculations based on an initial cohort of 10 000 patients. In primary care, it is estimated that the volume of tests would approach 75 000 per annum. The volume of tests in secondary care is estimated at 53 000 per annum., Main Outcome Measures: The primary outcome measure was quality-adjusted life-years (QALY), which were employed to derive incremental cost-effectiveness ratios (ICER) in a cost-effectiveness analysis., Results: Results indicate that using a blood-based spectroscopic test in both scenarios has the potential to be highly cost-effective in a health technology assessment agency decision-making process, as ICERs were well below standard threshold values of £20 000-£30 000 per QALY. This test may be cost-effective in both scenarios with test sensitivities and specificities as low as 80%; however, the price of the test would need to be lower (less than approximately £40)., Conclusion: Use of this test as triage tool in primary care has the potential to be both more effective and cost saving for the health service. In secondary care, this test would also be deemed more effective than the current diagnostic pathway., Competing Interests: Competing interests: MJB, MGH, HJB and DSP are all involved in ClinSpec Diagnostics, a prospective spin-out company from the University of Strathclyde focusing on the translation of serum spectroscopic diagnostics (Company No SC535447)., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Unnecessary pathology tests performed in intensive care units (ICU) might lead to increased costs of care and potential patient harm due to unnecessary phlebotomy. We hypothesised that a multimodal intervention program could result in a safe and effective reduction in the pathology tests ordered in our ICU. We conducted a single-centre pre- and post-study using multimodal interventions to address commonly ordered routine tests. The study was performed during the same six month period (August to February) over three years: 2012 to 2013 (pre-intervention), 2013 to 2014 (intervention) and 2014 to 2015 (post-intervention). Interventions consisted of staff education, designing new pathology forms, consultant-led pathology test ordering and intensive monitoring for a six-month period. The results of the study showed that there was a net savings of over A$213,000 in the intervention period and A$175,000 in the post-intervention period compared to the pre-intervention period. There was a 28% reduction in the tests performed in the intervention period ( P <0.0001 compared to pre-intervention period) and 26% in the post-intervention period ( P <0.0001 compared to pre-intervention period). There were no ICU or hospital mortality differences between the groups. There were no significant haemoglobin differences between the groups. A multimodal intervention safely reduced pathology test ordering in the ICU, resulting in substantial cost savings.

Earlier detection is key to reducing cancer deaths. Here, we describe a blood test that can detect eight common cancer types through assessment of the levels of circulating proteins and mutations in cell-free DNA. We applied this test, called CancerSEEK, to 1005 patients with nonmetastatic, clinically detected cancers of the ovary, liver, stomach, pancreas, esophagus, colorectum, lung, or breast. CancerSEEK tests were positive in a median of 70% of the eight cancer types. The sensitivities ranged from 69 to 98% for the detection of five cancer types (ovary, liver, stomach, pancreas, and esophagus) for which there are no screening tests available for average-risk individuals. The specificity of CancerSEEK was greater than 99%: only 7 of 812 healthy controls scored positive. In addition, CancerSEEK localized the cancer to a small number of anatomic sites in a median of 83% of the patients., (Copyright © 2018 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Objectives: To determine the need and impact of repeating critical values in hematology and coagulation., Methods: We prospectively evaluated the need for repeating critical values. The cost of this practice was estimated using a workflow analysis. Retrospective chart review before and after removal of this process was performed to assess the clinical impact of removing this practice., Results: Over 95% of the repeated values remained critical and all but one of the repeats were within the expected analytical precision of the assays. The practice of repeating critical values delayed turnaround time for these results and wasted resources, most notably manpower. The delay associated with repeating hematology critical values resulted in delayed administration of blood product (RBC units)., Conclusions: Repeating critical hematology and coagulation results was found to be an unnecessary process that wasted laboratory resources and lengthened turnaround time, delaying clinical intervention., (© American Society for Clinical Pathology, 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: The primary hypothesis of this article is that a team approach in creating a protocolized laboratory monitoring schedule for home parenteral nutrition (PN) patients improves patient safety by decreasing the occurrence of nutrition deficiencies and is cost-effective., Methods: In this prospective cohort study of home PN patients, each patient followed an established protocol of laboratory monitoring and weekly review by an interdisciplinary team of dietitians, nurses, and physicians. Data collected included anthropometric measurements, laboratory results, deviations from laboratory protocols, laboratory charges, PN shortage information, and means of ameliorating such shortages. Cost-effectiveness analysis was only performed for nonmicronutrient laboratory tests., Results: Fifteen children (male, n = 6) with a median age of 59 months (range, 19-216) were included in this study. Primary diagnoses included short bowel syndrome (47%) and intestinal pseudo-obstruction (40%). Patients received PN mixtures from 6 different infusion companies and experienced 60 different shortages in the PN formulation requiring adjustments or substitutions (mean, 4 shortages per patient). All patients had appropriate growth and complete micronutrient monitoring. No patient experienced any clinical symptoms due to shortages. The median number of laboratory draws/patient per month was 2.9 preprotocol compared with 1.14 postprotocol (P = .003). The median per patient per month charges were $2014 (interquartile range [IQR], 1471-2780) preprotocol compared with $792 (IQR, 435-1140) postprotocol (P = .002)., Conclusions: A structured team approach to laboratory monitoring of home PN patients can simplify PN management, significantly decrease monthly laboratory costs, and lead to fewer laboratory draws while improving micronutrient monitoring and preventing deficiencies., (© 2016 American Society for Parenteral and Enteral Nutrition.)

Objectives: We implemented a policy of reflex serotonin-release assay (SRA) testing for all patients with a positive heparin-induced thrombocytopenia (HIT) immunoassay., Methods: We identified all patients who had SRA testing sent as a consequence of a positive HIT immunoassay test. We reviewed charts of patients to calculate the 4Ts clinical score, determined the effect of testing on clinical management, and documented the change in utilization of direct thrombin inhibitors (DTIs)., Results: The likelihood of a positive SRA varied with the optical density (OD) of the immunoassay. The performance of the immunoglobulin G (IgG)-specific and polytypic enzyme-linked immunosorbent assay was not statistically different. Both OD and 4Ts score correlated with the likelihood of a positive SRA but demonstrated poor specificity. Discontinuation of DTIs in patients with negative SRAs resulted in decreased drug utilization., Conclusions: The IgG-specific HIT immunoassay OD correlates with the likelihood of a positive SRA but does not achieve high specificity. The reflex testing algorithm allows for definitive classification of patients, and the cost of such a reflex testing program may be offset by decreased utilization of DTIs., (© American Society for Clinical Pathology, 2017. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: Lifelong medical follow-up is mandatory after bariatric surgery. The aim of this study was to assess the 5-year follow-up after bariatric surgery in a nationwide cohort of patients., Methods: All adult obese patients who had undergone primary bariatric surgery in 2009 in France were included. Data were extracted from the French national health insurance database. Medical follow-up (medical visits, micronutrient supplementation and blood tests) during the first 5 years after bariatric surgery was assessed, and compared with national and international guidelines., Results: Some 16 620 patients were included in the study. The percentage of patients with at least one reimbursement for micronutrient supplements decreased between the first and fifth years for iron (from 27.7 to 24.5 per cent; P < 0.001) and calcium (from 14·4 to 7·7 per cent; P < 0·001), but increased for vitamin D (from 33·1 to 34·7 per cent; P < 0·001). The percentage of patients with one or more visits to a surgeon decreased between the first and fifth years, from 87·1 to 29·6 per cent (P < 0·001); similar decreases were observed for visits to a nutritionist/endocrinologist (from 22·8 to 12·4 per cent; P < 0·001) or general practitioner (from 92·6 to 83·4 per cent; P < 0·001). The mean number of visits to a general practitioner was 7·0 and 6·1 in the first and the fifth years respectively. In multivariable analyses, male sex, younger age, absence of type 2 diabetes and poor 1-year follow-up were predictors of poor 5-year follow-up., Conclusion: Despite clear national and international guidelines, long-term follow-up after bariatric surgery is poor, especially for young men with poor early follow-up., (© 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.)

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.

Rationale, Aims and Objectives: The increasing number of diagnostic tests requests all over the world is a problem that can partially be explained by inappropriate testing. Impact on the total costs of health systems becomes relevant when tests are performed in a large amount. In this paper, retesting of total cholesterol, ferritin, vitamin B 12 , vitamin D, and folate is assessed., Methods: The Quality Unit of Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano (Fondazione) decided to perform a first assessment of the appropriate use of the laboratory tests cholesterol, ferritin, vitamin B 12 , vitamin D, and folate focusing on the retesting interval for the same patient in the time period January 1, 2012, to December 31, 2014, in every care setting. The minimum retesting intervals were chosen following the ACB recommendations. The Fondazione is a research and teaching hospital with 3 emergency units (adult, pediatric, and obstetric), kidney, liver, lung, cornea, and bone marrow transplant centers and a medical school. Record linkage of laboratory records selected for the time interval January 1, 2012, to December 31, 2014, was applied using tax code. For each marker, the distribution of retesting intervals was evaluated for every year and the total period. With the same record linkage variable, requests on inpatients were identified from hospital discharge records. A cost analysis of inappropriate retesting was performed for every test., Results: We examined 466 035 requests for 113 019 patients. Proportions of tests judged potentially inappropriate varied between 8.1% for 1,25-dihydroxy vitamin D and 37.1% for total cholesterol. The rates of inappropriate tests from year to year never showed significant decrease, and the maximum increase corresponded to an odds ratio of 1.85 (95% CI, 1.36-2.51) for 1,25-dihydroxy vitamin D from 2012 to 2013. Calculated loss of money was approximately €500 000 in the 3 years., Conclusions: Inappropriate requests represent a waste of time and money resources. Our analysis highlighted economically unacceptable rates of inappropriate retesting, with no evidence of decreasing trend. Actions to raise awareness in clinicians or automated electronic solutions are necessary to limit unnecessary test repetitions., (© 2017 John Wiley & Sons, Ltd.)

Clinical decision support (CDS) is the use of information and communication technologies to improve clinical decision making and patient care. CDS applications have been used in many aspects of health care, including medication ordering and diagnostic prediction algorithms. As economic and regulatory pressures place a strain on laboratory resources, the potential of CDS to improve utilization of laboratory testing has also begun to be realized. Hematology and coagulation laboratories stand to gain tremendously from the implementation of CDS interventions, given their mixture of high-volume, low-cost tests (eg CBC, PT, aPTT) and tests that carry a high potential of being misused or misinterpreted (eg lupus anticoagulant, erythrocyte sedimentation rate, heparin-induced thrombocytopenia testing). This brief review will define the key terms in the field of clinical decision support, provide instructive examples of CDS interventions to improve utilization of hematology and coagulation testing, introduce methods to implement these interventions effectively, and discuss metrics by which the success of these interventions can be evaluated., (© 2017 John Wiley & Sons Ltd.)

Objective: To assess the utility of frequent sodium checks (every 6h) in patients receiving hypertonic saline (HS) after elective brain tumor surgeries., Patients and Methods: A single-institution retrospective review of patients having undergone elective craniotomies for brain tumors and treated with postoperative continuous intravenous infusions of 3% HS was performed. Changes in serum sodium values were analyzed at different time points. The rates of <12.5, 25, and 50cc/h infusions were also examined. Healthcare cost analysis was performed by extrapolating our cohort to the total number of craniotomies performed in the United States., Results: No significant differences among sodium values checked between 0 to 4, 4-6, 6-8, 8-10, and >10h were observed (P=.64). In addition, no differences in serum sodium values among the rates of <12.5, 25, and 50cc/h were found (P=.30). No patients developed symptoms of acute hypernatremia., Conclusions: Serum sodium values did not significantly change more than 10h after infusion of HS. Further studies are needed to determine the optimal frequency of routine sodium checks to increase the quality of care and decrease healthcare costs., (Copyright © 2017 Elsevier B.V. All rights reserved.)

The number of serum 25-hydroxyvitamin D (25OHD) assays has increased tenfold in France in less than 10 years, sometimes for invalidated reasons. In 2013, the French National Authority for Health (Haute autorité de santé, or HAS) limited the indications for serum 25OHD measurements to rickets/osteomalacia, older adults with recurrent falls, monitoring of kidney transplant in adults, and surgical treatment of obesity in adults. Our aim here was to note that other indications for serum 25OHD measurements are supported by previous literature and by a number of national and international recommendations, in particular the following: any situation of bone fragility, any chronic renal failure <45 mL/min/1.73m 2 , any situation of malabsorption, clinical signs consistent with vitamin D deficiency or vitamin D overload, and calcium phosphorus evaluation. We suggest that the measurement of serum 25OHD concentration should remain reimbursed as part of these extended indications.

Small-fiber polyneuropathy (SFPN) causes non-specific symptoms including chronic pain, cardiovascular, gastrointestinal, and sweating complaints. Diagnosis is made from history and exam in patients with known risk factors such as diabetes, but objective test confirmation is recommended for patients without known risks. If tests confirm SFPN, and it is "initially idiopathic" (iiSFPN), screening for occult causes is indicated. This study's aim was to evaluate the 21 widely available, recommended blood tests to identify the most cost-effective ones and to learn about occult causes of iiSFPN. Records were reviewed from all 213 patients with SFPN confirmed by distal-leg skin biopsy, nerve biopsy, or autonomic-function testing in our academic center during 2013. We determined the prevalence of each abnormal blood-test result (ABTR) in the iiSFPN cohort, compared this to population averages, and measured the costs of screening subjects to obtain one ABTR. Participants were 70 % female and aged 43.0 ± 18.6 years. High erythrocyte sedimentation rate (ESR) and antinuclear antibody (ANA; ≥1:160 titer) were most common, each present in 28 % of subjects. The ABTR ≥3 × more prevalent in iiSFPN than in the total population were high ESR, high ANA, low C3, and Sjögren's and celiac autoantibodies. Together, these suggest the possibility of a specific association between iiSFPN and dysimmunity. ABTR identifying diabetes, prediabetes, and hypertriglyceridemia were less common in iiSFPN than in the population and thus were not associated with iiSFPN here. The six most cost-effective iiSFPN-associated blood tests-ESR, ANA, C3, autoantibodies for Sjögren's and celiac, plus thyroid-stimulating hormone-had estimated cost of $99.57/person and 45.6 % probability of obtaining one abnormal result. Angiotensin-converting enzyme was elevated in 45 %, but no patients had sarcoidosis, so this test was futile here.

β-Thalassemia is a hemoglobin genetic disorder characterized by the absence or reduced β-globin chain synthesis, one of the constituents of the adult hemoglobin tetramer. In this study the possibility of using thermogravimetric analysis (TGA) followed by chemometrics as a new approach for β-thalassemia detection is proposed. Blood samples from patients with β-thalassemia were analyzed by the TG7 thermobalance and the resulting curves were compared to those typical of healthy individuals. Principal Component Analysis (PCA) was used to evaluate the correlation between the hematological parameters and the thermogravimetric results. The thermogravimetric profiles of blood samples from β-thalassemia patients were clearly distinct from those of healthy individuals as result of the different quantities of water content and corpuscular fraction. The hematological overview showed significant decreases in the values of red blood cell indices and an increase in red cell distribution width value in thalassemia subjects when compared with those of healthy subjects. The implementation of a predictive model based on Partial Least Square Discriminant Analysis (PLS-DA) for β-thalassemia diagnosis, was performed and validated. This model permitted the discrimination of anemic patients and healthy individuals and was able to detect thalassemia in clinically heterogeneous patients as in the presence of δβ-thalassemia and β-thalassemia combined with Hb Lepore. TGA and Chemometrics are capable of predicting ß-thalassemia syndromes using only a few microliters of blood without any pretreatment and with an hour of analysis time. A fast, rapid and cost-effective diagnostic tool for the β-thalassemia screening is proposed., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Magnetic levitation has emerged as a technique that offers the ability to differentiate between cells with different densities. We have developed a magnetic levitation system for this purpose that distinguishes not only different cell types but also density differences in cells of the same type. This small-scale system suspends cells in a paramagnetic medium in a capillary placed between two rare earth magnets, and cells levitate to an equilibrium position determined solely by their density. Uniform reference beads of known density are used in conjunction with the cells as a means to quantify their levitation positions. In one implementation images of the levitating cells are acquired with a microscope, but here we also introduce a cell phone-based device that integrates the magnets, capillary, and a lens into a compact and portable unit that acquires images with the phone's camera. To demonstrate the effectiveness of magnetic levitation in cell density analysis we carried out levitation experiments using red blood cells with artificially altered densities, and also levitated those from donors. We observed that we can distinguish red blood cells of an anemic donor from those that are healthy. Since a plethora of disease states are characterized by changes in cell density magnetic cell levitation promises to be an effective tool in identifying and analyzing pathologic states. Furthermore, the low cost, portability, and ease of use of the cell phone-based system may potentially lead to its deployment in low-resource environments.

Objective: To estimate the cost-effectiveness of first trimester non-invasive fetal RHD screening for targeted antenatal versus no routine antenatal anti-D prophylaxis (RAADP) or versus non-targeted RAADP., Design: Model based on a population-based cohort study., Setting: The Swedish health service., Population: Intervention subjects in the underlying cohort study were RhD-negative pregnant women receiving first trimester fetal RHD screening followed by targeted anti-D in 2010-2011 (n = 6723). Historical comparators were RhD-negative women who delivered in 2008-2009 when standard care did not include RAADP (n = 7099)., Methods: Healthcare costs for the three strategies were included for the first and subsequent pregnancies. For the comparison with non-targeted RAADP, the immunisation rate was based on the observed rate for targeted therapy and adjusted downwards by removing the influence of false negatives., Main Outcome Measure: Additional cost per RhD immunisation averted., Results: Compared with RAADP, targeted prophylaxis was associated with fewer immunisations (0.19 versus 0.46% per pregnancy) and lower costs (cost-savings of €32 per RhD-negative woman). The savings were from lower costs during pregnancy and delivery, and lower costs of future pregnancies through fewer immunisations. Non-targeted anti-D was estimated to result in 0.06% fewer immunisations and an additional €16 in cost-savings per mother, compared with targeted anti-D., Conclusion: Based on effect data from a population-based cohort study, targeted prophylaxis was associated with lower immunisation risk and costs versus no RAADP. Based on effect data from theoretical calculations, non-targeted RAADP was predicted to result in lower costs and immunisation risk compared with targeted prophylaxis., Tweetable Abstract: Fetal RHD screening and targeted prophylaxis resulted in lower immunisation risk and costs compared with no RAADP., (© 2015 Royal College of Obstetricians and Gynaecologists.)

Introduction: Parenteral nutrition (PN) is indicated for patients who are unable to progress to oral or enteral nutrition. There are no local studies done on estimating the cost of PN in acute settings. The aims of this study are to describe the demographics, costs of PN and manpower required; and to determine the avoidable PN costs for patients and hospital on short-term PN., Materials and Methods: Patient data between October 2011 and December 2013 were reviewed. Data collected include demographics, length of stay (LOS), and the indication/duration of PN. PN administration cost was based on the cost of the PN bags, blood tests and miscellaneous items, adjusted to subsidy levels. Manpower costs were based on the average hourly rate., Results: Costs for PN and manpower were approximately S$1.2 million for 2791 PN days. Thirty-six cases (18.8%) of 140 PN days were short-term and considered to be avoidable where patients progressed to oral/enteral diet within 5 days. These short-term cases totalled $59,154.42, where $42,183.15 was payable by the patients. The daily costs for PN is also significantly higher for patients on short-term PN (P <0.001)., Conclusion: In our acute hospital, 90% of patients referred for PN were surgical patients. Majority of the cost comes from the direct daily cost of the bag and blood tests, while extensive manpower cost was borne by the hospital; 18.8% of our cohort had short-term avoidable PN. Daily PN may cost up to 60% more in patients receiving short-term PN. Clinicians should assess patient's suitability for oral/enteral feeding to limit the use of short-term PN.

Background: Failure to follow-up laboratory test results has been described as one of the major processes contributing to unsafe patient care. Currently, most of the laboratories do not know with certainty not only their rate of missed (or unreviewed) requests but the economical cost and impact that this issue implies. The aim of our study was to measure that rate and calculate the resulting costs., Material and Methods: In January 2015, we checked in our Laboratory Information Management System (LIMS) for every emergency request from 1(st) July 2011 to 30(th) June 2014, if they had been reviewed by any allowed user or not. 319,064 requests were ordered during that period of time. Results were expressed as "ordered requests", "missed requests" and its percentage. Additionally, total cost of missed requests was calculated in euros (€). "Non-productive days" were theorised (as the days producing requests that were not reviewed) based on these results., Results: 7924 requests (2.5%) were never reviewed by clinicians. This represented a total cost of 203,039 € and 27 "non-productive" days in three years. Significant differences between inpatients, outpatients and emergency department as well as different emergencies units were found after application of statistical analysis., Conclusions: In terms of resources, never reviewed or missed requests appear to be a not negligible problem for the clinical laboratory management. Electronic result delivery, with electronic endorsement to indicate follow-up of requests along with better systems of electronic requesting should be investigated as a way of improving patient outcomes and save unnecessary expenses.

Background: The recent overdiagnosis of subclinical, low-risk papillary thyroid cancer (PTC) coincides with a growing national interest in cost-effective health care practices. The aim of this study was to measure the relative cost-effectiveness of disease surveillance of low-risk PTC patients versus intermediate- and high-risk patients in accordance with American Thyroid Association risk categories., Methods: Two thousand nine hundred thirty-two patients who underwent thyroidectomy for differentiated thyroid cancer between 2000 and 2010 were identified from the institutional database; 1845 patients were excluded because they had non-PTC cancer, underwent less than total thyroidectomy, had a secondary cancer, or had <36 months of follow-up. In total, 1087 were included for analysis. The numbers of postoperative blood tests, imaging scans and biopsies, clinician office visits, and recurrence events were recorded for the first 36 months of follow-up. Costs of surveillance were determined with the Physician Fee Schedule and Clinical Lab Fee Schedule of the Centers for Medicare and Medicaid Services., Results: The median age was 44 years (range, 7-83 years). In the first 36 months after thyroidectomy, there were 3, 44, and 22 recurrences (0.8%, 7.8%, and 13.4%) in the low-, intermediate-, and high-risk categories, respectively. The cost of surveillance for each recurrence detected was US $147,819, US $22,434, and US $20,680, respectively., Conclusions: The cost to detect a recurrence in a low-risk patient is more than 6 and 7 times greater than the cost for intermediate- and high-risk PTC patients. It is difficult to justify this allocation of resources to the surveillance of low-risk patients. Surveillance strategies for the low-risk group should, therefore, be restructured., (© 2015 American Cancer Society.)