Conducted by Sunquest, the meeting introduced medical laboratory professionals to ideas and improved patient outcomes that result when pathologists actively help physicians select the right lab tests and understand how to act upon the results
PHOENIX, ARIZONA—Most pathologists and clinical laboratory scientists are quick to agree that overutilization of medical laboratory tests is a major problem in healthcare. But underutilization of medical lab tests is an equally significant problem. That’s the message delivered here last Monday by pathologist Michael Laposata, M.D., Ph.D., during a presentation he delivered at the Sunquest Executive Summit.
Laposata, who recently assumed new duties as the Chair of Pathology at the University of Texas Medical Branch in Galveston, Texas, was speaking about the value of what he calls “diagnostic management teams,” or DMTs. In recent years, while at Vanderbilt University Medical Center, Laposata and his colleagues introduced DMTs in support of several medical specialties. These DMTs proved quite successful at improving patient outcomes, while reducing the overall cost per healthcare encounter for these patients.
Unaddressed Issues in Clinical Laboratory Medicine
Dark Daily would like to highlight a few of the unaddressed issues in laboratory medicine as it is practiced today, which were discussed by Laposata. These issues demonstrate the potential that exists for clinical pathologists and laboratory scientists to deliver more value to physicians if they addressed these issues within their hospitals and clinical communities. As a summary, Dark Daily will provide the characteristics of a DMT as described by Laposota.
One powerful example of how the profession of laboratory medicine can confuse physicians involves the multiplicity of names that different laboratories use to describe the same laboratory test. “Start with the assumption that many physicians are overwhelmed by the hundreds of clinical laboratory tests offered today by their local laboratory,” observed Laposata. “Laboratories make it even more difficult for these physicians because individual labs will call the same test by many different names.
Same Medical Laboratory Test Can Have Many Different Names
“This can be illustrated by the names for the test to measure the function of an important coagulation-related protein—von Willebrand factor,” he said. “In the table below, here are common names labs use for this test, along with the abbreviations:”
• Ristocetin cofactor • VWF activity
• Von Willebrand factor function • VWF: RCoF
• Von Willebrand factor • VWF function
• Factor VIII-related activity • VWF, functional
• Functional von Willebrand factor • F VIII – related act
“How do these various names for the same lab test help clinicians?” asked Laposata.
Next, he took up the fact that, not only do labs use different names for the same tests, there may be different assays associated with the same condition. “This can create more confusion when a physician is ready to order a test,” explained LaPosta. “With a patient in the exam room, a doctor wants to know if a patient has vitamin D deficiency.
Confusing Physicians with Different Tests for Vitamin D
“Which single test of all the ones listed below with the name vitamin D should be ordered?” he again asked.
• Vitamin D
• Vitamin D2
• Vitamin D3
• 25 hydroxy vitamin D
• 25-OH vitamin D
• 25 hydroxy vitamin D2
• 25-OH vitamin D2
• 25 hydroxy vitamin D3
• 25-OH vitamin D3
• 1,25 dihydroxy vitamin D
• 1,25-diOH vitamin D
• 1,25 dihydroxy vitamin D2
• 1,25-diOH vitamin D2
• 1,25 dihydroxy vitamin D3
• 1,25-diOH vitamin D3
“Don’t forget that these test names are also presented as abbreviations in multiple different ways!” he emphasized. “Why don’t we make it easy for a doctor to select the one test which indicates whether or not the patient is vitamin D deficient?”
LaPosata’s ‘Vast Array of Medical Laboratory Testing Options’
Laposata explained that there are consequences to what he called the “Vast Array of Testing Options.” “All too often, doctors pick unnecessary lab tests or miss the necessary ones,” he noted. “Dozens of approaches emerge for diagnosis of the same condition—some better than others.
“The correct diagnosis may be achievable promptly,” Laposata continued. “But it is common for the diagnosis to be missed or commonly delayed. That has adverse clinical consequences to the patient, along with adverse financial consequences to the institution.”
Multi-Decade Crusade to Help Clinicians Order the Right Test
Many long-time readers of Dark Daily know that LaPosata has been on a multi-decade mission to help clinicians achieve precision in always ordering the correct test for the right patient at the right time—then using the medical laboratory test results to select the most appropriate therapy. This effort started during the 1990s when he was Director of Laboratories at Massachusetts General Hospital and a professor at Harvard Medical School in Boston.
In recent years, LaPosata and his colleagues at Vanderbilt have made great progress in helping doctors improve the accuracy of their lab test ordering and use of lab test results. This has happened because of the implementation of DMTs. At Vanderbilt, LaPosata said, DMTs are functioning or planned in the areas of:
• Transfusion Medicine
• Breast Cancer
• Renal Pathology
• Lung Cancer
• Other cancers
Having shared with the audience these insights about the opportunities for pathologists and clinical laboratory scientists to help physicians better order medical laboratory tests, LaPosata then discussed the attributes of an effective DMT.
Simple in Execution and Powerful in Improving Patient Outcomes
He pointed out that the DMT has a rather simple organization. It starts when “physicians order tests by requesting evaluation of an abnormal screening test or clinical sign or symptom,” explained LaPosata. “Upon receiving that request, the expert physician and colleagues in the DMT then synthesize the clinical and laboratory data and provide a narrative interpretation based upon medical evidence. This happens not only when specifically requested by the referring physician, but also for every case handled by the DMT.”
Having established that context, Laposata then discussed what is often missing in efforts to offer a DMT. He said that it is not a DMT activity if any of the following are true:
- The interpretation does not consider clinical information.
- The service does not meet on a regular schedule.
- The interpretation is not written or is not included in the medical record.
- The interpretation is so self-evident that it is not clinically valuable for the treating physician. (For example: The interpretation only provides a report of test results as abnormal but fails to explain why.)
At this year’s Executive War College on Laboratory and Pathology Management, LaPosata delivered a similar presentation on the topic of DMTs. The full powerpoint can be viewed here. (Or copy and paste this URL into your browser: http://www.executivewarcollege.com/wp-content/uploads/EWC14.GS_.Wed_.9.40AM.Laposata.pdf).
Your Dark Daily Editor,
Robert L. Michel
Diagnostic management efforts thrive on teamwork
The Diagnostic Management Team and More at Vanderbilt: Moving Lab Medicine Closer to the Physicians and Patients to Deliver More Value (PDF)