Elsevier

Clinica Chimica Acta

Volume 280, Issues 1–2, 1 February 1999, Pages 35-45
Clinica Chimica Acta

The clinical importance of laboratory reasoning

https://doi.org/10.1016/S0009-8981(98)00196-XGet rights and content

Abstract

The radical changes made in the delivery of modern health care have serious implications for laboratory services, because reasoning in laboratory medicine should follow a clinical rather than a technological logic. Appropriate test requesting and interpretation coupled with a patient-oriented vision improve the outcomes for patients, and so ensure the best cost containment strategy. The fact that analytical operations are standardized and quality controlled, may lead to a greater recognition of the importance of pre- and post-analytical issues. Particularly critical aspects are the formulation of the clinical question and the interpretation of laboratory results. Laboratory–clinic communication is fundamental in achieving and maintaining total quality in laboratory services. Effective consultancy stands or falls with the knowledge and experience of laboratorians, as well as continuous education is required to maintain the best utilization of laboratory information in clinical decision-making. As clinical audit is an important tool for reviewing and improving the quality of the service in clinical laboratories, it should make up an important part of programs for accreditation and quality improvement. If a patient-centered vision predominates, the clinical laboratory will be linked to both physicians and patients, making it more tangible to the latter.

Introduction

There have been radical changes in the delivery of health care, and the changes in medical practice are being driven by a need to contain costs. It has been predicted that in the US total spending on health will grow 50% faster than the gross domestic product, and similar trends are evident in other countries [1].

Attention has been turned to laboratory testing, since laboratory charges due to extensive growth over the last 30 years, currently make up 10% of hospital billings, or about 5% of health care billings. Between 1960 and 1990, laboratory tests increased at an annual rate of 10% in the US consequent to automation, computerization and technological advances, as well as the need to meet clinical demands [2].

Two types of growth in the laboratory workload have been identified. The first, intrinsic growth, derives from the availability of new tests and/or the increased utilization of existing tests (i.e., more tests per patient). The second, extrinsic growth, derives from increased test volume due to new clinical programs (e.g., organ transplantation, higher number of intensive care units).

One goal of the US managed care providers is to significantly reduce laboratory spending [3]. Here, clinical laboratories are experiencing important challenges and problems: consolidation, centralization, downsizing, re-engineering, rationalization and restructuring are painfully familiar terms in laboratory medicine.

The changes have serious implications, not just for the laboratory professions, but also, and above all, for the quality of medical care. In fact, a reduced utilization of laboratory tests may lead to missed or delayed diagnoses and may even compromise patient outcomes. It could, moreover, lead to higher costs for health care systems due to delayed decisions and prolonged hospital stays. Thus, the first question is what exactly is current laboratory medicine? What is its role in modern medicine?

Section snippets

Laboratory medicine as a medical discipline

Laboratory medicine is considered either a technical or a medical discipline. However, if it is a technical discipline, its goal is simply to give accurate and speedy analytical results; if it is a medical discipline, its aim is to promptly give the correct answer to a medical question. This conflict is well reflected by the fact that in British laboratories tests are `requested', and can, therefore, be questioned, whereas in the US clinicians prefer to `order' tests. However, the ultimate

Cost-containment strategies

There are two types of approach to reduce costs: Type I (the `classical–technological approach'), aims at lowering costs per assay through consolidation of laboratories, larger laboratory units, improvements in laboratory automation etc., and Type II (the pathophysiology-based approach) aims at lowering costs by improving the diagnostic performance of tests, creating more effective diagnostic strategies and leading to the effective utilization of laboratory information for the diagnosis and

The laboratory role in assessing patient outcomes

One of the advantages of managed care systems and other cost-containment processes is that they have forced individuals in different areas of health care to cooperate to get the entire picture of patient care. Patient outcomes are the result of medical care for a patient's well-being, in terms including functional status, healthy status and quality of life, that are perceptible to the patient. Research into laboratory outcomes enhances the value of the information concept, which means the

Consultancy in laboratory medicine

The observation that analytical operations constitute the more standardized component of many laboratory services has been accepted slowly [24]. Today, state-of-the-art laboratory competence calls for the ability to conduct test ordering, specimen collection, transport, storage, analysis, and result reporting in an accurate, timely and cost-effective way [25]. The laboratory–clinic interface is, therefore, of fundamental importance for quality, because it is the site for exchange of information

A patient-centered organization of clinical laboratory services

Some clinicians endlessly repeat that the “laboratory does not make the diagnosis”. Of course it does not; reaching a diagnosis is a complex process involving the interplay of several different sources of knowledge and information. However, clinicians cannot correctly manage a patient's disease without a contribution from the laboratory. The days when the X-ray department acted merely as photographic shop are long gone, and the time will come when clinical laboratories are providers of

Conclusions

Laboratory medicine is part of the total process of health care, and clinical laboratories should be expected to improve outcomes, not provide tests. Relevant outcomes include the cost of services, turnaround time, physician satisfaction, and overall system effectiveness. However, rigorous outcome studies must document the value of laboratory testing in the care process. Such value should be measured by the degree to which laboratory services advance the management of patients. Improvement in

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