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Clinical Pathology Abstracts, 7/16

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Editor: Deborah Sesok-Pizzini, MD, MBA, professor, Department of Clinical Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, and chief, Division of Transfusion Medicine, Children’s Hospital of Philadelphia.

 

Utilization management to reduce unnecessary lab testing at a VA hospital

It is estimated that laboratory and pathology testing account for four percent of annual health care costs. A laboratory utilization management system, or laboratory expert system (LES), can be employed to reduce such costs. A variety of functionality, including passive and active alerts, in the computerized physician order entry (CPOE) system provide decision-making support for physicians ordering tests. Within the CPOE system, systemwide rules may be established for utilization management. Creating these rules requires a significant amount of work on the part of administrators, clinicians, laboratorians, and information technology personnel. The authors conducted a study in which they described their experience with an LES, a set of frequency filter subroutines, that had been incorporated in a VA hospital laboratory information system to help providers use laboratory testing more efficiently and effectively. They used an interdisciplinary medical team to formulate their LES. The system functioned as gatekeeper software that allowed the laboratory to suppress redundant testing by defining order-frequency rules for specific tests or test panels for a given patient. If the order exceeded the predefined rule for order frequency, the test was declined. If necessary, the ordering physician could still obtain testing on the patient by contacting the laboratory and asking for an exception. Furthermore, rules could be turned off for specific patient populations. The results showed that since implementing the LES, total test volume decreased by a mean of 11.18 percent per year compared with the authors’ pre-LES test volume. Laboratory cost savings were estimated to be $151,184 for 2012 and $163,751 for 2013. A significant percentage of the cost savings was attributed to reductions in high-volume, large-panel testing. No adverse events were reported, and mean length of stay was not impacted as a result of the LES intervention. The authors concluded that an electronic automated laboratory utilization system can reduce unnecessary laboratory testing. An important consideration in the success of such a utilization program is the availability of a robust CPOE system. A good working relationship among clinicians, hospital administration, information specialists, and the laboratory is also necessary.

Konger RL, Ndekwe P, Jones G, et al. Reduction in unnecessary clinical laboratory testing through utilization management at a US government Veterans Affairs hospital. Am J Clin Pathol. 2016;145:355–364.

Correspondence: Dr. Raymond Konger at rkonger@iupui.edu

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Esophageal histological changes associated with acute gastroesophageal reflux disease

The histological changes associated with acute gastroesophageal reflux disease have not been studied prospectively in humans. Recent studies in animals have challenged the commonly held belief that reflux esophagitis develops when esophageal surface epithelia cells are exposed to lethal chemical injury from refluxed acid. The authors conducted a study to evaluate histologic features of esophageal inflammation in acute gastroesophageal reflux disease (GERD) to analyze its pathogenesis. They enrolled in their study 12 patients with GERD that was successfully treated with proton pump inhibitors (PPIs). The patients began 24-hour esophageal pH and impedance monitoring and esophagoscopy with biopsies from non-eroded areas of the distal esophagus at baseline (taking PPIs) and at one week and two weeks after stopping the PPI medication. The primary outcome was change in esophageal inflammation two weeks after stopping the PPI medication, determined by comparing the lymphocyte, eosinophil, and neutrophil infiltrates in esophageal biopsies. Biopsies performed after one week and two weeks showed a significant increase in intraepithelial lymphocytes, which were mostly T cells. The eosinophils and neutrophils were few or absent. Basal cell and papillary hyperplasia developed without surface erosions. Two weeks after stopping the PPI medication, esophageal acid exposure increased, mucosal impedance decreased, and all patients had evidence of esophagitis. The authors concluded that discontinuing the PPI medication was associated with T lymphocyte inflammation without loss of surface cells. This suggests that the pathogenesis for reflux esophagitis may be cytokine mediated rather than the result of direct chemical injury to surface cells, as previously thought. Therefore, anti-inflammatory PPI effects, independent of their impact on acid inhibition, might contribute to GERD healing.

Dunbar KB, Agoston AT, Odze RD, et al. Association of acute gastroesophageal reflux disease with esophageal histologic changes. JAMA. 2016;315:2104–2112.

Correspondence: Dr. Stuart J. Spechler at sjspechler@aol.com

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