Clinical pathology selected abstracts

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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.

Use of thromboelastography to guide blood product transfusion

January 2020—Thromboelastography and rotational thromboelastometry provide insights into blood clot development, stabilization, and dissolution. The coagulation tests provide a tracing through the clotting process, but although they are similar, they are not interchangeable. The cups and pins used in each system are slightly different, leading to some differences in the measured parameters. With thromboelastography (TEG) and rotational thromboelastometry (ROTEM), the goal is to use the tracing to provide semi real-time management of excessive bleeding through targeted administration of the appropriate hemostatic blood components. The tracings may be transmitted in real time to the operating room, emergency department, or patient floors to hasten decision-making. This optimizes hemostasis while potentially minimizing unnecessary blood product exposure. The authors of this study analyzed the utility of thromboelastography to guide blood product transfusion. They discussed a case scenario—an infant on extracorporeal membrane oxygenation (ECMO) with coagulopathy—and the interpretation of the TEG tracings, and they reviewed literature examining the use of TEG/ROTEM for blood transfusions. The authors identified studies that showed that TEG/ROTEM is useful for evaluating clot kinetics in trauma patients and those bleeding acutely and that the results are more rapidly available than those of standard coagulation assays. However, TEG/ROTEM is more costly. TEG/ROTEM may be helpful in assessing excessive bleeding, such as with cardiac surgery, liver transplantation, and trauma. Based on their literature review and the scenario of the infant on ECMO, the authors determined that TEG/ROTEM may help guide resuscitation and blood product transfusion. However, other studies have not found TEG/ROTEM to be as clinically effective for guiding transfusion. The authors concluded that there may be clinical scenarios where TEG/ROTEM is a more convenient and expeditious test for assessing coagulation function than standard assays. It may be particularly useful for detecting fibrinolysis, which is not as rapidly assayed by other coagulation tests.

Schmidt AE, Israel AK, Refaai MA. The utility of thromboelastography to guide blood product transfusion: an ACLPS critical review. Am J Clin Pathol. 2019;157:407–422.

Correspondence: Dr. Amy Schmidt at aschmidt@urmc.rochester.edu

Cost per CMI-adjusted hospital day as a measure of lab utilization efforts

As health care costs are rising, hospital laboratories are often facing such financial challenges as a drop in reimbursement for services, denial of claims, and increasing pressure from administration to reduce expenses and improve test utilization. Laboratory directors must work with front-line ordering clinicians and provide education and data about the value and utility of limiting laboratory tests and reducing costs. Many of these efforts are time consuming and are not accounted for in physician measurements of productivity. The authors conducted a study to demonstrate that an aggregate of small measures of improvement can lead to cost savings in the form of inpatient tests/case mix index (CMI)-adjusted discharge and cost/CMI-adjusted hospital day. They changed test menus, educated physicians, and provided laboratory utilization feedback to address costs and the overuse of tests. The authors used test volume and cost review to monitor the effectiveness of the measures. Test volume, laboratory costs, CMI, length of hospital stay, and number of discharges were obtained through the hospital finance department from 2010 through 2016. The authors showed that cost/CMI-adjusted hospital day and inpatient tests/CMI-adjusted discharge better demonstrated the impact of utilization improvements than did traditional metrics of cost-per-test analysis. This was because the cost/CMI-adjusted hospital day and inpatient tests/CMI-adjusted discharge accounted for changes in patient volume and acuity. In conclusion, the authors recommended that cost/CMI-adjusted hospital day and inpatient tests/CMI-adjusted discharge be used to demonstrate the effectiveness of laboratory utilization efforts. They noted that the CMI is based on hospital financial calculations, which depend on accurately assessing diagnosis-related groups and discharges. They suggested that sharing and benchmarking across other laboratories can help drive improvements in laboratory test utilization.