CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
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.
How to teach laboratory stewardship in the undergraduate medical curriculum
December 2020—The National Academy of Medicine estimated that approximately 30 percent of U.S. health care spending constitutes nonvalue-added waste. This waste may be generated through unnecessary laboratory tests and services, inefficiency of care delivery, excessive administrative costs, and high prices. A goal of medical educators is to inform undergraduate medical students about health care management and health care delivery to make them better stewards of cost-effective, high-value care (HVC). The authors described the results of a needs analysis to inform the design of an online case-based educational tool for teaching laboratory stewardship to medical students. To this end, they conducted a needs assessment that included semi-structured interviews of core clerkship directors and residency program directors, a national survey of the Undergraduate Medical Educators Section of the Association of Pathology Chairs, and a review of existing online resources for teaching HVC. Their results showed that all of the core clerkship directors and residency program directors thought that teaching laboratory stewardship as part of the undergraduate medical education (UME) curriculum was important. The two major themes that emerged from the analysis to enhance laboratory stewardship education were appropriate test ordering and interpretation. The authors also found several organizations that provide HVC education through online modules or clinical cases. These cases cover pediatric and adult clinical scenarios that address high-value, cost-effective diagnostic testing and focus on eliminating waste. In addition, some specialty journals highlight HVC in special sections or series and, therefore, may serve as an educational resource on this topic. Furthermore, data have shown that even short, required educational experiences dedicated to laboratory medicine may enhance learning. The authors, working with a diverse team of educators who can contribute their clinical perspectives to the diagnostic process, plan to develop a teaching tool that outlines the steps and pitfalls of diagnostic test ordering and interpretation. They acknowledge that for this initiative to be effective, the curricular intervention must be combined with reflective practice, a supportive learning environment, and role modeling by teaching faculty.
Roth CG, Huang WY, Caruso AC, et al. How to teach laboratory stewardship in the undergraduate medical curriculum? Am J Clin Pathol. 2020;153:66–73.
Correspondence: Dr. Christine G. Roth at christine.roth@bcm.edu
Correlates of RBC, platelet, and plasma transfusions among hospitalized children and neonates
Indications for transfusion of red blood cells, platelets, and plasma in pediatric patients, including neonates, vary across institutions and depend on a number of factors, such as age and severity of underlying disease. A recent study examined a decline in RBC transfusions across hospitalized patients of all ages, except pediatric patients, who were excluded from the study. The study detailed herein is a comprehensive analysis of a pediatric inpatient database to characterize the demographic and hospital-level correlates of RBC, plasma, and platelet transfusions for hospitalized pediatric and neonatal patients. The authors used the Kids’ Inpatient Database (KID), which is the largest publicly available all-payer pediatric inpatient care database in the United States, to determine the percentage of hospitalizations where patients underwent one or more allogenic RBC transfusions. Percentages of plasma and platelet transfusions were assessed as secondary outcomes. The KID database is a random sampling of 10 percent of all uncomplicated in-hospital births and 80 percent of remaining pediatric discharges from approximately 4,200 U.S. hospitals. The authors found that among 5,604,984 hospitalizations, the overall prevalence of transfusion was 1.07 percent for RBCs, 0.17 percent for plasma, and 0.35 percent for platelets. A further breakdown of the data showed that RBC transfusions occurred among 0.43 percent of neonatal admissions and 2.63 percent of pediatric admissions. For neonatal admissions, RBC transfusions were associated with nonwhite race, longer length of hospitalization, highest risk of mortality, and occurrence at an urban teaching hospital. For pediatric admissions, RBC transfusions were associated with the same factors as for neonates, with the addition of older age, female gender, and elective admissions status. Platelet and plasma transfusion factors were similar to those associated with RBC transfusion, except that older age groups had a lower percentage of pediatric plasma transfusions. The authors concluded that there is variability among the percentage of neonatal and pediatric patients transfused annually in the United States and there are several similar, yet unique, nonlaboratory predictors for transfusion. Because nationally representative data about factors associated with transfusion in neonatal and pediatric patients are limited, this study may further understanding of transfusion practices applied to these patients and may help lay the groundwork for standardizing pediatric transfusion therapy.