Put it on the Board, 6/14

To help the physician understand the test results, a patient-specific, expert-driven narrative is provided for all evaluations in a number of specialty areas. This involves the interpretation of all evaluations in these areas of laboratory medicine—not just cases in which the physician asks for help to understand the meaning of the test results. This, Dr. Laposata said, transforms clinical lab test interpretation into something that works like anatomic pathology and radiology, where patient-specific interpretations are provided for all cases by specialists in the field.

This and other lab initiatives save Vanderbilt about $3 million each year by, for example, cutting unnecessary testing for leukemia and ordering pharmacogenomics testing to determine which patients do not get the expected antiplatelet effect from clopidogrel. While it costs Vanderbilt $300 per patient to order the pharmacogenomics testing, looking only at that side of the equation is shortsighted, Dr. Laposata said.

“It costs about $25,000 to bring someone in with a thrombosed stent. What if we can prevent one of those? It more than pays for the pharmacogenomics,” he told the crowd of more than 800.

The diagnostic management teams take on all cases that emerge from the special coagulation laboratory, all hematopathology cases, each sentinel case from microbiology, and every transfusion case that involves transfusion reactions, massive transfusions, handling errors, and Rh incompatibility. Vanderbilt is expanding the approach to endocrinology, toxicology, and autoimmunity on the clinical lab side. The diagnostic management team is also active in neuropathology, with plans to expand it to all other areas of anatomic pathology.

Clinicians need lab reports that include concise, meaningful, individualized narratives, said Dr. Laposata, the Edward and Nancy Fody professor of pathology at Vanderbilt University School of Medicine. He will take over as pathology chair at the University of Texas Medical Branch at Galveston in July. He recounted, to appreciative peals of laughter from the audience, the first time he sent a report to a neurologist with a simplified narrative explaining which tests were ordered, why, and the results’ clinical importance for the patient’s care.

“Hey, Mike, under the numbers today there was a paragraph,” Dr. Laposata recalled the neurologist saying in a phone call. “I understood it! And I handed it to the nurse who is also taking care of this patient, and she understood it!”

This kind of narrative report is now standard practice in the Vanderbilt clinical laboratory, Dr. Laposata said.
Robert L. Michel, editor-in-chief of The Dark Report, says the 30-second standing ovation Dr. Laposata received at the meeting in March was a first.

“In the 19 years we’ve produced this event, and that covers at least 800 people who have graced the podium, I cannot think of anyone else who got a standing ovation,” Michel tells CAP TODAY.

“More to the point, these attendees are leaders in their own labs and recognize the commitment and zeal it takes to accomplish integrated diagnostics per Michael Laposata’s vision,” he adds. “That’s because of all the inertia that exists with hospitals and physicians’ practices. It was very clear that this standing ovation was the audience’s recognition of his extraordinary commitment and the level of energy he has invested to achieve those phenomenal results. For these reasons, that moment was all the more moving for Mike and the audience both.”

—Kevin B. O’Reilly

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Cancer care and patient demands

Despite claims suggesting otherwise, inappropriate cancer patient demands are few and rarely lead to unnecessary tests and treatments from their health care providers, according to new results from a study that was presented by researchers in the Abramson Cancer Center and the Perelman School of Medicine at the University of Pennsylvania during the annual meeting of the American Society of Clinical Oncology in Chicago in early June.

The Penn Medicine team, including lead author Keerthi Gogineni, MD, MSHP, an instructor in the Division of Hematology-Oncology in the Abramson center, surveyed 26 oncologists and nurse practitioners immediately after patient encounters at the center—2,050 in total—to determine frequency of patient requests or demands for tests and treatment, whether those requests were appropriate, whether they were granted, and why (abstract No. 6530).

“The results from this new study help debunk many of the misconceptions people have about patient demands leading to unnecessary tests and treatments as a major source of higher health care costs in the U.S.,” Dr. Gogineni said in a statement. “In this study, inappropriate cancer patient demands were uncommon, and in less than one percent of the cases did providers order an inappropriate treatment or test when requested by patients.

“Clinicians felt that the majority of patient-directed requests were appropriate,” she added. “The data suggests that rather than being driven by patients to employ low-value, high-cost care, most of the time oncologists and nurse practitioners incorporated patients’ requests into a suitable plan of action.”

Questions about patient demands were raised last year after results from a study presented at ASCO by Penn Medicine researchers revealed that more than 80 percent of the general public, 69 percent of patients, and 70 percent of doctors surveyed believed hospitals and doctors conducted unnecessary tests and provided unnecessary treatments, and over 50 percent believed patients requested unnecessary tests or treatments.

To find out, the team broke down the 177 encounters in which patients had requests or demands regarding treatment or tests. Nearly 80 percent of the time, the requests or demands from patients were deemed appropriate by the clinician and followed through. The rest were considered inappropriate based on the clinician’s judgment and were not ordered. Of the total number of encounters, there were only four instances (0.2 percent) in which a clinician ordered an inappropriate test or treatment because of a patient’s demand.

The patient base was mostly non-Hispanic white (73 percent), with a mean age of 60. Overall, 42 percent had advanced stage or refractory disease, and 66 percent were undergoing active treatment—49.5 percent had palliative intent.

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FDA OKs Qiagen Therascreen KRAS to guide treatment, Artus C. diff kit

Qiagen’s Therascreen KRAS RGQ PCR kit received Food and Drug Administration approval to guide the treatment of metastatic colorectal cancer patients with Amgen’s Vectibix (panitumumab).

Qiagen’s Artus C. difficile QS-RGQ MDx kit has been cleared by the FDA to qualitatively detect Clostridium difficile. In addition, the FDA has granted 510(k) regulatory clearance for the QIAsymphony RGQ MDx system, Qiagen’s automation platform.

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Beckman Coulter’s phi named in NCCN guidelines

Beckman Coulter’s Prostate Health Index (phi) has been recommended by the National Comprehensive Cancer Network as a blood test to improve specificity for prostate cancer detection in its recently updated clinical practice guidelines.

“It is exciting to see phi recommended in the NCCN guidelines. I started offering phi to my patients this year and it has proven to be a valuable addition to our shared decisionmaking process,” said William Catalona, MD, principal investigator on the Prostate Health Index clinical study, in a statement. He is a urologist at Northwestern Medicine and director of the Clinical Prostate Cancer Program at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.