الفهرس 
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Abstract
Laboratory test utilization is defined as a strategy for performing appropriate laboratory testing with the goal of providing high-quality, cost-effective patient care. A test utilization initiative cannot be driven solely for cost-cutting purposes without also focusing on patient outcome; otherwise, any utilization programme will be either short-lived or ineffective.
Inappropriate laboratory testing may take several forms; overutilization, which refers to tests that are ordered but not indicated, underutilization, which refers to tests that are indicated but not ordered, and misutilization is when a test is clinically indicated but an inappropriate one is requested instead or the test is ordered correctly but in wrong timings or its result is never delivered to the physician.
Many factors can affect laboratory test utilization; there are factors related to clinicians who attributed the primary cause of over testing to fear of legal action. The clinicians, also have a lot of difficulties in ordering tests accurately; there are so many different tests, each with its own name and reported in various units. There are factors related to laboratory as; inappropriate test requests, order entry, misidentification of patient and specimen, and sample collection errors. There are, also other factors that are related to health system and factors related to the patients.
Inappropriate retesting is a cause of laboratory overutilization that can be avoided through implementation of minimal retesting intervals (MRI) into the laboratory order entry system. Minimal retesting intervals (MRI) are defined as the shortest time before a test should be repeated, based on the properties of the test and the clinical condition in which it is performed.
In 2013, the Association for Clinical Biochemistry and Laboratory Medicine (ACB), with the support of the Royal College of Pathologists, published recommendations aiming to provide assistance for implementation of MRI. They determined the best MRI for a large set of laboratory tests based on evidence-based guidelines and best state of the art practice, as well as requirements for MRI implementation.
Quality indicators (QIs) are recommended by the international standard for accreditation of clinical laboratories ISO 15189:2012 to monitor and assess all steps of the total testing process. However, various challenges prevent laboratories from using Qis effectively and consistently in actual practice. According to the last version of the international standard for clinical laboratory accreditation (ISO 15189: 2012). “quality indicators (Qis) can measure how well an organization meets the needs and requirements of users and the quality of all operational processes.”
The Working group on Laboratory Errors and Patient Safety (WG-LEPS) of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) has launched a project in 2008, Its primary goal is to identify a set of QIs; model of QIs (MQI) that can be used in all laboratories around the world, to define data collection procedures, and to provide quality specifications for evaluating laboratory results. Hi consists of 53 QIs, with 28 indicators for the preanalytical phase, 6 for the intra-analytical phase, and 11 for the postanalytical phase being described for the main processes. In addition, 5 indicators for monitoring support processes (2 for personnel competence, 2 for user satisfaction, and one for
laboratory information system efficiency) and three for outcome measures were created. An order of priority has been assigned for quality indicators to facilitate their introduction into practice, based on the importance of the specific indicator and the difficulty of data collection.
The WG-LEPS contact person collects and processes data from participating laboratories and issues a report. The laboratory results are described in the report in to a specific time period and the corresponding Sigma value with confidence level is specified. On the basis of the mean calculated from the Sigma values of laboratories from the same country and all participating laboratories, the laboratory can compare its performance to that of other participants. The results and Sigma value trends are displayed in a graph, as well as the frequency distribution.
In our study quality indicators that are relevant to Laboratory test utilization concept were selected and measured according to the IFCC Program aiming at cost control and best patient outcome and thus it was considered an improvement project.
According to the IFCC MQI project, the QIs relevant to the utilization concept were measured for three successive months, and initially reported through the Chemical Pathology Department account on the MQI project and were compared to other laboratories participating in the project. As regards reordered tests; Percentage of the number of inappropriate tests (laboratory tests with short minimal retesting interval and un accepted justification)/total reordered tests was measured on the following tests: serum creatinine and liver function tests. The ratio of inappropriate laboratory tests to the total tests reordered in one month were calculated for 3 months.
An improvement plan was established and implemented and it has been succeeded in improving the physicians’ reordering practices, then the ratio of inappropriate laboratory tests to the total tests reordered in one month were recalculated for another 3 months.
All quality indicators selected measured zero and this indicates that our laboratory of The Chemical Pathology Department of MRI follow the guidelines of ISO 15189. In Case of serum creatinine test, there was significant reordering and overriding of the MRI rule. As regarding liver function tests, it was found that the MRI rule was followed.
Results showed that there was a high statistically significant negative association between the plan implementation and the rate of non-justified serum creatinine retesting, This highlights the impact of our improvement plan, it has succeeded in reducing the percentage of non justified tests from 55.6% (pre improvement) to 23.8% (post improvement).There was a percent reduction of 57.3% in the risk of ordering a non -justified retested serum creatinine in the three months post-improvement compared to the three months pre-improvement. Results showed that there was a statistically significant positive association between the time since improvement plan implementation and the rate of non-justified serum creatinine retesting. The non justified tests percentage was found to be increased from 18.8% in the early 45 post improvement to 32.8% in the late 45 days post improvement. This finding pays our attention to the fact that the improvement plans should be repeated at short regular time intervals. The calculated risk ratio (RR) (95% CI)= 1.745 (1.043 to 2.919), i.e there was a 74.5% percent increase in the risk of ordering a non -justified retested serum creatinine in Late 45 days post improvement period compared to the early 45 Days post improvement.
Also our results showed that, high levels of serum creatinine influences the physician decision to reorder serum creatinine test to follow up the patient for appropriate management and this reordering practice is reasonably justified, but they are much restricted in reordering serum creatinine when its initial result is not increased even if it is clinically justifiable which in this case should be considered a picture of underutilization.