Pre-Preanalitik Evreye Güncel Yaklaşım
Özet
Pre-preanalitik evre, toplam laboratuvar test sürecinin klinik laboratuvar kontrolü dışındaki ilk aşamasıdır ve klinisyenlerin test seçimi ile bu isteği iletmesini kapsar. Modern sağlık hizmetlerinde kararlar büyük oranda laboratuvar sonuçlarına dayansa da, bu süreçte en sık karşılaşılan hata türü uygunsuz test istemidir. Artan test yüküne rağmen azalan bütçeler, talep yönetimini zorunlu hale getirmiştir. Uygunsuz test kullanımı; rutin testlerin aşırı istenmesi veya gerekli tanı testlerinin istenmemesi (yetersiz kullanım) şeklinde ortaya çıkar ve hasta güvenliğini tehdit ederken ciddi mali kaynak israfına yol açar. Talep yönetimi stratejileri arasında refleks ve reflektif test uygulamaları, kanıta dayalı klinik protokollerin kullanımı ve istem formlarının yeniden düzenlenmesi öne çıkar. Ayrıca, testlerin tekrarlanması için biyolojik süreçlere dayalı "minimum tekrar aralıkları" belirlenmesi ve hekimlere bilgisayar tabanlı karar destek sistemleri üzerinden geri bildirim verilmesi gereksiz istemleri önemli ölçüde azaltmaktadır. Eğitim ve farkındalık çalışmaları uzun vadeli başarı için kritiktir. Sonuç olarak, pre-preanalitik evrenin optimize edilmesi, yalnızca maliyetleri düşürmekle kalmayacak, aynı zamanda hasta bakım kalitesini ve laboratuvar hizmetlerinin değerini artıracaktır.
The pre-preanalytical phase is the initial stage of the total laboratory testing process that remains outside the control of the clinical laboratory, encompassing the clinician's test selection and the communication of this request. Although modern healthcare decisions rely heavily on laboratory results, inappropriate test ordering is the most common error in this process. Despite an increasing test workload, decreasing budgets have made demand management mandatory. Inappropriate test use manifests as over-ordering routine tests or failing to order necessary diagnostic tests (underuse), which threatens patient safety and causes significant waste of financial resources. Key demand management strategies include reflex and reflective testing, the use of evidence-based clinical protocols, and the redesign of requisition forms. Additionally, establishing "minimum retesting intervals" based on biological processes and providing feedback to physicians via computer-based decision support systems significantly reduce unnecessary requests. Education and awareness initiatives are critical for long-term success. In conclusion, optimizing the pre-preanalytical phase will not only reduce costs but also enhance the quality of patient care and the overall value of laboratory services.
Referanslar
Zemlin AE. Errors in the extra-analytical phases of clinical chemistry laboratory testing. Ind J Clin Biochem. 2018;33(2):154-162. doi:10.1007/S12291-017-0657-2/TABLES/1
Mrazek C, Lippi G, Keppel MH, et al. Errors within the total laboratory testing process, from test selection to medical decision-making – A review of causes, consequences, surveillance and solutions. Biochem Med. 2020;30(2):215-233. doi:10.11613/BM.2020.020502
Wertheim BM, Aguirre AJ, Bhattacharyya RP, et al. An educational and administrative ıntervention to promote rational laboratory test ordering on an academic general medicine service HHS public access. Am J Med. 2017;130(1):47-53. doi:10.1016/j.amjmed.2016.08.021
Smit I, Zemlin AE, Erasmus RT. Demand management: an audit of chemical pathology test rejections by an electronic gate-keeping system at an academic hospital in Cape Town. Ann Clin Biochem. 2015;52(4):481-487. doi:10.1177/0004563214567688
Janssens PMW. Managing the demand for laboratory testing: Options and opportunities. Clin Chim Acta. 2010;411(21-22):1596-1602. doi:10.1016/J.CCA.2010.07.022
Bucholc M, O’Kane M, Mullan C, at al. Primary care use of laboratory tests in Northern Ireland’s Western Health and Social Care Trust: a cross-sectional study. BMJ Open. 2019;9(6). doi:10.1136/BMJOPEN-2018-026647
Cadamuro J, Gaksch M, Wiedemann H, et al. Are laboratory tests always needed? Frequency and causes of laboratory overuse in a hospital setting. Clin Biochem. 2018;54:85-91. doi:10.1016/J.CLINBIOCHEM.2018.01.024
Ferraro S, Panteghini M. The role of laboratory in ensuring appropriate test requests. Clin Biochem. 2017;50(10-11):555-561. doi:10.1016/J.CLINBIOCHEM.2017.03.002
Lippi G, Bovo C, Ciaccio M. Inappropriateness in laboratory medicine: An elephant in the room? Ann Transl Med. 2017;5(4). doi:10.21037/ATM.2017.02.04
Zhi M, Ding EL, Theisen-Toupal J, at al. The landscape of inappropriate laboratory testing: a 15-year meta-analysis. PLOS ONE. 2013;8(11):e78962. doi:10.1371/JOURNAL.PONE.0078962
Duddy C, Wong G. Efficiency over thoroughness in laboratory testing decision making in primary care: findings from a realist review. BJGP Open. 2021;5(2):1-12. doi:10.3399/BJGPOPEN20X101146
Misra S, Barth JH. How good is the evidence base for test selection in clinical guidelines? Clin Chim Acta. 2014;432:27-32. doi:10.1016/J.CCA.2014.01.040
Jones BJ, Twomey PJ. Comparison of reflective and reflex testing for hypomagnesaemia in severe hypokalaemia. J Clin Pathol. 2009;62(9):816-819. doi:10.1136/JCP.2008.060798
Whiting P, Toerien M, de Salis I, et al. A review identifies and classifies reasons for ordering diagnostic tests. J Clin Epidemiol. 2007;60(10):981-989. doi:10.1016/J.JCLINEPI.2007.01.012
Smellie WSA, Galloway MJ, Chinn D. Benchmarking general practice use of pathology services: a model for monitoring change. J Clin Pathol. 2000;53(6):476-480. doi:10.1136/JCP.53.6.476
Mogyorósy Z, Mogyorósy G. Practice pattern and geographic variation in test ordering. A literature review. Orvosi Hetilap. 2006;147(1):25-31. Accessed March 16, 2022. https://europepmc.org/article/med/16519067
Sackett DL, Rosenberg WMC, Gray JAM, at al. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-72. doi:10.1136/BMJ.312.7023.71
Patel V, Gillies C, Patel P, et al. Reducing vitamin D requests in a primary care cohort: a quality improvement study. BJGP Open. 2020;4(5):1-8. doi:10.3399/BJGPOPEN20X101090
Fryer AA, Hanna FW. Managing demand for pathology tests: Financial imperative or duty of care? Ann Clin Biochem. 2009;46(6):435-437. doi:10.1258/acb.2009.009186
Lapić I, Rogić D, Fuček M, at al. Effectiveness of minimum retesting intervals in managing repetitive laboratory testing: experience from a Croatian university hospital. Biochem Med. 2019;29(3). doi:10.11613/BM.2019.030705
Mindemark M, Larsson A. Long‐term effects of an education programme on the optimal use of clinical chemistry testing in primary health care. Scand J Clin Lab Invest. 2009;69(4):481-486. doi:10.1080/00365510902749123
Gouzi F, Hédon C, Blervaque L, et al. Interactive whiteboard use in clinical reasoning sessions to teach diagnostic test ordering and interpretation to undergraduate medical students. BMC Med Educ. 2019;19(1). doi:10.1186/S12909-019-1834-1
Niès J, Colombet I, Zapletal E, at al. Effects of automated alerts on unnecessarily repeated serology tests in a cardiovascular surgery department: A time series analysis. BMC Health Serv Res. 2010;10(1):1-7. doi:10.1186/1472-6963-10-70/FIGURES/3
Poley MJ, Edelenbos KI, Mosseveld M, et al. Cost consequences of ımplementing an electronic decision support system for ordering laboratory tests in primary care: Evidence from a controlled prospective study in the Netherlands. Clin Chem. 2007;53(2):213-219. doi:10.1373/CLINCHEM.2006.073908
Bunting PS, van Walraven C. Effect of a controlled feedback ıntervention on laboratory test ordering by community physicians. Clin Chem. 2004;50(2):321-326. doi:10.1373/CLINCHEM.2003.025098
