R: [IMPROVEDX] Erroneous laboratory results

Mario Plebani mario.plebani at UNIPD.IT
Sat May 28 08:51:39 UTC 2016


The attachment was missed. It's the pdf of the paper cited.
Sorry about it
Mario

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Da: Elias Peter [mailto:pheski69 at GMAIL.COM] 
Inviato: venerdì 27 maggio 2016 23.43
A: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Oggetto: Re: [IMPROVEDX] Erroneous laboratory results


Regarding the relative roles of history, exam and extra testing, context
matters. A lot. 

For the majority of patients in a primary care office presenting with a new
issue, a properly done history and exam coupled with the diagnostic device
between our ears and allowed to work for sufficient time will provide the
diagnosis in an overwhelming majority of cases. (Based both on 40 years
personal experience and a fair amount of literature.) 

Further testing (lab, radiology, following the natural history by seeing the
patient back and repeating the initial process after a suitable wait) are
very useful to:


*	Confirm a suspected diagnosis, especially important if the diagnosis
is going to lead to treatment that could do harm if the diagnosis is wrong. 

*	Evaluate the extent of the diagnosis (anemia with a hemoglobin of 6
and MCV of 68 is different from anemia with a hemoglobin of 9 and a normal
MCV). 

*	Differentiate among several possible diagnoses that could explain
the presentation. 

*	Investigate why a treatment based on a diagnosis has not had the
expected result. 

*	Reassure the patient or clinician. 

*	Satisfy an external process (“What do you mean you started the
patient on a BP medicine for newly diagnosed hypertension without checking
an LDL and calcium?”)


In primary care, however, additional testing at the initial visit often
reflects less admirable triggers:


*	No clue what’s going on. Let’s go fishing. (How many red herrings
can we catch along with the target fish?) 

*	Too little time to do a good history and exam. 

*	Too little training to do a good history and exam. 

*	Too little experience to trust one’s history and exam. 

*	The reasonable possibility that there is a time-sensitive and life
threatening issue that will only be identified by further testing. (Feared
far more often than justified.)


That’s in primary care and with a known patient presenting with a new
problem.  If I am on call for my local hospital and the ED calls me to
evaluate/admit a patient I do not know with severe abdominal pain. that is a
totally different story. If I am treating a patient with a medicine that
affects potassium or renal function or can depress platelet production or
Vitamin K metabolism, laboratory studies can be essential and skipping them
is like driving with one’s eyes closed. 

With regard to the claim that 70% of medical decisions are based on
laboratory studies which represent 5% of costs, I believe that is an example
of a ‘zombie’ statistic that has been refuted but refuses to die. A couple
years ago in preparation for a talk, I tried to find the origin. I think it
comes from this paper by Forsman in 1996
(http://www.clinchem.org/content/42/5/813.full.pdf) where it is stated but
not referenced beyond saying that at Mayo they knew that 5% of their costs
at Mayo (which are arguably not broadly representative) were lab related and
that 70% of ‘critical decisions’ (admissions, discharges, drug therapy) were
‘leveraged by’ lab results.  If someone has newer documentation about this,
I would love to hear.

One of the problems, and this is what I understood Jason Maude to be
referencing, is that laboratory testing -= because it is concrete and easy
to measure/monitor - is talked and written about, used as a metric,
specified in recipes far more often than the cognitive processes which
should occur prior to obtaining the laboratory study, in order to be able to
use the laboratory study result.

Just my take. YMMV.

Peter Elias, MD




On 2016.05.27, at 2:14 PM, Knapp, Lucy <LKnapp at PEACEHEALTHLABS.ORG> wrote:


As a medical technologist with close to 40 years’ experience I am so
offended by this poorly educated comment I don’t even know how to respond. I
do agree that history and physical are extremely important, but objective
data and the ability to correctly use the data – both in ordering tests and
interpreting results is just as important. Recent studies (sorry, I can’t
quote a source, but I’m sure anyone with laboratory experience will agree)
have shown as much as 70% of medical decisions are based on diagnostic
testing and at the same time the cost of that testing is 3% of the total
medical costs in the US.

 

Personal experience – History and physical diagnosed a painful uterine
“fibroid’ in 2012. I had a hysterectomy using morcellation; no danger of
cancer, obviously. Pathology testing of the removed tissue showed
Leiomyosarcoma – unstageable because of the morcellation, but undoubtedly
spread by morcellation. I’m currently trying to deal with recurrence.
Additional pathology testing for estrogen receptors has provided me an
additional “gun” in the fight. 

 

Please – don’t dismiss what you don’t understand. 

 

Lucy

 

Lucy Knapp, MT(ASCP)   |  Technical Specialist, Chemistry  |  Laboratory

 <http://www.peacehealth.org/> PeaceHealth  |  400 NE Mother Joseph Place  |
Vancouver, WA 98664

office 360-514-2732  |  fax 360-514-1646

 

From: Jason Maude [mailto:jason.maude at ISABELHEALTHCARE.COM] 
Sent: Friday, May 27, 2016 2:55 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Erroneous laboratory results



This message originated outside of PeaceHealth's email system and contains
web links. Use caution when clicking on links. VERIFY THE SENDER before
opening attachments, clicking links or providing information.

How is it the profession has ended up placing such reliance on an aspect
which is shown to contribute so little and cost so much? 

 

This study backs up the old adage that 80% of the diagnosis is given by the
history and physical with relatively little contributed by tests

http://archinte.jamanetwork.com/article.aspx?articleid=1106285
<https://mail2.peacehealth.org/enduser/classify_url.html?url=SRKJG9+bKBsCsym
7kQNOcDkS6NcPUsik/R0n2BFbRkRPfGwyYd2lLfnMCg+upqON3/dK89OabI4jSAPKTwURVA==> 

 

To paraphrase Churchill, never in an industry has so much been shown to
contribute so little for so much expense!

 

Regards

Jason Maude

 

 

From: Tom Benzoni <benzonit at GMAIL.COM>
Reply-To: Society to Improve Diagnosis in Medicine
<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Tom Benzoni <benzonit at GMAIL.COM>
Date: Wednesday, 25 May 2016 17:08
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG"
<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Erroneous laboratory results

 

I'm a "thin" lab tester and 90% of what I order I don't need.

My junior confreres order easily double my volume.

Same outcomes narrowly defined; fully defined, worse outcomes.

(I don't order d-dimer on patients without at least moderate likelihood PEs
or DVT. My junior guys do so routinely and so do many more CTA and U/S. We
have the same rate of final diagnoses. But I (likely) have fewer renal
failures (we don't see followup) and fewer bankruptcies.


Take, for example, ABGs. They are rarely needed; the same data is available
venously and from already done tests (BMP/MGA/SMA7), pulse ox and EtCO2, yet
I see 40% of our ICU tests are ABG.

CBC with diff when most folks can't interpret the diff but don't know they
can't. CBC without diff when you only need the Hgb.

EKG in my shop is an excellent predictor that you do NOT have ACS.

All LPs go to IR.

I could go on. 

So overtesting is huge.

 

tom benzoni

 

On Wed, May 25, 2016 at 10:20 AM, Cameron Powell
<cameron at physiciancognition.com> wrote:

Perhaps some of you have already seen this study on under- and over-testing.

 

“First we found that the rate of overuse, meaning [medical laboratory] tests
that we performed that shouldn’t have been performed, average around 20%.
That means out of every 10 tests ordered about two tests on average should
not have been ordered.

“Even more surprising was the rate of underuse [of medical laboratory
tests]. This is the rate of tests that should have been ordered in a given
time but weren’t ordered. That rate was over 40%. So, for every three tests
performed, an additional two tests should have been ordered.”   

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0078962
<https://mail2.peacehealth.org/enduser/classify_url.html?url=BxZ18kZyS6/KbPy
/1ujgfTFrANiURXwk9lu0BcA37sQiueOJlTGHIQYgv3MPwM/VOughlTjYANbZQFZKLC1gNg1hOHM
tXP+U9p3xGL+KxP0=>  

 

We’ve taken a run at solving suboptimal testing strategies and it’s going
very well. We’ll keep you posted on our progress.

 

Cameron

 

 


Teaching Mode is Here! (Android
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Cameron Powell  |  CEO, Physician Cognition, Inc.

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<image001.png>

 

On May 20, 2016, at 12:40 PM, DR WILLIAM CORCORAN
<williamcorcoran at SBCGLOBAL.NET> wrote:

 

What do you think of the YouTube video and the comments posted?

 

WSJ journalist John Carreyrou shares year-long Theranos
<https://mail2.peacehealth.org/enduser/classify_url.html?url=PXYTP0DfAoGKNy2
qWUaxDadPXd0hfftNChM33MkbHcI=> investigation & breaks latest, stunning news



 
<https://mail2.peacehealth.org/enduser/classify_url.html?url=PXYTP0DfAoGKNy2
qWUaxDadPXd0hfftNChM33MkbHcI=> image


 
<https://mail2.peacehealth.org/enduser/classify_url.html?url=PXYTP0DfAoGKNy2
qWUaxDadPXd0hfftNChM33MkbHcI=> WSJ journalist John Carreyrou shares
year-long Theranos ...

	


 
<https://mail2.peacehealth.org/enduser/classify_url.html?url=PXYTP0DfAoGKNy2
qWUaxDadPXd0hfftNChM33MkbHcI=> View on youtu.be

Preview by Yahoo

	


								

 



Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran at 1959.USNA.com
 
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zQmUTYus/AVT/0rp7IZvdELgtXB4A4KGm7s1jjip5XmzH7/aM>
http://www.linkedin.com/in/williamcorcoranphdpe

https://www.box.com/shared/kfxg1lt9dh
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iyojPU/yR/XxJlJP0hwHBPJK0K0oNzuk4e6kW5e4oJx26XJW4>  

 

On Friday, May 20, 2016 11:10 AM, Dwight Oxley <dwight.oxley at GMAIL.COM>
wrote:

 

The link below details how a large number of erroneous results were reported
from a commercial medical laboratory. This report is just the latest in the
Wall Street Journal’s coverage of the Theranos Co. Lab results account for
more than 50% of the information in a medical record, thus the impact of
these is enormous.

 

Dwight Oxley

 

 

 
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52qqWhkdYtwG9sKVjV9kGwBzHuhU=> http://on.wsj.com/1TpKiL3

 


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