Gion Massimo, Trevisiol Chiara, Fabricio Aline S C
Regional Center for Biomarkers, Department of Clinical Pathology and Transfusion Medicine, Azienda ULSS3 Serenissima, Venice, Italy.
Istituto Oncologico Veneto IOV-IRCCS, Padua, Italy.
Ann Transl Med. 2017 Jul;5(13):274. doi: 10.21037/atm.2017.06.19.
Appropriateness is crucial to provide efficient and high-quality health services at affordable costs. Laboratory medicine is a sector of special interest for the investigation of inappropriateness, due to the high rate of technological innovation and its pivotal role in many diseases and clinical settings. Some subjective aspects related to either the patient or physician seem to have a major role on inappropriateness rates. Given the psychological impact of cancer on both patients and physicians, tumor markers represent a case of study for appropriateness. The assessment of inappropriateness of laboratory tests has been focused mainly on ordering patterns. Appropriateness can barely be appraised by matching the requested test with the clinical problem because clinical information on the test requisition form is usually inadequate. Monitoring inappropriateness through individual clinical information may be feasible in inpatient (clinical data are available), while an indirect approach should be used for outpatients. To estimate inappropriateness in outpatients our group developed innovative models based on comparison between the actually ordered and expected requests of tumor marker, calculated according to recommendations of clinical practice guidelines (CPGs) applied to figures of cancer prevalence. The implementation of the model at national scale in Italy led to recognize a very high rate of overordering of tumor markers. The model was further focused by a dedicated algorithm to be adapted to different clinical conditions or organizational settings by applying performance indicators to cohort-wide structured information in electronic health records (EHRs). With this novel approach, we showed that inappropriateness is multifaceted even within the specific category of tumour markers. The model was effective in identifying both over- and underordering. Implementation of evidence based information and monitoring their impact on the clinical practice are parts of the same, multistage, process aimed at the progressive improvement of health care.
适宜性对于以可承受的成本提供高效、高质量的医疗服务至关重要。检验医学因其技术创新率高及其在许多疾病和临床环境中的关键作用，是调查不适当性的一个特别受关注的领域。一些与患者或医生相关的主观因素似乎在不适当率方面起主要作用。鉴于癌症对患者和医生的心理影响，肿瘤标志物是适宜性研究的一个案例。对实验室检查不适当性的评估主要集中在开单模式上。由于检验申请单上的临床信息通常不充分，仅通过将所申请的检查与临床问题相匹配几乎无法评估适宜性。通过个体临床信息监测不适当性在住院患者中可能可行（临床数据可用），而对于门诊患者则应采用间接方法。为了估计门诊患者中的不适当性，我们小组开发了创新模型，该模型基于根据应用于癌症患病率数据的临床实践指南（CPG）建议计算的肿瘤标志物实际开单与预期申请之间的比较。该模型在意大利全国范围内的实施导致认识到肿瘤标志物的过度开单率非常高。该模型通过一种专用算法进一步聚焦，通过将性能指标应用于电子健康记录（EHR）中全队列的结构化信息，使其适用于不同的临床情况或组织环境。通过这种新方法，我们表明即使在肿瘤标志物的特定类别中，不适当性也是多方面的。该模型在识别过度开单和开单不足方面均有效。实施基于证据的信息并监测其对临床实践的影响是旨在逐步改善医疗保健的同一多阶段过程的一部分。
