Worldlab 2011, Berlin ‘ ‘ Counting the Cost of the Preanalytical Phase Counting the Cost of the Preanalytical Phase ’ ’ • • The Impact of Preanalytical Errors on Patients Treatment: The Impact of Preanalytical Errors on Patients Treatment: Prof. G. Lippi, Prof. G. Lippi, Universitaria di Parma, Italy Universitaria di Parma, Italy • • Understanding the Cost of the Preanalytical Phase in an Outpati Understanding the Cost of the Preanalytical Phase in an Outpati ent Setting: ent Setting: Dr. G. Dr. G. Soffiati Soffiati , , Ospedale ʺS. Bortoloʺ, Italy Ospedale ʺS. Bortoloʺ, Italy • Discovering the Opportunity Cost of Preanalytical Errors: Discovering the Opportunity Cost of Preanalytical Errors: Prof. M. Nauck, Prof. M. Nauck, University Hospital Greifswald University Hospital Greifswald, Germany Germany • • Questions & Discussions Questions & Discussions • • Co Co ‐ ‐ chairs chairs Prof. M. Prof. M. Plebani Plebani & Prof. V. & Prof. V. Palicka Palicka WORLDMEDLAB 2011 Berlin WORLDMEDLAB 2011 Berlin ISW # 32 ISW # 32
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Worldlab 2011, Berlin
‘‘Counting the Cost of the Preanalytical PhaseCounting the Cost of the Preanalytical Phase’’
•• The Impact of Preanalytical Errors on Patients Treatment:The Impact of Preanalytical Errors on Patients Treatment:
Prof. G. Lippi, Prof. G. Lippi, Universitaria di Parma, ItalyUniversitaria di Parma, Italy
•• Understanding the Cost of the Preanalytical Phase in an OutpatiUnderstanding the Cost of the Preanalytical Phase in an Outpatient Setting:ent Setting:
Dr. G. Dr. G. SoffiatiSoffiati, , Ospedale ʺS. Bortoloʺ, ItalyOspedale ʺS. Bortoloʺ, Italy
• Discovering the Opportunity Cost of Preanalytical Errors:Discovering the Opportunity Cost of Preanalytical Errors:
Prof. M. Nauck, Prof. M. Nauck, University Hospital GreifswaldUniversity Hospital Greifswald, GermanyGermany
•• Questions & DiscussionsQuestions & Discussions
•• CoCo‐‐chairschairs Prof. M. Prof. M. PlebaniPlebani & Prof. V. & Prof. V. PalickaPalicka
The Impact of Preanalytical Errors on The Impact of Preanalytical Errors on
Patients TreatmentPatients Treatment
Prof. G. Prof. G. LippiLippiUniversity HospitalUniversity Hospital
Parma,Parma, ItalyItaly
‘‘Counting the Cost of the Preanalytical PhaseCounting the Cost of the Preanalytical Phase’’
Worldlab 2011, Berlin
Preanalyticalerrors
PreanalyticalPreanalyticalerrorserrors
Worldlab 2011, Berlin
Worldlab 2011, Berlin
Worldlab 2011, Berlin
Clinical ChemistryLaboratory
Worldlab 2011, Berlin
The consequences of laboratory errors might often be serious, especially for those related to specialised tests, as these are often considered as ‘diagnostic’. Thus, patients might be diagnosed with a particular disorder,when in fact they don't have it (i.e., ‘falsepositive’ test result is obtained), or else apatient with a true disorder might be missed(i.e., ‘false negative’ test result is obtained),both circumstances jeopardizing the patient health and producing unnecessary costs tothe healthcare system.
Worldlab 2011, Berlin
Worldlab 2011, Berlin
Worldlab 2011, Berlin
Worldlab 2011, Berlin
Worldlab 2011, Berlin
Economical impact of repeating blood collectionEconomical impact of repeating blood collection
Group n. of tubes / year
Group 1 3,5000,000
Group 2 800,000
Group 3 400,000
Group 4 100,000
% of repeated collection
Group 1 Group 2 Group 3 Group 4
2% $7,000 $1,600 $800 $200
5% $17,500 $4,000 $2,000 $500
10% $35,000 $8,000 $4,000 $1,000
15% $52,500 $12,000 $6,000 $1,500
20% $70,000 $16,000 $8,000 $2,000
Economical impact of repeating blood collection:
n. of tubes ____ x repetition of tube % = _______ x $0,10 = overall expense for repeating blood collection.
Understanding the Cost of the Preanalytical Understanding the Cost of the Preanalytical
Phase in an Outpatient SettingPhase in an Outpatient Setting
Dr. G. Dr. G. SoffiatiSoffiati,,Hospital ʺS. Bortoloʺ, Hospital ʺS. Bortoloʺ,
VicenzaVicenza , Italy, Italy
‘‘Counting the Cost of the Preanalytical PhaseCounting the Cost of the Preanalytical Phase’’
Worldlab 2011, Berlin
Preanalytic phase in the diagnosticprocess (% of work)
20%
37%
25%
14%4%
Preanalytic phase outof the laboratory
Preanalytic phase inthe laboratory
Analytic phase
Post analytic phase
Transportation
G. Guder et al. 2001
Worldlab 2011, Berlin
Documents
Much literature is available about preanalytic phase
Much literature is available about blood collection technique
There are no documents about management and organization of clinics and blood collection points
Worldlab 2011, Berlin
Organization and network of ClinicalLaboratories in Italy
• Public Laboratory– In the hospital
• Inpatients• Outpatients
• Private Laboratory– In the hospital
• Inpatients• Outpatients
– Out of the hospital• Outpatients
• Public Laboratories are more widespread in Northern Italy, while private outpatients laboratories are widely present in South.
Worldlab 2011, Berlin
Location of clinics and points ofblood collection
• Hospitals– Laboratory clinics– Integrated laboratory– Day service clinics
• Ex hospitals• Districts• Extra hospital policlinics• Retirement home• Care centers• Private clinics• Private policlinics • GP• At home service• Shopping centers
• With booking service• Without booking service • From Monday to Friday• From Monday to Saturday• Administrative check in office • Laboratory check in office • Informed Approval – Informative note (privacy)• Cashier service• Vein blood collection• Functional tests• Biological material delivery • OAT monitoring
Worldlab 2011, Berlin
Materials in clinics and bloodcollection points
• Blood collection system • Sanitary materials (cotton, disinfecting liquid, tourniquet, etc.)• Drugs• Informative System
– LIS– HIS– Software for booking office– Dedicated software, linked with LIS
Costo Beni Costo personale Costo tecnologia Costo pre-analitica Costo post-analitica Costo Comuni e Indiretti Costo GeneraliBloo
dco
llect
ion
Comparison between the cost of collecting blood samples and other categories of tests
Worldlab 2011, Berlin
BOCCONI UNIVERSITY- Milan Benchmarking Veneto Region (2010)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Prelievo
(Endocrinologia) Immunometria
Chimica clinica e metabolismo
Farmacotossicologia ed esoterici
HPLC Spettrometria di massa
Proteine ed elettroforesi
Citoflorimetria
Coagulazione
Emocitometria
VES
Batteriologia
Micologia
Parassitologia
Sierologia
Virologia
Calcoli
Feci
Liquidi biologici
UrinePr
elie
voC
him
ica
Clin
ica
Emat
olog
iaM
icro
biol
ogia
clin
ica
Pato
logi
a cl
inic
a
Costo Beni Costo personale Costo tecnologia Costo pre-analitica Costo post-analitica Costo Comuni e Indiretti Costo Generali
Blo
odco
llect
ion
Cost components
Worldlab 2011, Berlin
BOCCONI UNIVERSITY- MilanBenchmarking Veneto Region (2010)
0%
20%
40%
60%
80%
100%
Prestazioni obsolescenti
Genetica
Immunologia clinica
Biologia Molecolare
Patologia clinica
Microbiologia clinica
Ematologia
Chimica Clinica
Prelievo
Blood collection
Comparison the cost of each individual laboratory speciality
Attending Labs
Worldlab 2011, Berlin
Conclusions
• Of course the quality of the data collection to evaluate the aspects considered in this presentation should be improved.
• The methods used to manage the collection of blood samples is very diverse in the different laboratories we considered.
• This activity, blood collection, is often not taken into account in assessing the overall costs of the laboratory.
• This activity, blood collection, has relevant economic impact. It is important to agree whether it should be included within the budget of the laboratory
• Is the general belief claiming “we can save money by consolidating labs”really true? The reality is that most analyses do not take into account the cost of collecting blood samples to come to this conclusion.
• And finally, in a consolidation setting, what is and what will be the quality of our samples?
Worldlab 2011, Berlin
Thanks
This is not a bloodsample, thisis a patient
Caring is theguaranteefor betterresults
Worldlab 2011, Berlin
Discovering the Opportunity Cost of Discovering the Opportunity Cost of
‘‘Counting the Cost of the Preanalytical PhaseCounting the Cost of the Preanalytical Phase’’
Worldlab 2011, Berlin
Costs in German Health Care
Worldlab 2011, Berlin
Preanalytical Phase – Why do we care?
Costs
RiliBÄK 2008
Patient safety
Most errors occur outside the lab1, 2
Reputation
• 1 Plebani M & Carraro P. Mistakes in a Stat Laboratory: types and frequency. Clinical Chemistry 1997, 43(8): 1348-135.• 2 Carraro P & Plebani M. Errors in a Stat Laboratory: types and frequency 10 years later. Clinical Chemistry 2007, 53(7): 1338-1342.
Worldlab 2011, Berlin
Case report I - noticed
Adult twins with very similar names
Both had been in our hospital before
One was admitted with diagnosis stroke
Admission under twin brothers´ name
Noticed after several days (visitors)
Among others all lab results were reported under wrong patient
No severe consequences for patient – fortunately
Due to kind of error wristband was wrong as well
Worldlab 2011, Berlin
Case report II - noticed
Patient, female 51 years: Immunofixationelectrophoresis positive, no previous results available
Rerun of test after a few days(confirmation)
Immunofixation electrophoresis negative
Further reruns with fresh blood samplesgave also negative results
Next step: who was positive in the first place?
Patient in question had already been releasedand had to be called back in.
Worldlab 2011, Berlin
„Case report“ - unnoticed
Big number of rare mistakes
Various number of constantly re-occuring preanalytic mistakes, e.g.
Noticed (lab and ward) patient mix-ups occur several times a week
24h urine collection patient mix-up
Blood collection while intravenous-drip is still running
Wrong material e.g. plasma instead of serum for serum protein electrophoresis
Prolonged or wrong transportation (ammonia, glucose)
Worldlab 2011, Berlin
Approaches to quantify costs
Bottom-up approach
versus
Top-down approach
total costs of errors
Top: total costs of hospital
estimate cost of each error and addover estimated errors
estimated frequency of errors
estimated severity of errors
errors costs as % total hospital costs
wrong
Bottom: single errors
Worldlab 2011, Berlin
Cost Model estimates Opportunity costs
Costs that could have been saved if
the sample had not been rejected
due to preanalytical reasons.
Worldlab 2011, Berlin
Top-down approach
No need to chase single errors in a complex process
Decreased risk of over estimation of single error
No need to address all individual costs
but:
motivation of participants plays important role (positive and negative)
€ etc.+€ sample transport+€ consumables+€ work time
Worldlab 2011, Berlin
Cost Model
Developed by Frost & Sullivan and BD Diagnostics, Preanalytical Systems
Model estimates opportunity costs
Cost of hospital stay per patient and hour
Delay in procedures caused by errors
Costs of preanalytical errors in lost treatment hours and money
annual cost
number of patients
number of beds
number of repeatedblood collection
in different scenarios
Worldlab 2011, Berlin
Worldlab 2011, Berlin
Assumptions for the model
Restriction to repeated blood collection
100% utilisation of hospital and laboratory are assumed
Patients are categorised into three groups
Impact of a preanalytical error classified into three levels
Motivation of participants is neutral
Worldlab 2011, Berlin
Patient Categories
Critical care unit
Stationary non-critical patients
Out-patients
Worldlab 2011, Berlin
Impact of preanalytical errors
Low impact
Medium impact
High impact
“Best Case”
The error is spotted early in the process and a repeated blood collection is initiated.
“Medium Case”
The error is not spotted immediately, but there are no substantial consequences for the patient. Wrong results have been reported, no consequence for patient, redraw is initiated.
“Worst Case”
The error is only spotted after the patient was affected severely.
Worldlab 2011, Berlin
Cost Model – Strengths and Weaknesses
No detailed information about causes
Interview method can be biased
Quick and easy mandatory for compliance
Good estimate of magnitude
Worldlab 2011, Berlin
Greifswald
First application of model on basis:
one critical care unit
one regular ward
one ambulatory ward
Worldlab 2011, Berlin
Greifswald
0.08162mean
3 wards
% of total costCosts/bed/year €
Worldlab 2011, Berlin
Greifswald
0.19391Mean
34 wards
0.08162mean
3 wards
% of total costCosts/bed/year €
Worldlab 2011, Berlin
Greifswald
0.972025Worst case
0.0246Best case
0.19391Mean
34 wards
0.08162mean
3 wards
% of total costCosts/bed/year €
Worldlab 2011, Berlin
Cost Model – Results
7 hospitals in Europe and US (2008 – 2011)
Heterogeneous group of hospitals (e.g. 300-1500 beds)
Minimum MaximumMedian
Source: Frost & Sullivan, BD Diagnostics
49 € 2537 €185 €Error costs per bed and year
Error costs in % of total hospital costs0.05 % 0.10 % 0.82 %
162 €
0.08 %
391 €
0.19 %
Worldlab 2011, Berlin
Thank you for your attention!
Worldlab 2011, Berlin
QuestionsQuestions & & DiscussionsDiscussions
ProfProf. V. . V. Palicka, Palicka, University Hospital, Hradec University Hospital, Hradec KrKráálovlovéé, , Czech RepublicCzech Republic
Prof. M. PlebaniProf. M. Plebani, , University Hospital of University Hospital of PadovaPadova, Italy , Italy
‘‘Counting the Cost of the Preanalytical PhaseCounting the Cost of the Preanalytical Phase’’