005 - Diagnostic effectiveness: the pre-preanalytic phase
Autor(s): P. Cappelletti
Issue: RIMeL - IJLaM, Vol. 2, N. 1, 2006 (MAF Servizi srl ed.)
Page(s): 5-19
To answer to its own nature, Laboratory Medicine should maintain the governance of the total testing process. In this framework, the key is the clinic-laboratory interface, where the essential activities of Laboratory Medicine such as pre and post analytical phases occur. The pre-pre-analytical phase consists of three steps: identifying the question, selection of the appropriate test, the test order or request. Identifying the clinical question seems an obvious matter; nevertheless, all conceptual uncertainties and discrepancies of the methodological vision of the diagnosis, the complexity of the diagnostic process, and the issues of the clinical and societal background meet each other at that point. The appropriateness should be the cornerstone of the test selection. Nevertheless, the definition of the appropriate use of laboratory tests remains an unreached goal, because of the difficulties in determining its essence, measuring the field, pointing out the borders, and founding it on solid evidences. Methodologies have been designed to measure the appropriateness and were used to determine the rate of overuse in the laboratory tests requests. The concept of outcome became the meter of measure of inappropriateness and defined the intimate relationship between appropriateness and evidence-based medicine. But the evidence in Labora tory Medicine is weak because of the issue of gold standard, the designs of primary studies, the problems in outcome studies, and biases in systematic studies and meta-analyses. However, intervention strategies have been selected, as combination of educational, administrative and feed-back techniques, and their results in terms of volume of tests, costs, and effectiveness were measured. Redesigning the request forms is one of main tools in the battle for appropriateness. This change should be accompanied and underpinned by sharing educational intervention and research results with clinicians. It is an incomparable opportunity of communication with the other side of the medicine. If the Laboratory does not know the reasons of clinical ordering, the diagnostic logic, the issues of clinical decision making following the laboratory testing, it is not able to answer effectively to the actual clinical question.