Deferoxamina: revolucionario tratamiento para la talasemia.
Por: Sebastián A. Ríos
LA NACION 30.09.2006 Página 26 Ciencia/Salud
http://www.lanacion.com.ar/cienciasalud/nota.asp?nota_id=845082
"Camila siempre me pregunta cuándo va a haber un medicamento para que no haya que pincharla todos los días", cuenta Patricia Rey, su mamá. Camila tiene talasemia, un trastorno de la sangre que requiere periódicas transfusiones. Esas transfusiones producen una acumulación de hierro en el organismo que obliga a los pacientes a recibir un segundo tratamiento.
"Todas las noches -dice Patricia, de 48 años-, después de cenar, le pinchamos la panza para colocarle una bomba, que le queda conectada hasta la mañana, cuando se despierta para ir al colegio." La bomba infunde una droga llamada deferoxamina, que limpia la sangre de hierro; sin ella, la expectativa de vida se reduce considerablemente.
Ayer fue anunciado el lanzamiento en la Argentina del primer tratamiento oral para la llamada sobrecarga de hierro. "El deferasirox es una pastilla diaria: el chico no se pincha más, se olvida de tener que dormir conectado a la bomba, es otra vida, es revolucionario", comenta el doctor Guillermo Drelichman, médico de planta del Servicio de Hematología del hospital Gutiérrez.
Drelichman tiene experiencia con este nuevo medicamento, ya que su hospital participó de un estudio clínico internacional que comprobó la eficacia y seguridad del deferasirox. "La experiencia fue increíble -asegura-. Al estar al lado del paciente te das cuenta de cómo le cambia la vida: chicos que eran retraídos, parcos, porque se tenían que pinchar todas las noches ahora son otros chicos."
Además, agrega, "cumplen con el tratamiento, que es lo que les permite tener una mayor expectativa de vida y una mejor calidad de vida. Con la bomba de infusión, muchos pacientes no cumplían con el tratamiento: imaginá un chico o un adolescente que tiene que dormir toda la noche conectado."
Patricia da testimonio de lo difícil que es mantener el uso de la bomba en el tiempo. "Camila pasó por todas las etapas -cuenta-. Desde el llanto hasta cuestionar por qué me tengo que poner la bomba; ahora lo entiende: sabe que es algo que le está salvando la vida. Pero igual a veces pregunta cuándo la vamos a dejar de pinchar."
Huérfanos
El deferasirox es un tratamiento efectivo no sólo para las personas con talasemia mayor, aclara el doctor Drelichman. También es efectivo para otras enfermedades como la mielodisplasia o anemias raras (como la de Fanconi), cuyos tratamientos requieren periódicas transfusiones de sangre y una terapia que evite la sobrecarga de hierro.
"Se calcula que entre 4000 y 5000 argentinos podrían beneficiarse con este nuevo tratamiento", estima Drelichman. Al momento, las únicas barreras son su alto costo y la falta de cobertura por parte de obras sociales, prepagas y del Estado mismo. Aunque no precisó cuál es su precio, el laboratorio Novartis informó que el tratamiento cuesta un poco más que la deferoxamina -"estará en el rango de los modernos tratamientos oncológicos"-, que cuesta entre 2000 y 3000 pesos al mes.
"Los quelantes de hierro [como la deferoxamina y ahora el deferasirox] no están incluidos en el Programa Médico Obligatorio (PMO), por lo que las obras sociales y prepagas cubren sólo un 30% o un 50% del tratamiento", dice Drelichman. "El PMO cubre las transfusiones, pero no sus complicaciones, como la sobrecarga de hierro", confirma Adriana Feldman de Justo, presidenta de la Fundación Argentina de Talasemia ( info@fundatal.org.ar ). "Estas son enfermedades huérfanas, que afectan a pocas personas, pero que son muy graves para las familias, por lo que deberían tener una cobertura del 100%", concluye Drelichman.
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Test de Laboratorios Innecesarios
Capitulo Bioquimico - Sociedad Argentina de Terapia Intensiva
Unnecessary Lab Tests
Can Laboratorians Stop Clinicians From Ordering Them?
Whether a laboratory test should be considered unnecessary or not depends primarily upon who you ask. In the eyes of a clinician, every test he or she orders is necessary. Most laboratori ans, on the other hand, can tell multiple stories about clinicians who submitted duplicate test orders, insisted on the use of outdated tests, or ordered tests that were not recommended by the standard of care for a particular condition. The debate over unnecessary lab testing seems to be a perennial aspect of the rela tionship between laboratorians and clinicians. As health care costs continue to escalate, however, the problem of unnecessary lab tests will become even more acute, as the financial burden to the system may run into the hundreds of millions—if not billions—of dollars. Some observers think that unless steps are taken to address the issue, the overall quality of health care in the U.S. may suffer. One recent study of diagnostic tests and procedures ordered by physicians during routine health exams estimated the direct cost of five diagnostic interventions for which there lacked strong justifica tion in asymptomatic patients at between $59.2 million and $255.6 million per year (American Journal of Preventive Medicine 2006;30:521–527). Dan Merenstein, MD, Assistant Professor of Medicine at Georgetown University Medical Center (Washington, D.C.) and lead author of the study, says that even more troubling is that these assumptions are conservative. “This might not seem like an excessive amount of money at first, we only looked at the direct costs of nonrecommended tests using Medicare reimbursement rates, which are significantly less than non-Medicare rates,” he said. “If you look at non-Medicare costs and focus on cost-effectiveness, it’s even more expensive. We’re talking potentially billions of dollars wasted on unwarranted tests.”
Minor Tests Add Up
Merenstein and his colleagues examined data from the 1997–2002 National Ambulatory Medical Care Survey (NAMCS) and discovered that clinicians were ordering three common lab tests, as well as X-rays and electrocardiograms, on asymptomatic patients at a relatively routine pace. The three tests—CBCs, hematocrits, and urinalyses—all hold “C” or “D” rankings from the U.S. Preventive Services Task Force (USPSTF) evidence-based guidelines for interventions offered during routine health exams. The USPSTF gives a “C” ranking to procedures that it does not recommend for or against, and provides a “D” ranking to procedures which it recommends against routinely providing to asymptomatic patients. A urinalysis currently holds a USPSTF “D” ranking, while CBCs and hematocrits are assigned a “C” recommendation.
“It’s interesting to note that the least valuable test—according to the USPSTF guidelines—was ordered most often by physicians,” Merenstein pointed out. “The physicians ordered a urinalysis in approximately one quarter to one third of all cases.” Clinicians in the study ordered CBCs at a similar rate, 27–29%, and requested hematocrits for asymptomatic patients 14–17% of the time. Merenstein says that it’s not just the financial costs of these seemingly minor tests that can be troublesome. He and his colleagues also calculated the implications of false positives from these unnecessary tests.
“If for some reason you have a false-positive urinalysis, the test will be repeated and if there is another false-positive it might lead to an ultrasound and a kidney biopsy,” he said. “Based on the results of our study, we would expect about 8,000 renal biopsies leading to 427 complications. In some cases, those complications can mean patient deaths.” Merenstein explains that the physicians who order these nonrecommended tests often do not see the consequences of a false positive. Following an abnormal test result, a physician will usually send the patient to a sub-specialist for follow-up, who will then order the repeat tests and more serious interventions. The additional costs, both financial and health-related, may therefore be invisible to the general practitioner.
Meeting Patient Expectations
Clinicians order nonrecommended diagnostic tests on outpatients for a variety of reasons, some of which are familiar to laboratorians and others which are unique to the intimacy of the doctor-patient relationship. “Many physicians order lab tests during routine exams because they think it improves their relationship with patients,” said Allan V. Prochazka, MD, Professor of Medicine at the University of Colorado Health Sciences Center (Denver). “Some may order nonrecommended tests because they’re not familiar with the USPSTF guidelines, but they also know that patients have certain expectations, and in many cases they agree with those expectations.” Prochazka’s own research into public attitudes toward annual physical exams and lab testing found that both patients and their primary care providers put greater emphasis on low-yield diagnostic tests like CBCs and urinalyses than on procedures of proven preventive value such as cholesterol screens.
“There seems to be a real disconnect between the recommendations for testing of outpatients in routine exams, the desires of patients, and physician practice,” Prochazka noted. “Patients generally feel that more is better in regard to lab testing, and in some cases they will even ask for certain tests.” Clinicians can also order multiple tests with relative ease, which encourages ‘blanket testing’ of patients who come in for routine exams. Prochazka explains that whether clinicians use a paper system or a computerized physician order entry (CPOE) system, it is all too easy to order potentially unwarranted tests. “In some cases, you can check one box on a requisition form or a computer screen and order a dozen tests, some of which you may not be completely familiar with,” he said. “You can imagine that if it’s that easy, many providers might not think twice about it.”
Merenstein agrees that pressure from patients may induce clinicians to order tests they might not otherwise request. “Many patients come to a primary care physician having done a lot of background research, and they might expect a doctor to order not just a urinalysis or a CBC but more ‘emergent’ tests like C-reactive protein or BNP,” he said. “Truthfully, some physicians might worry about getting sued by patients and will order tests that aren’t indicated by symptoms in order to protect themselves down the line.” Merenstein believes, however, that patient ‘over-education’ may not be to blame. He says that if patients are truly educated about certain medical issues they will respond appropriately. “I think we’ve educated patients about the dangers of overprescribing certain antibiotics, and that has had positive consequences. Ultimately, I don’t think we can fault the patient. It’s the physicians who order these nonrecommended tests and the responsibility must lie with them.”
Inappropriate Inpatient Orders
Routine outpatient testing isn’t the only culprit when it comes to the unnecessary use of lab resources. Laboratorians can cite many examples of inpatient test orders that might not be indicated by patient symptoms. “We see lots of tests that we consider to be ordered inappropriately,” said David G. Grenache, PhD, Director of Special Chemistry and Blood Gas Laboratories and Associate Director of the Core Laboratory at the University of North Carolina Hospitals (Chapel Hill). He gives the example of PTH-related peptide tests, for which his lab gets many requests. “A patient gets admitted to the hospital, and among the first tests ordered is a total calcium,” Grenache explained. “If the calcium is elevated, the clinician will often order both a PTH and a PTH-related peptide to evaluate parathyroid function. But these should not be ordered simultaneously. What the clinician should have done is wait a day or two to confirm that the calcium elevation is authentic before ordering a PTH.” Grenache points out that the calcium concentration in a dehydrated patient might read high, but when the patient is placed on IV fluids the calcium level often normalizes. At the very least, it would make more sense for the clinician to first measure ionized calcium, which is a better indication of calcium status. “Unfortunately, many clinicians order the PTH and PTH-related peptide together immediately after the calcium result. A request for PTH-related peptide should only be considered after you get PTH results.”
“Most of our CSF electrophoresis tests come from neurology and are generally ordered to investigate signs of multiple sclerosis,” he said. “But then we started seeing test orders on everyone who had a lumbar puncture.” Grenache says that when his lab began to contact clinicians, they learned that—in 90% of cases—the test was unwanted but had been ordered automatically because the CPOE system defaulted to a cluster of tests that included CSF electrophoresis. “That test is very labor-intensive and uses up a lot of lab resources,” he lamented. “We were ultimately able to work with the IT experts who handled CPOE and convinced them to change the defaults, but this one example goes to show how the lab can be used inappropriately even with an electronic ordering system.”
Change Comes Slowly
Fantz claims that often just picking up a phone is the easiest way to educate a clinician about misuse of lab tests and prevent unnecessary orders in the future. “Working at an academic medical center, we often get requests for esoteric tests that aren’t in the catalog,” she noted. “We flag these non-routine tests and ask our pathology residents to call the clinicians to determine if the test was mis-ordered. The interaction can be a learning opportunity for both sides. Often the responses are positive, and most clinicians appreciate the additional information, especially with difficult cases.”
Grenache thinks that clinicians need to know more about the actual costs of the tests themselves, in addition to gaining a deeper knowledge of how the lab functions. “Most labs don’t publish the costs of the tests on their Web site, and prices aren’t often easily obtainable,” he said. “While our primary concern is helping clinicians select the most appropriate test for their patients, I sometimes think that the costs of each test should be listed on CPOE so the clinicians can better appreciate the financial impact of what they’re doing.”
As Merenstein’s study demonstrates, the cumulative costs of even minor, nonrecommended tests like urinalyses can be substantial. Cost concerns become even more critical as the tests increase in complexity and price. Fantz says that with the advent of molecular testing, labs may have to take a firmer stand on unnecessary test orders. “In some ways, molecular testing is a scary thought for the lab, as many of those tests are not fully reimbursable,” she indicated. “If a clinician orders an expensive molecular test that does not affect patient care, and the test isn’t reimbursable, the laboratory stands to waste valuable hospital resources. Laboratorians should collaborate with their clinical colleagues and present the benefits of controlling ordering behavior.”
Prochazka suggests that while CPOE and EMR systems—with proper lab input on the design end—would do most to help guide clinician decision-making at the point-of-care, the traditional education approaches cannot be abandoned. “Seminars and email notices are not enough on their own, because many physicians don’t make it to training sessions and don’t remember the information in handouts and emails,” he said. “Labs really have to do a combination of things to get the message out. You have to strike the right balance because many clinicians are reluctant to accept changes if they think it will frustrate their attempts at patient care.” CLN
How One Lab Addressed Excessive Test Orders
Corinne R. Fantz, PhD, Co-Director of the Core Laboratory at Emory Crawford Long Hospital (Atlanta, Ga.), explains how her lab initiated a performance improvement project to examine send-out tests that ultimately eliminated a rash of unnecessary tests and saved money.
“We began our project with the aim of determining which high volume tests we should consider bringing in-house rather than continuing to send to a reference lab. As we reviewed the data, we were surprised to find that we were sending out a very large number of serum drug screens for transplant patients.
When we contacted the reference lab, we learned that our hospital was ordering more serum drug screens than any of their other customers. After discovering this, we attended meetings of the transplant faculty and asked why they were ordering so many serum drug screens. We were told that the drug screens were standard practice for their kidney transplant protocol and that in anuric renal transplant patients this was appropriate. But we also discovered that the requirements for the kidney transplant protocol were inadvertently copied to all the different transplant protocols—such as liver, heart, lung, and bone marrow. They were ordering serum drug screens for every transplant case in the hospital. We were sending out over $70,000 in serum drug screen testing each year.
Once we realized the problem, we developed a plan with the transplant division to order urine drug screens, which are performed in-house. This change resulted in significant savings for the hospital.”
_________________________________________________________________________________
Partes del articulo publicado en:
Clinical Laboratory News - September 2006
BY RICHARD PIZZI
Capitulo Bioquimico - Sociedad Argentina de Terapia Intensiva
http://www.sati.org.ar
Unnecessary Lab Tests
Can Laboratorians Stop Clinicians From Ordering Them?
Whether a laboratory test should be considered unnecessary or not depends primarily upon who you ask. In the eyes of a clinician, every test he or she orders is necessary. Most laboratori ans, on the other hand, can tell multiple stories about clinicians who submitted duplicate test orders, insisted on the use of outdated tests, or ordered tests that were not recommended by the standard of care for a particular condition. The debate over unnecessary lab testing seems to be a perennial aspect of the rela tionship between laboratorians and clinicians. As health care costs continue to escalate, however, the problem of unnecessary lab tests will become even more acute, as the financial burden to the system may run into the hundreds of millions—if not billions—of dollars. Some observers think that unless steps are taken to address the issue, the overall quality of health care in the U.S. may suffer. One recent study of diagnostic tests and procedures ordered by physicians during routine health exams estimated the direct cost of five diagnostic interventions for which there lacked strong justifica tion in asymptomatic patients at between $59.2 million and $255.6 million per year (American Journal of Preventive Medicine 2006;30:521–527). Dan Merenstein, MD, Assistant Professor of Medicine at Georgetown University Medical Center (Washington, D.C.) and lead author of the study, says that even more troubling is that these assumptions are conservative. “This might not seem like an excessive amount of money at first, we only looked at the direct costs of nonrecommended tests using Medicare reimbursement rates, which are significantly less than non-Medicare rates,” he said. “If you look at non-Medicare costs and focus on cost-effectiveness, it’s even more expensive. We’re talking potentially billions of dollars wasted on unwarranted tests.”
Minor Tests Add Up
Merenstein and his colleagues examined data from the 1997–2002 National Ambulatory Medical Care Survey (NAMCS) and discovered that clinicians were ordering three common lab tests, as well as X-rays and electrocardiograms, on asymptomatic patients at a relatively routine pace. The three tests—CBCs, hematocrits, and urinalyses—all hold “C” or “D” rankings from the U.S. Preventive Services Task Force (USPSTF) evidence-based guidelines for interventions offered during routine health exams. The USPSTF gives a “C” ranking to procedures that it does not recommend for or against, and provides a “D” ranking to procedures which it recommends against routinely providing to asymptomatic patients. A urinalysis currently holds a USPSTF “D” ranking, while CBCs and hematocrits are assigned a “C” recommendation.
“It’s interesting to note that the least valuable test—according to the USPSTF guidelines—was ordered most often by physicians,” Merenstein pointed out. “The physicians ordered a urinalysis in approximately one quarter to one third of all cases.” Clinicians in the study ordered CBCs at a similar rate, 27–29%, and requested hematocrits for asymptomatic patients 14–17% of the time. Merenstein says that it’s not just the financial costs of these seemingly minor tests that can be troublesome. He and his colleagues also calculated the implications of false positives from these unnecessary tests.
“If for some reason you have a false-positive urinalysis, the test will be repeated and if there is another false-positive it might lead to an ultrasound and a kidney biopsy,” he said. “Based on the results of our study, we would expect about 8,000 renal biopsies leading to 427 complications. In some cases, those complications can mean patient deaths.” Merenstein explains that the physicians who order these nonrecommended tests often do not see the consequences of a false positive. Following an abnormal test result, a physician will usually send the patient to a sub-specialist for follow-up, who will then order the repeat tests and more serious interventions. The additional costs, both financial and health-related, may therefore be invisible to the general practitioner.
Meeting Patient Expectations
Clinicians order nonrecommended diagnostic tests on outpatients for a variety of reasons, some of which are familiar to laboratorians and others which are unique to the intimacy of the doctor-patient relationship. “Many physicians order lab tests during routine exams because they think it improves their relationship with patients,” said Allan V. Prochazka, MD, Professor of Medicine at the University of Colorado Health Sciences Center (Denver). “Some may order nonrecommended tests because they’re not familiar with the USPSTF guidelines, but they also know that patients have certain expectations, and in many cases they agree with those expectations.” Prochazka’s own research into public attitudes toward annual physical exams and lab testing found that both patients and their primary care providers put greater emphasis on low-yield diagnostic tests like CBCs and urinalyses than on procedures of proven preventive value such as cholesterol screens.
“There seems to be a real disconnect between the recommendations for testing of outpatients in routine exams, the desires of patients, and physician practice,” Prochazka noted. “Patients generally feel that more is better in regard to lab testing, and in some cases they will even ask for certain tests.” Clinicians can also order multiple tests with relative ease, which encourages ‘blanket testing’ of patients who come in for routine exams. Prochazka explains that whether clinicians use a paper system or a computerized physician order entry (CPOE) system, it is all too easy to order potentially unwarranted tests. “In some cases, you can check one box on a requisition form or a computer screen and order a dozen tests, some of which you may not be completely familiar with,” he said. “You can imagine that if it’s that easy, many providers might not think twice about it.”
Merenstein agrees that pressure from patients may induce clinicians to order tests they might not otherwise request. “Many patients come to a primary care physician having done a lot of background research, and they might expect a doctor to order not just a urinalysis or a CBC but more ‘emergent’ tests like C-reactive protein or BNP,” he said. “Truthfully, some physicians might worry about getting sued by patients and will order tests that aren’t indicated by symptoms in order to protect themselves down the line.” Merenstein believes, however, that patient ‘over-education’ may not be to blame. He says that if patients are truly educated about certain medical issues they will respond appropriately. “I think we’ve educated patients about the dangers of overprescribing certain antibiotics, and that has had positive consequences. Ultimately, I don’t think we can fault the patient. It’s the physicians who order these nonrecommended tests and the responsibility must lie with them.”
Inappropriate Inpatient Orders
Routine outpatient testing isn’t the only culprit when it comes to the unnecessary use of lab resources. Laboratorians can cite many examples of inpatient test orders that might not be indicated by patient symptoms. “We see lots of tests that we consider to be ordered inappropriately,” said David G. Grenache, PhD, Director of Special Chemistry and Blood Gas Laboratories and Associate Director of the Core Laboratory at the University of North Carolina Hospitals (Chapel Hill). He gives the example of PTH-related peptide tests, for which his lab gets many requests. “A patient gets admitted to the hospital, and among the first tests ordered is a total calcium,” Grenache explained. “If the calcium is elevated, the clinician will often order both a PTH and a PTH-related peptide to evaluate parathyroid function. But these should not be ordered simultaneously. What the clinician should have done is wait a day or two to confirm that the calcium elevation is authentic before ordering a PTH.” Grenache points out that the calcium concentration in a dehydrated patient might read high, but when the patient is placed on IV fluids the calcium level often normalizes. At the very least, it would make more sense for the clinician to first measure ionized calcium, which is a better indication of calcium status. “Unfortunately, many clinicians order the PTH and PTH-related peptide together immediately after the calcium result. A request for PTH-related peptide should only be considered after you get PTH results.”
“Most of our CSF electrophoresis tests come from neurology and are generally ordered to investigate signs of multiple sclerosis,” he said. “But then we started seeing test orders on everyone who had a lumbar puncture.” Grenache says that when his lab began to contact clinicians, they learned that—in 90% of cases—the test was unwanted but had been ordered automatically because the CPOE system defaulted to a cluster of tests that included CSF electrophoresis. “That test is very labor-intensive and uses up a lot of lab resources,” he lamented. “We were ultimately able to work with the IT experts who handled CPOE and convinced them to change the defaults, but this one example goes to show how the lab can be used inappropriately even with an electronic ordering system.”
Change Comes Slowly
Fantz claims that often just picking up a phone is the easiest way to educate a clinician about misuse of lab tests and prevent unnecessary orders in the future. “Working at an academic medical center, we often get requests for esoteric tests that aren’t in the catalog,” she noted. “We flag these non-routine tests and ask our pathology residents to call the clinicians to determine if the test was mis-ordered. The interaction can be a learning opportunity for both sides. Often the responses are positive, and most clinicians appreciate the additional information, especially with difficult cases.”
Grenache thinks that clinicians need to know more about the actual costs of the tests themselves, in addition to gaining a deeper knowledge of how the lab functions. “Most labs don’t publish the costs of the tests on their Web site, and prices aren’t often easily obtainable,” he said. “While our primary concern is helping clinicians select the most appropriate test for their patients, I sometimes think that the costs of each test should be listed on CPOE so the clinicians can better appreciate the financial impact of what they’re doing.”
As Merenstein’s study demonstrates, the cumulative costs of even minor, nonrecommended tests like urinalyses can be substantial. Cost concerns become even more critical as the tests increase in complexity and price. Fantz says that with the advent of molecular testing, labs may have to take a firmer stand on unnecessary test orders. “In some ways, molecular testing is a scary thought for the lab, as many of those tests are not fully reimbursable,” she indicated. “If a clinician orders an expensive molecular test that does not affect patient care, and the test isn’t reimbursable, the laboratory stands to waste valuable hospital resources. Laboratorians should collaborate with their clinical colleagues and present the benefits of controlling ordering behavior.”
Prochazka suggests that while CPOE and EMR systems—with proper lab input on the design end—would do most to help guide clinician decision-making at the point-of-care, the traditional education approaches cannot be abandoned. “Seminars and email notices are not enough on their own, because many physicians don’t make it to training sessions and don’t remember the information in handouts and emails,” he said. “Labs really have to do a combination of things to get the message out. You have to strike the right balance because many clinicians are reluctant to accept changes if they think it will frustrate their attempts at patient care.” CLN
How One Lab Addressed Excessive Test Orders
Corinne R. Fantz, PhD, Co-Director of the Core Laboratory at Emory Crawford Long Hospital (Atlanta, Ga.), explains how her lab initiated a performance improvement project to examine send-out tests that ultimately eliminated a rash of unnecessary tests and saved money.
“We began our project with the aim of determining which high volume tests we should consider bringing in-house rather than continuing to send to a reference lab. As we reviewed the data, we were surprised to find that we were sending out a very large number of serum drug screens for transplant patients.
When we contacted the reference lab, we learned that our hospital was ordering more serum drug screens than any of their other customers. After discovering this, we attended meetings of the transplant faculty and asked why they were ordering so many serum drug screens. We were told that the drug screens were standard practice for their kidney transplant protocol and that in anuric renal transplant patients this was appropriate. But we also discovered that the requirements for the kidney transplant protocol were inadvertently copied to all the different transplant protocols—such as liver, heart, lung, and bone marrow. They were ordering serum drug screens for every transplant case in the hospital. We were sending out over $70,000 in serum drug screen testing each year.
Once we realized the problem, we developed a plan with the transplant division to order urine drug screens, which are performed in-house. This change resulted in significant savings for the hospital.”
_________________________________________________________________________________
Partes del articulo publicado en:
Clinical Laboratory News - September 2006
BY RICHARD PIZZI
Capitulo Bioquimico - Sociedad Argentina de Terapia Intensiva
http://www.sati.org.ar
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