The clinical laboratory reinforces its commitment to quality in the National Health System with 5 recommendations of things "not to do"
- Unnecessary tests are performed daily in clinical laboratories, despite having little or no efficacy and not being cost-effective.
- Clinical laboratory professionals should be committed to reviewing and evaluating the analytical tests requested by clinicians and avoiding unnecessary testing.
- The SEQCML has a Strategic Plan in advanced stages of development that includes an extensive test optimization policy, with the philosophy of "not to do" at the forefront.
The Spanish Society of Laboratory Medicine (SEQCML), a member of the "Not To Do" project of the Ministry of Health, has implemented 5 recommendations to reinforce its commitment to quality and efficiency in the National Health System. These are guidelines aimed at reducing the number of unnecessary tests in daily use at clinical laboratories, that is, those that have not demonstrated efficacy, have little or dubious effectiveness, and are not cost-effective.
The creation of the recommendations and the inclusion of the SEQCML in this project respond to the need for "direct involvement of the clinical laboratory in this initiative for commitment to quality", explains Dr. Francisco A. Bernabeu, member of the Board of the SEQCML and the person responsible for the "Not To Do" project. In his view, "Clinical laboratory practitioners should collaborate with requesting clinicians in seeking to improve the quality and efficiency of patient care."
The "Not To Do" initiative was launched in 2013 by the Ministry of Health, Social Services, and Equality in response to an initiative of the Spanish Society of Internal Medicine (SEMI), which in turn was based on similar international experiences such as "Choosing Wisely" in the United States, or that developed by NICE in the United Kingdom. The project is part of the activities of the Spanish Network of Health Technology Assessment Agencies. To date, 50 scientific societies have participated. The SEQCML joined in 2015, but it was in 2016 when the five agreements on things "not to do" in the clinical laboratory were presented. The recommendations are as follows:
- Do not request multiple tests on the initial assessment of a patient with suspected thyroid disease. First, request a test of thyroid stimulating hormone (TSH), and if it is abnormal, continue with additional evaluation or with treatment.
- The determination of total CK or CK-MB, or AST, or LDH, or myoglobin for the diagnosis of myocardial damage (or myocardial infarction) is not recommended.
- Do not test for allergen-specific IgE in a patient whose clinical history shows no symptoms of adverse reactions or without previous "in vivo" tests. In any case, do not perform systematic studies of various immunoglobulins against allergens without a thorough review of the patient's medical history.
- Do not carry out population screening for vitamin D deficiency by measuring serum 25-hydroxy vitamin D (Calcidiol).
- Do not request a sedimentation rate or erythrocyte sedimentation rate (ESR) to assess inflammation in patients with undefined diagnosis. To detect proinflammatory status in the acute phase, request C-reactive protein (CRP).
Dr Bernabeu points out that "these five measures were selected from a large number proposed by the SEQCML expert group, from which 10 were selected and of these the five priority recommendations (through the Delphi method)." These guidelines were presented, along with those of seven other scientific societies, in the "Commitment to Quality by Scientific Societies in Spain" Conference, held on May 31, 2016.
Dr. Silvia Izquierdo, member of the Laboratory Accreditation Commission within the SEQCML, explains that "clinical laboratory professionals must make a commitment to review and evaluate the analytical tests requested by clinicians and to avoid unnecessary testing". In her opinion, "sometimes clinicians request tests from the laboratory for reasons that deviate from the true purpose: diagnosis, monitoring, confirmation of a clinical suspicion, and prognosis." It is here that "the responsibility of the clinical laboratory doctor plays a key role". Dr. Izquierdo believes that sometimes lists of services are not updated adequately, and these "should be revised and modified in accordance with recommendations established by the scientific societies related to clinical laboratories and with agreements established by clinicians".
This SEQCML project is part of its strategic approach to accreditation of clinical laboratories, in which new steps will be taken soon. Dr. Bernabeu explains that "the SEQCML has a Strategic Plan in advanced stages of development in which the philosophy 'not to do' is a central element. One of the main focuses of the Plan is the promotion of excellence in scientific and technical activities, in which demand management and benchmarking play a prominent role. Laboratory professionals also have a lot to contribute in their role as consultants, as reflected in the Plan´s focus on enhancing Laboratory Medicine."
This is a necessity, as "variability in the use of the tests available in the clinical laboratory can have consequences for the patient, since it is possible to end up doing analytical determinations that are not effective", says Dr. Izquierdo. In this vein, the close relationship between the implementation of new regulations (ISO 15189: 2012) and the "not to do" tests stands out. This standard "makes available to the clinical laboratory professional an appropriate request form", which is important for improving quality and efficiency in daily clinical practice.