Changing resident test ordering behavior: a multilevel intervention to decrease laboratory utilization at an academic medical center.

Hospital laboratory test volume is increasing, and overutilization contributes to errors and costs. Efforts to reduce laboratory utilization have targeted aspects of ordering behavior, but few have utilized a multilevel collaborative approach. The study team partnered with residents to reduce unnecessary laboratory tests and associated costs through multilevel interventions across the academic medical center. The study team selected laboratory tests for intervention based on cost, volume, and ordering frequency (complete blood count [CBC] and CBC with differential, common electrolytes, blood enzymes, and liver function tests). Interventions were designed collaboratively with residents and targeted components of ordering behavior, including system changes, teaching, social marketing, academic detailing, financial incentives, and audit/feedback. Laboratory ordering was reduced by 8% cumulatively over 3 years, saving $2 019 000. By involving residents at every stage of the intervention and targeting multiple levels simultaneously, laboratory utilization was reduced and cost savings were sustained over 3 years.

Creating a clinical video-conferencing facility in a security-constrained environment using open-source AccessGrid software and consumer hardware.

The Department of Laboratory Medicine at the University of California, San Francisco (UCSF) has been split into widely separated facilities, leading to much time being spent traveling between facilities for meetings. We installed an open-source AccessGrid multi-media-conferencing system using (largely) consumer-grade equipment, connecting 6 sites at 5 separate facilities. The system was accepted rapidly and enthusiastically, and was inexpensive compared to alternative approaches. Security was addressed by aspects of the AG software and by local network administrative practices. The chief obstacles to deployment arose from security restrictions imposed by multiple independent network administration regimes, requiring a drastically reduced list of network ports employed by AG components.

Parathyroid surgery: separating promise from reality.

We set out to determine the accuracy in predicting the success of biochemical and localizing studies for use in a minimally invasive parathyroidectomy. Preoperative sestamibi scans, intraoperative gamma-probe examinations, and intraoperative PTH (IOPTH) monitoring were performed on a prospective cohort of patients. Seventy-one patients were included in the study. Of the 59 patients (83%) with primary HPT, adenoma localization by sestamibi scanning was correct in 95% with solitary adenomas, but was correct in only 25% of the 14 patients with multiple adenomas. In patients with secondary and tertiary disease, sestamibi scanning incorrectly identified a single hot spot in 64% of cases. In no case of hyperplasia was the probe useful in locating other glands after a single gland was removed. IOPTH was accurate in 78% of patients with primary disease and in only 45% of patients with nonprimary disease. A minimal approach can be considered in a select group of patients that does not have familial primary HPT, secondary or tertiary disease, coexisting thyroid pathology, or an equivocal sestamibi scan. Only patients with a positive single hot spot on sestamibi scan can be considered candidates. Using this criteria only 64% of all patients with hyperparathyroidism are candidates for a minimally invasive approach. The combination of a solitary hot spot on sestamibi scan and a fall in IOPTH allows the surgeon to make the correct decision regarding the need to convert to a bilateral approach in 93% of these selected patients.