Medical monitoring. What is it, how can it be improved?

Little has been published about optimizing medical monitoring protocols, although monitoring accounts for over half of all medical laboratory tests. Monitoring is a form of surveillance consisting of repeated testing intended to detect a specified change in a patient indicating a change in his prognosis, need for treatment or need for a change in treatment. The concept of monitoring overlaps with those of screening and diagnosis. One may monitor a physiologic or pathologic process, a therapeutic or noxious agent, comparing results with the patient's previous results or with a group reference range. Pertinent questions include: what are the indications, what is to be monitored, which tests are to be used, when to start, how frequently to test, when to stop. Preliminary improvement of monitoring protocols may be achieved by applying common sense guidelines for medical decision making; using best estimates of test characteristics, of possible risks and benefits of testing, not testing, treating and not treating. Sensitivity analysis may help determine when further clinical research is needed.

First national in-service examination for pathology residents.

To fulfill an identified need in pathology residency program training, in 1983 the American Society of Clinical Pathologists introduced the first national in-service examination for pathology residents. This 175-item objective examination structured with seven subtest categories for various clinical rotations was administered to 1,200 residents-in-training representing 145 training programs, 40 states, and the District of Columbia. Individual norm-referenced results reports returned to each examinee, and program reports to each residency program director, indicated rank of individual examinee performance in each category and in all categories as well as with defined peer groups. Anonymity of individual results was optional to program directors. The data indicate that although performance improves with each subsequent year of residency training, the improvement is not so great as expected and that the level of performance of residents entering training was higher than anticipated. Postexamination evaluation indicated the need for this effort to continue.

Ranking diagnostic protocols--a proposed process based on use of the nine-cell diagnostic decision matrix.

A process for ranking competing diagnostic protocols for a specific disease is presented. The process incorporates the basic principles of medical decision making, and provides for the consideration of equivocal test results as well as results for patients who have ill-defined or incompletely defined disease. It provides a means for developing an a priori optimization process prior to ranking competing diagnostic algorithms. Methods for transferring ranking information among populations with widely differing disease prevalences are given.

Nine-cell diagnostic decision matrix. A model of the diagnostic process; a framework for evaluating diagnostic protocols.

A nine-cell diagnostic decision matrix is described. This matrix can be viewed dynamically as a model of the diagnostic process. The matrix provides for display of equivocal test results and test results of patients who have ill-defined or incompletely determined disease. The matrix represents an improved model for evaluating diagnostic test protocols. Diagnostic test characteristics related to this model are described. Potential advantages and uses of the model are discussed; among them are possibilities for development of improved diagnostic protocols and improved definitions of disease.

Reasonableness of use of the serum isoenzymes creatine kinase and lactate dehydrogenase for the diagnosis of myocardial infarction at a medical center.

At Charity Hospital of Louisiana at New Orleans, in 1978, there was considerable underuse of serum creatine kinase and lactate dehydrogenase isoenzymes for the diagnosis of myocardial infarction. Laboratory generation of creatine kinase isoenzyme tests for patients suspected of having had myocardial infarctions was only partially effective in correcting underuse. It unnecessarily generated some overuse. Appropriate modifications of this policy could improve performance. Additional, effective educational efforts are needed to improve reasonable use of laboratory tests. The study uncovered an unexpected problem in the laboratory--in a significant percentage of cases, results of indicated and ordered tests failed to appear in the charts.