the need for clinical pathology …...the need for clinical pathology consultation in primary care...

THE NEED FOR CLINICAL PATHOLOGY CONSULTATION

IN PRIMARY CAREGraham V. Segal MD

Clinical Pathologist

LEARNING OBJECTIVES

• 1. Understand the challenges in the diagnostic process in today’s medical environment

• 2. Because of the challenges, there is over and underutilization of the clinical laboratory which can lead to misdiagnosis and or delayed diagnosis.

• 3. Laboratory tests involve complex biochemistry that if not interpreted in the right clinical context may lead the clinician down the wrong path – pun intended.

• 4. Identify how a Clinical Pathologist can have a tremendous positive influence in improving the diagnostic process.

OUTLINE

• 1. DIAGNOSTIC PROCESS - Past and Present

• 2. THE PROBLEMS

• 3. EXAMPLE CASES TO ILLUSTRATE

• 4. THE SOLUTIONS – Clinical Pathology Consultation

Back in the old days……

DIAGNOSTIC PROCESS

Factors affecting location of test threshold

FACTOR LOWERS THRESHOLD RAISES THRESHOLD

Test safety Low risk test Higher risk

Test cost Low cost test Higher cost

Test acceptability to patient High acceptability Lower acceptability

Prognosis of target disorder Serious if left undiagnosed Less serious if missed

Effectiveness of treatment Treatment is effective Treatment is less effective

Availability of treatment Treatment is available Treatment is not available

COMPLEX WORLD OF CLINICAL PATHOLOGY

• CLINICAL CHEMISTRY

• BLOOD BANKING

• IMMUNOLOGY

• MICROBIOLOGY

• COAGULATION

• MOLECULAR PATHOLOGY

• HEMATOPATHOLOGY

THE PROBLEMS

• PCPs are under pressure to see too many patients – both inpatients and outpatients

• They do not have time to research which lab tests to order and interpret results

• The combination of the two above delay correct diagnosis and lead to inappropriate consultations and a general waste of resources – iemore tests and more consults that are often unnecessary

• Furthermore, the testing that should be done is omitted

MORE PROBLEMS

• Clinical Pathology is a complex field in which clinicians are not well trained

• There are too many clinical lab tests available and no guidance on selection of appropriate tests

• Interpretation of lab tests are subject to individual practitioner (Most practitioners do not require assistance if the tests are within reference range)

Results of meta-analysis

• 1. Overall rate of inappropriate testing – 20.6%

• 2. Overall rate of underutilization – 44.8%

• 3. Rate of inappropriate initial testing – 43.9%

• 4. Rate of inappropriate repeat testing – 7.4%

Conclusions from Hickner et al april 2014

• 1768 physicians polled

• 14.7% reported uncertainty in ordering tests

• 8.3% reported uncertainty in interpretation of tests ordered

• Of the 500 million PCP visits a year – uncertainty affected 23 million patients

My day in the office

ORDERING LAB TESTS – not helpful

In my practice………….Clinical example #1

• 46 y/o HF presents to the office complaining of nonspecific joint pain

• Possible causes include:

• OA, RA, Fibromyalgia, Hypothyroidism, Gout, Vitamin D deficiency, Depression….list goes on

• Often we as PCPs will obtain X-rays, but the laboratory work up is incomplete

POTENTIAL LIST OF lab tests TO WORK UP JOINT PAIN• Rheumatoid factor

• Anti-CCP antibodies

• CRP, ESR, ANA

• Hepatitis Panel

• Vitamin D level 25 – OH – Vitamin D

• TSH, Uric Acid

• CMP and CBC

End result

• More visits to PCP for additional testing

• More visits to lab with more phlebotomy

• Consults to a specialist – who then repeats the work up which is often negative

Case #2

• 29 y/o WF presents to hospital with recurrent spontaneous abortion, leg pain, and shortness of breath – found to have DVT, PE with prolonged PTT

• Complex laboratory work up included :

• CBC, PT, PTT, mixing study, ESR, CRP, Anti-thrombin, Protein C, Protein S, Antiphospholipid antibodies, Factor V Leiden and Prothrombin Gene Mutation

• Pathology consult would be extremely helpful in this scenario –

• Which tests are valid in the acute setting?

• Were 4 consults necessary to manage a patient with APS ?

Case #3

• 33 y/o WF is admitted for new onset ascites –

• Main differential diagnosis is autoimmune vs liver pathology (including SBP) vs malignancy.

• Work up includes a CA 125 level that is positive, however CA 125 level in setting of peritonitis is falsely elevated

• Patient is scanned for malignancy with no obvious lesion identified

• Gyn consult obtained and she is taken to OR for diagnostic laparoscopy

• Diagnosis is Pelvic Inflammatory Disease (with negative STD work up)

Case #4

• 51 y/o WM presents to the hospital for hypercalcemia and neuromuscular weakness, and is dialysis dependent

• Multiple consults are obtained – again concern is malignancy.

• Patient has elevated iPTH – PTH related peptide is ordered and elevated.

• Patient stays in hospital for several days for CT scanning which is unremarkable.

• PTH related peptide is falsely elevated in setting of ESRD

SOLUTION #1-

• HAVE PCP OBTAIN CLINCAL PATHOLOGY CONSULT TO ORDER AND INTERPRET RESULTS

• This has been shown to improve outcomes in Harris Health System At UT

• Expert opinion will reduce unnecessary testing and unnecessary referrals

• Third party payors would surely want this as well!

Harris health experience

• Eliminated about 90% of unneeded referrals

• The average waiting time decreased more than in half (from 6 months to 1-3 months)

• The rate of referrals rejected by the RC due to incomplete testing dropped from 40% to less than 3%

• The average number of patients visits to phlebotomists before establishing the diagnosis decreased from 2.7 to 1.0

• Built a prototype of a functional billable Integrative CP Consulting Service and established a new consulting role of clinical pathologists at Harris Health System as an integral part of the healthcare team

Solution #1 continued:

• ALLOW CLINICIANS TO ORDER A PATHOLOGY CONSULT IN EMR

• FEEDBACK HAS BEEN OUTSTANDING

• Physicians at UT Family Practice Associates have found every consult to Clinical Pathology useful because it answers questions related to patient care

• Some clinicians, however are hesitant to use the service and feel they do not need laboratorian assistance (This is probably biggest threat to implementation)

Example consult case

• 15 y/o presenting to Pediatrician for epistaxis

• Initial work up included Prolonged PTT, mixing study that corrected which points to a factor deficiency as etiology.

• Instrinsic coag factors were ordered VIII, XI and XII and lupus anticoagulant, vWF antigen

RECOMMENDATIONS

• Obtaining factor IX assay.

• Lupus anticoagulant is not needed as mixing study corrected.

• Factor XII is not needed in the work up because deficiency is of no clinical consequence.

Another example consult case

• 51 y/o AAM with hx of HTN many years, atrial fibrillation, CVA presenting for wellness check up found to have elevated alkaline phosphatase.

• Next step GGT obtained and is 545 IU/L more than 5 X upper limit of normal.

• No hx of ETOH; no report of abdominal symptoms.

• Liver U/S normal.

• Next Step ?

SOLUTION #3

• Design a lab test menu that is coded by diagnosis

• My patient has symptom of Fatigue

• Why can’t I click on “Fatigue Labs” and receive an answer with interpretation making my life easier ?!

SOLUTION #4 - What is needed in MEDICAL EDUCATION ?• Specific Course on Clinical Pathology by Organ system is needed in

preclinical years

• During the fourth year, a mandatory one month rotation in clinical pathology

Rotating through Microbiology, Transfusion Medicine, Immunology, Coagulation, Hematopathology, Chemistry and Molecular Pathology

This rotation should be a requirement of ACGME accredited programs as well regardless of specialty

Mixed reactions among family medicine providers

• Some are excited and welcome the new assistance with patient care

• Other providers are skeptical and feel they do not need a Pathologist’s advice on test selection or interpretation

• Reality is most clinicians would benefit!

SPECIAL THANKS

• Dr. Amer Wahed – Associate Program Director – Department of Pathology, McGovern Medical School

• Dr. Semyon Risin – Director of DSRIP SLE and RA algorithm implementation

• Dr. Robert Hunter – Chairman, Department of Pathology, McGovern Medical School

• Dr. Carlos Moreno – Chairman, Department of Family Medicine, McGovern Medical School

• Dr. Michael Laposata – Chairman, Department of Pathology, UTMB Galveston