Hernandez, James S

Abstract Context. —Management of laboratories and pathology practices is increasingly complex. Residents and fellows in laboratory medicine and pathology need more structured curricula in leadership and management (L&M) training to function as medical and laboratory directors. Objective. —To define a curriculum that provides basic competency in L&M for residents and fellows in pathology. Design. —A year-long formal L&M course included didactic lectures, interactive sessions, case scenarios, team-building exercises, formal team presentations (capstone project), and precourse and postcourse assessment of L&M knowledge. The curriculum meets requirements of American College of Graduate Medical Education and supports goals for leadership training of the College of American Pathologists. Participants evaluated (5-point scale) the content and speakers of all sessions. Trainees were evaluated after considering postcourse examination results, quality of the capstone presentation, and a global assessment. Results. —The 5 non-capstone sessions received evaluation scores ranging from 4.4 (informatics) to 5 (L&M basics). Postcourse test scores showed significant improvement when compared with the pretest scores for the 2003– 2004 and 2004–2005 trainee cohorts. Conclusions. —Short-term results indicate that the course described improves trainee knowledge of L&M issues.

Abstract Context.—Managed care has changed the nature of medical practice. The practice of pathology has also changed and is likely to undergo further modification. Additional skills in leadership and management are needed to perform optimally in the current medical marketplace. Objective.—To determine whether pathologists view business and informatics skills as being important and valuable in their practices. Design.—A survey was sent electronically (via e-mail) to 2566 pathologists and pathology administrators. Results.—Two hundred sixteen survey recipients (8.4%) responded to the survey. The response rate to individual questions ranged from 86% to 99% (186 to 214 of 216 total respondents). Most who took the survey ranked communication (203/209; 97%), leadership skills (165/209; 79%), and systems thinking skills (155/209; 74%) as either “very important” or “essential.” Fewer respondents were willing to offer salary premiums for marketing (108/196; 55%), business or finance (92/196; 47%), or staff leadership (95/196; 48%) skills unless the candidate had a track record of measurable achievement using these skills. Those practicing in academia as well as those making hiring decisions by themselves were more likely to value leadership and management skills. Fewer than 1% of respondents in any category considered current pathology residency training in leadership and management to be adequate. Conclusions.—Prospective employers value leadership and management skills. Pathology residency programs must include meaningful training in pathology practice management and informatics to satisfy the demand for these skills in the modern pathology marketplace.

Abstract Objective. —To illustrate how laboratorians and pathologists must demonstrate accountability for efficiency (how well something is done), effectiveness (what is done), and cost-effectiveness (a proxy for value, in which value equals quality per cost). Data Sources. —A literature search was conducted, including documents in the National Library of Medicine. Study Selection. —The literature on cost-effectiveness of laboratory testing was reviewed. Conclusions. —The demand for proving the value of newer and more expensive medical technologies, including newer medical tests, will increase substantially. Payers, including Medicare, commercial insurers, and employers, will demand accountability and elimination of the abuse and misuse of ineffective testing strategies. Pathologists and laboratorians play a key role in guiding the most cost-effective use of testing strategies, including the judicious use of algorithms.

Abstract Background Collecting a predefined set of blood tubes (the “rainbow draw”) is a common but controversial practice in many emergency departments (EDs), with limited data to support it. We determined the actual utilization of rainbow draw tubes at a single facility and evaluated the perceptions of ED staff regarding the utility of rainbow draws. Methods We analyzed 2 weeks of ED visits (1326 visits by 1240 unique patients) to determine blood tube utilization for initial and add-on testing, as well as the incidence of additional venipunctures. We also surveyed ED staff regarding aspects of ED phlebotomy and test ordering. Utilization data analysis was structured to satisfy specific concerns addressed in the ED staff survey. Results Observed tube utilization data showed that fluoride/oxalate, citrate, and serum separator tubes were frequently discarded unused, and that the actual utility of the rainbow draw for add-on testing and avoiding additional venipunctures was low. ED staff perceived that the rainbow draw was highly valuable, both to expedite add-on testing and to avoid additional venipunctures. Contrasting the objective (utilization data) and subjective (survey results) to drive changes in the standard ED blood collection reduced the estimated waste blood by 175 L/year. Conclusions Comparison of perceptions and objective utilization data drove process changes that were mutually agreeable to ED and laboratory staff. Although specifics of ED and laboratory work flows vary between institutions, the principles and strategy of this study are widely applicable.

Background Platelet polyphosphate is an inorganic procoagulant polymer of orthophosphate units that is stored in dense granules and is released upon platelet activation. Here, we describe an assay to measure polyphosphate on the surface of procoagulant human platelets. Methods and Results Recombinant Escherichia coli ‐expressed exopolyphosphatase deletion mutant PPX_Δ12 labeled with fluorescent Alexa488 dye was used as a polyphosphate probe in flow cytometry. PPX_Δ12‐Alexa488‐signal dose‐dependently increased with long‐chain polyphosphate binding to platelets. In contrast, short‐chain polyphosphate that is found in the supernatant of activated platelets, did not bind to the platelet surface. Both exopolyphosphatase treatment and polyphosphate pre‐incubation abolished PPX_Δ12‐Alexa488 binding to polyphosphate on platelets. Stimulation of platelets with thrombin receptor agonist Trap6, and P2Y 12 receptor activator ADP increased polyphosphate accumulation on platelet surfaces and PPX_Δ12‐Alexa488 signal in a dose‐dependent manner. Conclusion This study indicates that long‐chain polyphosphate binds to platelet plasma membranes and presents a promising diagnostic assay to measure this interaction on human platelets in platelet‐rich plasma. Future investigations will aim to determine if polyphosphate can be used as a novel biomarker of thrombosis. © 2016 International Clinical Cytometry Society

Abstract Whether hemoglobin A1c (HbA1c) values are suitable for diagnosing diabetes has been debated. We sought to assess the prevalence of elevated HbA1c levels in a prediabetes patient population. Oral glucose tolerance tests and HbA1c levels were analyzed for patients entering a diabetes prevention program between January 1, 2007, and September 13, 2009. We calculated the percentage of patients with impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) who had HbA1c values in the 6.0% to 6.4% range or in the 5.7% to 6.4% range. The mean age of the 242 patients was 62 years; 64.0% were women, and 88.0% were white. Isolated IFG was detected in about 56.2% of patients and combined IFG and IGT in about 37.2%. Only 28.5% of patients had HbA1c values in the 6.0% to 6.4% range, whereas 65.3% had values in the 5.7% to 6.4% range. Our data suggest that reliance on HbA1c testing alone to identify candidates for a diabetes prevention program would miss a substantial number of eligible patients.