Should We Do It Here?

How do you decide whether to bring a test in-house or to send it out (or continue sending it out) to a reference lab? It’s not an easy decision, and it should be one based on as many facts as you can gather. The bullet points below are the considerations I employ for making this decision.

  • Cost: This is almost always the first consideration. Compare what the test currently costs to send out versus what it will cost to run in-house. If it costs more to run in-house than to send out, then there had better be some pretty over-riding reasons for doing it on-site. There are many items that contribute to the cost to run a test including:
    • Basic bottom line cost of the test – i.e. reagents, kit, etc
    • Technologist time – actual time to run the test, and to report the results if it’s not auto-verified
    • Supplies – test tubes, pipets, controls, calibrators, proficiency testing samples, etc.
    • Cost of instrumentation – determine whether a new instrument is needed or whether the test can go on an existing instrument. Either way, depreciation and service contract costs must be considered.
    • Development – for bringing in a newly released, FDA-approved assay on a current platform available in-house, this cost may be minimal, especially if the company brings it in and verifies its performance. For a laboratory developed test, this aspect of cost may be extensive and needs to be considered.
  • Test volume: The number of these tests that are performed will figure into all the rest of the parameters, including the cost of running it and the tech time involved. In addition, the test volume should be high enough to be able to maintain competency in the techs performing it, as well as to be able to keep in-date reagents on hand and instrument maintenance up to date.
  • Turnaround time (TAT): This is often a big factor in the decision to bring a test in-house. Doctors may request that tests be performed in-house to allow for better patient care. For example drug dosing decisions are not optimal if a drug result takes four days to return.
  • Workflow/tech time: How the new test will fit into the current workflow needs to be considered. Will it require additional technologist time or re-shuffling of coverage of other tests? Will it be a random access test or run in batches a few times a week and how will it impact staffing?
  • Patient care: Occasionally the reason for bringing a test in-house may be related to providing the best patient care, despite costs analysis and impact on the lab workflow and staff. An example is pentobarbital. We brought this test in-house even though we perform less than 50 of these a year because results were needed to make decisions related to continuing life support of not. Under these conditions, a 3 to 4 day TAT is not acceptable.

When all these costs are considered, think about your return on investment (ROI). Determine if you will save your institution money, and if so, over what time period. Sometimes it’s not an immediately obvious ROI, but over time you will save money. Sometimes the ROI is actually improved patient care rather than monetary savings. And sometimes the ROI is simply improved relations with the doctors and clinical staff, and that’s not a trivial ROI.

-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.

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