Direct To Consumer Testing: Wave of the Future?

Direct to consumer (DTC) testing is one of the fastest growing industries on the internet, and if laboratories are not careful, we’re going to be blind-sided by it. I wanted to know how this works because in general the websites for this testing have nothing whatsoever on them about the lab. I searched for lab information – accreditation, etc – and found nothing. What I found was that most of these sites are essentially online middlemen between the consumer and the labs – allowing access to lab testing and bypassing the doctor.  I decided to do an experiment and see just how easy it was.

I went online and found a DTC company and ordered tests. I skipped their specials, “test of the month” was a complete thyroid panel, and settled for their most popular, most ordered test. It is actually a group of tests which includes a CBC with differential and a chemistry panel for a total of 27 tests plus six calculated values (eGFR, HDL/total cholesterol ratio, etc). The complete test cost me $97.00 plus tax. I can tell you that those tests run at my institution would cost well over $2500.00, and even at a big reference lab, the best price I could get was about $425.00.

It was when I placed my order that any mention of a lab came into the process. Before I could place the order, I had to make sure there was a LabCorp near me.  I then went back to the website and printed the company’s requisition for the test and took it with me to a LabCorp draw station. They took the requisition, checked it against a photo ID, collected the appropriate blood samples and sent me on my way. Three days later I received an email from the online company that my results were available. I logged on, and it was just that easy.  There were all my test results with appropriate reference intervals and flags. If I want my physician to have a copy, I can have them sent or print them and take them with me.

Amazingly, this is incredibly easy to do, although I suppose you would have to know enough to know what tests to order, or be told what to order by your physician. But I now have the ability to order my own tests, and at significantly less cost than the average hospital or reference lab. If doctors begin telling their patients just what tests to get run and then to bring them the results, this DTC testing will put hospital labs out of business, at least out of the outpatient lab business. There’s no way for a hospital lab to compete with this cost structure. Now all you need is a LabCorp interface to your hospital system and the test results go right back into the chart where the doctor ordered them and the hospital lab is totally outside the loop.

Of course, you will also have people just running tests on themselves after doing some online research, but they will still have to hook up with a doctor somewhere to explain abnormal lab results. I’ve already seen some of that – calls or emails from people off the street looking for explanations of results of metabolic testing. DTC is going to open many, many cans of worms, but it’s coming, nonetheless. I suppose there might be a role for the laboratory professional here, to help the consumer understand their lab results when they do them directly. And hospital labs will always be necessary for STAT and critical tests for inpatients. But the world is changing. We need to be ready for it.

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-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.

On the Lab Medicine Website

In case you’ve missed it, here is the table of contents for the current issue of Lab Medicine. New articles are uploaded regularly, so be sure to check back often.

Theoretical knowledge helps troubleshoot wonky results, but unfortunately that knowledge is easy to forget if it’s not used every day. If you’ve worked the chemistry bench long enough to have forgotten some of theory behind the analytes, check out this series of articles to refresh your memory.

In the latest edition of our podcast series, Dr. Alex Thurman walks listeners through diagnosing a new acute leukemia in the middle of the night.

USCAP Fueled Thoughts about AP and CP

I recently returned from sunny San Diego where I attended the CAP Residents Forum and USCAP. While at USCAP, I met more than my fair share of pathologists from Canada. After all, the “C” in USCAP stands for Canadian. I was surprised to learn that pathology residency there is 5 years–they still have a clinical “intern-like” year–and their residencies are either AP only or CP (referred to as “general pathology”) only programs.

In the US, most pathology subspecialties belong to one group or the other. The one exception is hematopathology which bridges AP and CP;in some programs is considered as AP and in others as CP. So I asked how they consider hematopathology in Canada. Most of those whom I met were AP trained and told me that in terms of hemepath, they only look at bone marrows (“tissue”). The peripherals and aspirates (“liquids”) are read by hem/onc and not likely to be relinquished to pathology as it is a good source of revenue for them.

When I told them that I was trained to read peripheral blood smears, aspirates, clots, and bone marrows, they told me that was because I was “CP trained” in terms of hemepath. They also told me that when they study hemepath in Canada, (I’m not sure if I misunderstood this part) that they aren’t really trained to diagnose lymphomas well. So they prefer to go to the US to train in hemepath fellowships to get the exposure and tend to hire US-trained hematopathologists. But I was also told that Canadian residencies are transforming and now beginning to incorporate more training in lymphoma diagnosis.

So, this brings me to some thoughts on AP and CP training. I was re-reading my most recent posts and realized that some recent frustrations I’ve experienced on my surgpath rotations accentuated my natural proclivities and bias. So, first, I’d like to say that I do not dislike surgpath. But I do think that the culture and some personalities in surgpath don’t really mesh well with a research-trained physician-scientist me. I often get the comment that I am “too academic” or I’m “more like a scientist than a pathologist” (which I didn’t think was a bad thing for a CP-oriented resident).We all have our biases and there is nothing wrong with that. But I often notice that the needs of the AP portions of our programs sometimes dominate over CP.

At multiple programs I rotated through during medical school and in my current program, if there is no autopsy resident that month, residents on CP rotations are assigned autopsy duty during the week while the surgpath residents cover the weekends and holidays. AP inclined residents and attendings often try to convince me that I never know if I’ll end up practicing surgpath. Even though residents often take vacations during CP rotations or spend most of their time studying for boards and not 100% actively engaging in their CP rotations, most of the time, CP attendings just expect this sort of attitude towards CP.

And so this tension between the two pathologies sometimes befuddles me. A co-resident even asked me if I’d consider doing a little surgpath with hemepath like the general pathologists at our community hospitals do(my answer is “probably not”)or I’ve gotten the “what are you going to do with molecular training?” question as well. This is not because there is anything wrong with surgpath (I know I might rant when I’m frustrated but I think knowing surgpath can only help me with my future career choices). But I wonder why when a first year resident comes in saying they want to do dermpath, they get hooked up to do derm/dermpath research (it’s important to match for dermpath fellowships) and I have people trying to convince me that I should want to do surgpath. Why does it seem harder to accept when a resident says that they want to do a CP subspecialty (maybe with the exception of hemepath)? Have you had experiences where a tension between the AP and CP sides of pathology reared its ugly head?Why do you think this may be so?

 

Chung

Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Gut Flora and Chron’s Disease

I’m fascinated by the connection between gut flora and overall health. I just stumbled onto this article that discusses the connection between gut flora and Chron’s Disease. It’s based on this paper published in Cell. Recent articles about antibiotic’s role in obesity and papers on gut flora’s influence on the immune system  keep raising the issue: how much do common organisms like E. coli, Clostridium perfringes, and Bacteroides fragilis affect us? How can we use them to diagnose, prevent, or cure disease? I’ll be keeping my eye on future research.

 

Swails

Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

 

Antibiotic Stewardship

The draft of the federal budget released Tuesday allocates $30 million dollars in CDC funding in order to combat antibiotic resistance. Obviously the 2015 budget isn’t finalized, but even so, it’s encouraging that the Department of Health and Human Services recognizes the need for antibiotic stewardship.

What is antibiotic stewardship, you ask? Basically, it’s a program within a healthcare community that dictates the best practices for prescribing antibiotics. Such programs would be tailored for each setting based on population demographics and antibiograms. Perhaps a program would prohibit prescribing, say, ciprofloxacin for urinary tract infections because a rise in the percentage of strains of E. coli resistant to fluoroquinolones has been noted. Maybe the program would discourage prescribing more than two antibiotics at once to a patient, or suggest antibiotics other than vancomycin (such as levoquin) when treating MRSA.

Creating a stewardship program requires input from several departments (Infectious Disease, Pharmacy, Epidemiology, and the Microbiology Laboratory) as well as acceptance by the clinician population at large. In my experience, this has been the limiting factor. Physicians don’t like being told what they can and can’t do for their patients or the insinuation that they might lack the proper knowledge about antimicrobials and microbiology to provide good patient care. This is a hurdle that hospitals will have to overcome in order to make stewardship programs a success. (Mentioning that such programs can save money and shorten hospital stays could help tip the scales.)

If you’d like to institute a stewardship program at your institution, here are a few links to get you started:

CDC’s Vital Signs about prescribing practices
Antibiotic management guidelines at John Hopkins
Professional practice resources from the Association for Professionals in Infection Control and Epidemiology
The ever-insightful Maryn McKenna over at Superbug discusses the topic at length

Does your institution have an antibiotic stewardship program? If so, what steps did you have to take in order to implement it?

Swails

Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

Vinegar to the Rescue

Can a common pantry staple kill bacteria? Possibly, according a paper recently published in mBio. Researchers mixed acetic acid–the main ingredient in white vinegar–with suspensions of bacterial cultures and found that a exposure times as little as 20 minutes reduced the viable bacterial population by 710. The researchers then performed the same experiment, this time swapping out hydrochloric acid for the vinegar; they noted no bactericidal effect. Mycobacterium tuberculosis required a longer kill time (30 minutes vs. 20 minutes) to reach a 810 reduction in population.

These results suggest that vinegar could be used as a cheap-yet-effective disinfectant in resource-poor laboratory settings.

 

 

 

Balance Between Service Obligations and Education

These past couple of days I attended the CAP Residents Forum and USCAP in San Diego. It was both an inspiring and daunting experience. Inspiring because of the breadth and depth of research and amount of scholarly expertise in the room every time I attended a lecture; daunting because of this same fact and also because of the reminder that someday soon I will need to be as expert and competent as these speakers.

With these thoughts in mind, I attended the first half of the morning of the CAP Residents Forum for their “Dating Game” panel where new-in-practice and veteran pathologists spoke about to getting and keeping your first job. It was actually an engaging panel and I learned practical information that was new to me and that will help me not only to obtain my first job but also when I apply for fellowship in a couple of months.

I attended mostly molecular pathology talks and the cytology short course that for someone who hasn’t had cytology yet, was informative. I got to hang out with friends from other programs that I met through the CAP Residents Forum and to hear how they are taught the practice of pathology. These conversations got me to thinking about whether service obligations can compromise our education.

For someone who is CP-oriented, I am at a program that is heavy on the surgical pathology (we do 17 months; previous classes did many more). And most of us are trained at academic institutions but my program also has rotations at a VAhospital and two community private practice hospitals. Life is different at the community hospitals but I hear that most residents will go on to practice in this type of setting. The volume can be high, there may be many tumor boards/conferences to present at or attend, and the turnover time is so strictly adhered to that you might not always be able to get protected preview time – even if eventually you do get to sign-out with the attendings after they’ve verified a case.

But does it matter about protected preview time if you don’t look at the verified diagnosis before you sign out with your attending? Does your program have CP residents covering autopsy call? Do your residents gross on Saturdays? Just what constitutes service obligations interfering with resident education in your perspective? Working in a clinical setting, patient safety and service obligations can take on a predominant role, but the quality of our work cannot suffer. So what makes for the right balance between service obligations and resident education and what can we do to ensure that resident education is made a priority?

 

Chung

Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.