Keywords
laboratory tests, electronic gate keeping, cost savings, rejected tests, rural academic hospital, South Africa
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Mayekiso Z, Oladimeji KE, Pulido-Estrada GA et al. Cost effectiveness of Electronic Gate Keeping (EGK) system on laboratory tests demand at a rural academic hospital in Eastern Cape, South Africa: a cross sectional study [version 1; peer review: awaiting peer review]. F1000Research 2022, 11:1286 (https://doi.org/10.12688/f1000research.120560.1)
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Research Article
Cost effectiveness of Electronic Gate Keeping (EGK) system on laboratory tests demand at a rural academic hospital in Eastern Cape, South Africa: a cross sectional study
[version 1; peer review: awaiting peer review]
PUBLISHED 10 Nov 2022
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Abstract
Corresponding author:
Teke Apalata
Competing interests:
No competing interests were disclosed.
Grant information:
The Walter Sisulu University Research Unit provided the funding for payment of the article processing charge. We confirm that the research unit had no influence in the data collection, analysis and report.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2022 Mayekiso Z et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Mayekiso Z, Oladimeji KE, Pulido-Estrada GA et al. Cost effectiveness of Electronic Gate Keeping (EGK) system on laboratory tests demand at a rural academic hospital in Eastern Cape, South Africa: a cross sectional study [version 1; peer review: awaiting peer review]. F1000Research 2022, 11:1286 (https://doi.org/10.12688/f1000research.120560.1)
First published: 10 Nov 2022, 11:1286 (https://doi.org/10.12688/f1000research.120560.1)
Latest published: 10 Nov 2022, 11:1286 (https://doi.org/10.12688/f1000research.120560.1)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Background
Laboratory medicine, a branch of medicine and a component of the healthcare delivery system that provides diagnostic services such as laboratory investigations, the results of which are critical to clinicians' disease management decisions, is unfortunately affected by unnecessary laboratory investigations that are not required but repeatedly requested due to irregular documentation by clinicians.1–3 These unnecessary laboratory test requests could indicate a request made for the wrong patient, at the wrong time, or for the wrong disease condition.4 A B-type natriuretic peptide (NT-proBNP) test, for example, is useful as a diagnostic test for congestive heart failure patients. However, evidence suggests that while there is no guideline for repeated NT-proBNP measurements in the management of heart failure, it should be measured only once except in certain pragmatic situations such as clinical deterioration. As a result, requesting this test repeatedly, such as on a daily basis, is not the best course of action for determining the severity or stability of a heart condition.4 A rippling effect of this is that it leads to an increase in patient discomfort, duplication of laboratory investigations and monetary costs associated with the use of kits, staff and time.3–5 Consequently, countries have taken decisive action to review, develop robust and multifaceted strategies to tackle waste associated with repeated laboratory investigation and adopt those that work best in their environment.4,6–8 These initiatives are a response to the recognition of the need for an urgent reduction in unnecessary laboratory test requests and costs.9,10
In 2010, the South African National Department of Health (NDoH) and its partner - National Health Laboratory Services (NHLS), collaborated to develop a sustainable and affordable Electronic Gate Keeping (EGK) system. The EGK is a demand management system, defined as a full electronic stop (system-based intervention) to reduce overutilization on some laboratory test orders.11 It is a Laboratory Interface System (LIS) used to approve or reject laboratory tests based on the protocols for patient management devised by hospital management; the NHLS translates the rules into LIS. Upon a rejection of a test, an SMS alert is sent to the requesting medical officer notifying them that a test has been rejected. The SMS reads “Test automatically rejected on the basis of hospital electronic gate keeping rules”. If it is clinically necessary for the test to be performed, the rejection can only be reversed by providing a valid approval number to the laboratory, this must be done before the stability of the test is exceeded.
The primary application of this demand management is to ensure appropriate laboratory requesting and testing; for the right patient at the right time. For example, requesting a prostate specific antigen test for a male patient over 40 years for screening every six months if the previous result was normal, is appropriate and necessary testing. Since the inception of EGK in South Africa from 2011 to date, only two published articles have evaluated the EGK system. The two previous studies by Smit et al.4 in 2015 and Pema et al.8 in 2017 were conducted in urban hospital settings in the Western Cape and Gauteng provinces respectively. However, there was constrasting findings on the cost effectiveness of EGK. Therefore, this study builds on the previous studies' work and aims to provide evidence on the cost-effectiveness of the EGK system on laboratory tests requested at a rural academic hospital in the Eastern Cape province of South Africa.
Methods
Ethical considerations
The Walter Sisulu University Human Research Ethics and Biosafety Committee in South Africa reviewed and approved this study, which was assigned the ethics number 062/2019 on 05 November 2019.
Study design
The study used a descriptive cross-sectional study design to retrospectively audit EGK subjected tests at the NHLS in Mthatha by Nelson Mandela Academic Hospital for 24 months, from 2nd June 2015 to 31st May 2017. Through this audit, there was an estimate of cost savings from the unnecessary tests identified and rejected by the EGK system.
Study setting
The study was conducted at the Nelson Mandela Academic Hospital (NMAH), a tertiary teaching 507-bed hospital affiliated with Walter Sisulu University medical school and Lilitha Nursing training college. The hospital provides teaching and training to student medical doctors and registrars, and nurses. NMAH boasts specialized medical services, delivering comprehensive clinical care to inpatients and outpatients with complex medical conditions. The hospital is located in the rural area of the Eastern Cape Province, South Africa, in the OR Tambo district municipality.12
Sample and data collection
The data collected from 28 requested laboratory tests is shown in Table 1. The tests are billed on the National Tertiary Service Grant and categorized as high-volume tests, while others were high-cost tests. The sample for the study were medical laboratory tests subjected to EGK, any tests that were not subjected to EGK were excluded. Data collection entailed a review of pre-existing NHLS monthly electronically generated EGK rejection reports routinely supplied to the NMAH for monitoring and evaluation during the study period.
Table 1. List of test and EGK applied rules.
Data management and analysis
Data was managed and analysed using Microsoft Excel. Data analysis was mainly descriptive and it involved the use of summaries (such as counts, frequency, differences, multiplication) and graphs. Variables included the number of EGK subjected tests requested, the number of EGK subjected tests rejected for the estimation of test rejection and the cost savings in dollars. The cost savings were calculated by obtaining the number of rejected tests, multiplied by the cost of the rejected test charged at an official rate by the laboratory to perform the test.
All monetary values were computed from South African rands to United States Dollars (USD) using a conversion rate of ZAR 15.53 to 1 USD as per the South African Reserve Bank exchange rate on 19th November 2020.13 Further, the Consumer Price Index method was used to calculate the inflation rate since the USD in 2015 (USD 51,967.07) had the same purchasing power as in 2020 (USD 57,091.27). Considering the total inflation rate from 2015 to 2020 to be 9.9%, we interpreted the cost savings as preventative expenditure.
Results
Medical laboratory tests/investigations requested during the study period
Table 1 presents the laboratory tests requested duriing the 24 months study period (2nd June 2015 to 31st May 2017) and the EGK rules applied to deterrmine which should be processed or rejected. A total of 448,028 EGK subjected tests were requested during the study period (Table 1). The total number of tests was 27 and out of these; 21 were chemistry, two haematology and four serology tests.
The extent of requested tests rejected and the rejection rate
A total 17,480 tests were rejected and or prevented by EGK from being analyzed with a rejection rate of 3.9% (Table 2). Creatinine, urea and full blood count were the top three tests that were requested respectively (Figure 1). Calcium, magnesium and phosphate were the top three tests that were rejected respectively (Figure 2).
Table 2. Cost effectiveness of lab expenditure in US Dollars.
Figure 1. Top requested tests by quantity.
Figure 2. Top rejected tests by electronic gate keeping (EGK).
Cost effectiveness from the EGK system as an intervention
The top three tests that generated the most savings are c-reactive protein (USD 6,077.68), free thyroxine (USD 5,199.92) and hepatitis A IgM (USD 3,813.61) (Figure 3). The total cost savings as a result of the EGK system was USD 51,967.07.
Figure 3. Proportion of tests with cost savings in dollars.
Discussion
This study purposed to determine the cost savings obtained from tests rejected by the EGK system; a demand management tool (National Health Laboratory Service 2012). This is the first study that investigated the cost effectiveness of EGK, particularly in a rural setting in South Africa. In this paper, the majority of the 28 types of tests audited were low cost tests, i.e. were above USD 1.50 but less than USD 5.30 per test; and the minority of the tests studied that were high cost tests, i.e. were above USD 7.50 but less than USD 11.00 per test. We also found that the test that generated the highest savings was a low cost c-reactive protein (CRP) test; followed by free thyroxine (FT4) and hepatitis A IgM (HAM) which are both in the category of high cost tests. The top 15 tests that were rejected and thereby generated the highest cost savings were tests that are usually requested in a bundle with other accompanying tests; except for the CRP. In particular, the FT4 which generated the second highest cost savings in our study is a test that is often requested in a bundle, i.e. a thyroid function test, comprising a thyroid stimulating hormone (TSH) and tri-iodothyronine (FT3). Similarly, HAM generated the third highest cost savings because this test is usually requested in a bundle as part of a hepatitis screen, which is unnecessary most times, not unless it is clearly marked and requested on the laboratory form.
When we compare our study findings with that from the only two other studies that investigated the same intervention in South Africa,4,8 we found that the tests audited were quite similar; i.e. were basic, routine, frequently requested tests and as Konger et al.14 would say, ‘these tests were unnecessary and overused’. Furtheron, while we studied 28 tests, Smit et al.4 and Pema et al.8 studied 26 and 31 tests respectively. Our study revealed test requests of 448,028, while the number of requested tests by Smit et al.4 was 68,480 and Pema et al.8 was 1,493,965. The difference in the number of tests requested between our study and these studies could be due to the hospital facility's population coverage, which is much larger than our study setting, which serves a rural district with just over 5 million. Furthermore, the meagre number of test requests in the study by Smit et al.4 compared to our study could be justified and linked to their short six-month study period; thus, we presume that if their study were more than six months, more tests would have been requested.
Based on the top three repertoire of tests requested in this study compared to other studies, creatinine, urea and full blood count were the three most requested in this study. On the other hand, Smit et al.4 demonstrates calcium, magnesium and phosphate while Pema et al.8 reports the top most requested tests as urea and electrolytes, calcium, magnesium and phosphate. Parallel to the number of tests requested between our study and the two other studies, our study presented a rejection rate of 3.9%, which was found to be insignificantly higher (0.72%) than the rejection rate reported by Pema et al. at 3.18%, but significantly lower (2.9%) than the rejection rate reported by Smit et al. at 6.7%. The varying degree of rejection rate, especially between our study and Smit et al., may be linked mainly to our higher number of test requests compared to theirs and/or possibly the criteria of the EGK test rules applied between the two hospital settings. Regarding the cost savings, our study found the top three tests that generated the most savings to be single tests, i.e. CRP, FT4 and HAM respectively, whereas Smit et al. reported their cost savings to be generated by the thyroid function panel, liver function panel and CRP respectively. The CRP was the common test between the two studies. The tests that generated the greatest cost savings as reported by Pema et al. were urea and electrolytes panel, thyroid function tests and glycated hemoglobin. There were no similarities regarding the tests that generated cost savings between these two studies. In contrast, while our greatest cost savings were obtained on single tests, Smit et al. and Pema et al. reported having obtained theirs mainly on test panels and or profiles.
Limitation
The first limitation of the study is the fact that the clinical and patient outcomes of the rejections was not assessed, and therefore it is not known how much of patient management was affected by the rejections. Having said that, it should also be emphasized that EGK was not a closed system that rejected tests and not looked back, but rather opened a window of opportunity and allowed tests to be restored and analyzed if such a request had been submitted by the clinician with a clinical justification. Secondly, this study did not calculate the restored tests after they were initially requested and rejected respectively. This exercise would have provided useful information of how critical these tests were or not for patient management.
Conclusion
Based on these findings, we suggest that requesting tests in a bundle is discouraged as this may contribute to unnecessary testing that may not be clinically indicated. Besides, another resultant effect of requesting tests in a bundle is wasted resources accompanied by increased expenditure and increased laboratory workload amongst other things. So we advocte for selective testing to be the most encouraged type of medical laboratory investigations. More importantlly we note that to use a single intervention method, like we did with the EGK system, to address unnecessary laboratory testing might not have a great impact and/or result; but rather is a multifaceted approach that should be used for better outcomes. Therefore this novel EGK sytem as an intervention should be used in conjunction with continuous education focusing on the importance of making mindful laboratory test requesting, selective testing, the costs of individual tests and the impact these have on expenditures when they are requested unnecessarily; following of recommended guidelines on the management of acute and chronic diseases. Lastly, additional studies are recommended to assess the cost effectiveness of introducing EGK at across all facilities nationwide.
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how to cite this article
Mayekiso Z, Oladimeji KE, Pulido-Estrada GA et al. Cost effectiveness of Electronic Gate Keeping (EGK) system on laboratory tests demand at a rural academic hospital in Eastern Cape, South Africa: a cross sectional study [version 1; peer review: awaiting peer review]. F1000Research 2022, 11:1286 (https://doi.org/10.12688/f1000research.120560.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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