August 5, 2010

‘Clotting team’ aids diagnosis, decision making

Featured Image

Michael Laposata, M.D., Ph.D., jots down his interpretation of coagulation test results on a white board in The Vanderbilt Clinic’s pathology conference room. Laposata leads a new coagulation “diagnostic management team” that aims to help doctors diagnose patients’ conditions more quickly and accurately. (photo by Joe Howell)

‘Clotting team’ aids diagnosis, decision making

Every afternoon in a fourth-floor conference room in The Vanderbilt Clinic, experts in coagulation review the electronic medical records of patients with clotting or bleeding problems.

They're the first “diagnostic management team” (DMT) at Vanderbilt University Medical Center, and they began working last month to provide more than just numbers for coagulation test results.

Their goal is to help doctors diagnose patients' conditions more quickly and accurately, avoid unnecessary and costly tests, reduce complication rates and increase the likelihood that treatments will be successful the first time — and every time.

This is a first step in a grass-roots revolution in medical care that is being pioneered at Vanderbilt, said Bill Stead, M.D., associate vice chancellor for Health Affairs and the medical center's Chief Strategy and Information Officer.

“When the experiment works, it will help us handle diagnostic complexity and deliver on the promise of personalized medicine,” Stead predicted.

For patients with suspected clotting or bleeding disorders, an ever-increasing number of tests measure the ability of the blood to clot. In most hospitals, the clinical pathology lab conducts and reports the results of these measures — but usually without any patient-specific, expert-driven interpretation.

Most physicians are challenged to understand the results of the complex tests available to them, said Michael Laposata, M.D., Ph.D., the Edward and Nancy Fody Professor and executive vice chair of Pathology who leads the coagulation DMT.

“Everybody would think it's crazy if the internist got back a CAT scan and the radiologist just said, ‘Call me if you have a question,’” Laposata explained. “But across the country in the clinical lab, we just give doctors complicated numbers and say, ‘Good luck.’”

Laposata, who joined the Vanderbilt faculty in 2008, has been concerned about this problem since the early 1980s. At Massachusetts General Hospital, where he implemented an interpretation service in the early 1990s, he saw first-hand what can happen when the wrong tests are ordered or test results are misinterpreted.

Among the cases referred from other hospitals: a man sentenced to prison after a bleeding disorder in his child was mistaken for abuse; a woman who terminated a normal pregnancy after her doctor misread a test result and concluded she was at high risk of clotting during pregnancy; and a man with an undetected bleeding risk who suffered severe hemorrhaging after brain surgery and now cannot walk or talk.

“This is a huge problem,” Laposata said, “because the number of complex laboratory tests is increasing so fast.”

Responding in surveys, doctors overwhelmingly endorsed the interpretations they received from clinical pathology. “They said it prevented them from making a mistake and shortened the time they had to spend making the diagnosis,” he said.

By avoiding unnecessary tests, procedures and hospital admissions, Laposata estimated the interpretation of coagulation studies alone saved roughly $500,000 a year at MGH, while in some cases, the pathologists picked up diseases that otherwise may have gone undetected. Vanderbilt physicians also are responding positively to this new partnership role for clinical pathology, Laposata said.

Every day a resident in pathology collects the clinical and laboratory information from about 10 patient cases involving bleeding and clotting disorders and presents his or her preliminary interpretations to the attending physician during their afternoon meeting.

The interpretation of blood clotting test results is just the first step.
This fall, pathologists will launch a second DMT, this one focused on hematopathology, the diagnosis primarily of blood cancers like leukemia and lymphoma.

By the end of the year, a third team will be assembled to interpret data for lung cancer patients. It will include radiologists and anatomic pathologists, who will examine lung tissue biopsies under the microscope.

The DMT initiative, part of Vanderbilt's effort to innovate personalized medicine, is led by Laposata and Samuel Santoro, M.D., Ph.D., chair of Pathology.

The idea is to develop what Stead calls a “diagnostic cockpit,” where experts from a wide range of disciplines discuss and combine their interpretations — as well as their testing and treatment recommendations — into a single report for attending physicians.

Laposata said Vanderbilt is uniquely positioned to take diagnostic management to the next level. Instead of just seeing the barriers to change, its leaders, including Stead, Santoro and Jeff Balser, M.D., Ph.D., vice chancellor for Health Affairs and dean of the School of Medicine, “look at what should be and just know they're going to get there,” Laposata said.

“To begin to deliver on the promise of personalized medicine, we need systems fit to the individual,” Stead added. “We've learned that systems start with getting agreement on what we want to do, using evidence and so forth, then coming up with a combination of people, process and technology that does what we want to do every time and … (gets) the result we want every time.”