CLN - Focus on Laboratory Stewardship
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Clinicians order peripheral smear reviews (CPSR) by pathologists for a variety of reasons, including CBC abnormalities or signs and symptoms of hematologic disease (1). For decades, this practice has been deeply embedded in the minds of many physicians, reinforced by textbooks and decision-support tools. In a CPSR, the pathologist reviews the morphology of erythrocytes, leukocytes, and platelets along with the CBC and renders an interpretation.
More than 20 years ago, I first came across the CPSR as a freshly graduated hematopathologist in a 500-bed tertiary hospital. Every day, I would interpret 10–20 CPSRs on nonspecific abnormalities, such as macrocytosis without anemia and neutrophilia not otherwise specified. I also would review peripheral smears that met laboratory criteria for pathologist review (laboratory-derived smear review or LDSR). The LDSR would include abnormalities such as hemolysis, myelodysplastic syndrome, and acute leukemia, among others.
I soon questioned the utility of the CPSR. In the last several decades, advances in automated analyzers coupled with middleware software programs have significantly improved the detection of hematologic abnormalities, including blast identification, with near 100% sensitivity (2). It was time to examine this practice systematically.
Change management in a hospital setting
In 2016, I assessed 106 CPSRs at a 500-bed tertiary care hospital in the Midwest, including inpatient and outpatient clinics. The findings showed that CPSR was unnecessary more than 99% of the time; LDSR captured virtually all significant hematologic abnormalities, including hemolysis, chronic myeloproliferative disorders, and acute leukemia. These findings and the literature confirmed that pathologists’ CPSR were of low clinical utility.
A committee of pathologists, oncologists, and primary care physicians reviewed the data and unanimously agreed that CPSR was unnecessary. This led to an educational campaign and smooth discontinuation. However, despite having an oncologist on the committee, one oncology group resisted. We collected 2 months of additional data on their patients (n=212) and showed that 99.5% of cases were caught with LDSR criteria. The LDSR criteria were further improved to catch the one false negative case.
Additional data did not influence the oncologists’ opinion. With the intervention of the facility’s chief medical officer and additional education, the oncologists reluctantly agreed to the discontinuation. Based upon this discontinuation, a significant amount of pathologists’ time was reallocated to more clinically relevant activities.
Change management in a reference lab setting
Upon arriving at Labcorp, I saw the same pattern of nonspecific findings in the nearly 300,000 CPSRs/year ordered across the enterprise. Our teams wondered whether discontinuation of CPSR could be accomplished in a reference laboratory with thousands of physicians spanning the country.
To accomplish this gargantuan task, we realized we needed a systematic approach to change management. Our strategy would include 1) reviewing peer-reviewed literature, 2) performing an internal study to validate the literature, 3) educating and obtaining feedback from internal stakeholders and key external clients, 4) obtaining internal stakeholder buy-in, and 5) planning ongoing educational support.
Published studies suggested that CPSRs have limited clinical utility, but the literature was sparse. Beckman et al. found that CPSRs infrequently provide clinical value (13% of the time) in reviews for anemia and thrombocytopenia (the most common indication for CPSR) (3). Mangold et al. found that CPSRs were clinically useful only 1% of the time in a large tertiary care hospital (4).
We performed our internal study at the Burlington Labcorp location. In early 2023, we reviewed 200 consecutive CPSRs and asked whether standard processes with CBC and LDSR capture significant hematologic abnormalities seen in CPSR. We also established whether LDSR missed any significant hematologic abnormalities.
Our findings confirmed that CPSR had limited value and that significant hematologic abnormalities would have been detected by LDSR. The discrepancy rate between CPSR and LDSR was negligible (0.6%) because of a minor discrepancy between platelet counts (5).
Securing stakeholder buy-in, addressing dissent, and offering education
Obtaining buy-in from internal stakeholders and quelling internal dissent was another challenge that required carefully crafted conversations with leaders in affected areas. We presented our study findings to the internal laboratory stewardship committee and recommended test discontinuation. The committee approved our request and recommended discontinuation after an extensive educational effort.
Next, we embarked on an externally facing educational campaign that covered the scientific basis of discontinuation, a CBC guide describing how to interpret nonspecific abnormalities that don’t meet the criteria for LDSR, and a webinar. All materials were published on Labcorp’s webpage. Hematology directors also had meetings with field team members.
Before discontinuation, we encountered pockets of dissent with several internal stakeholders. A few sales executives believed that clinicians should be able to order whatever they want based on the patient’s clinical picture.
Pathologists also had concerns. How would they effectively communicate the discontinuation to their clinician partners who have utilized this test for decades? We reassured them that physicians should be directed to the educational materials, and if they were not satisfied, the hematology directors would consult with them.
Managing physician concerns and resistance
On July 29, 2024, we discontinued CPSR. Although educational materials were provided several months before the discontinuation, many physicians were unaware of the change. The number of calls from providers and field executives increased logarithmically. We held additional educational meetings with field executives as well as many one-on-one meetings with physicians.
Despite educational materials, some physicians, especially oncologists, resisted the change. They were upset that some patient’s CBC abnormalities did not reflex in a pathologist review. We reviewed the peripheral smears on these patients and reassured the physicians that the findings were nonspecific.
Yet a handful of oncology providers continued to resist. They felt they needed a CPSR regardless of reflex criteria and threatened to use another laboratory. Based on their concerns, we realized they needed more time to accept this change. We allowed these select providers to continue ordering CPSR for a limited time while additional educational material was offered.
Our experience with this project has highlighted a pearl in lab stewardship: Changing deeply-seated clinician beliefs takes time and patience. We are confident that physicians will embrace these changes through education and become confident of our LDSR processes. We hope that these changes can be adopted by other best practice committees, such as ASCP’s Choosing Wisely, so that there can be a broad recommendation to discontinue CPSR ordering for all laboratories.
Sanjai Nagendra, MD, MMM, is the medical director of the center for esoteric testing, Atlantic Division Regional Laboratory and ViroMed Laboratory, and co-discipline director in hematology at Labcorp in Burlington, North Carolina. +Email: [email protected]
References
- Adewoyin AS, Nwogoh B. Peripheral blood film - a review. Ann Ib Postgrad Med. 2014; 12:71-79.
- Petrone J, Jackups R Jr, Eby CS, et al. Blast flagging of the Sysmex XN-10 hematology analyzer with supervised cell image analysis: Impact on quality parameters. Int J Lab Hematol 2019; doi: 10.1111/ijlh.13069
- Beckman AK, Ng VL, et al. Clinician-ordered peripheral blood smears have low reimbursement and variable clinical value: a three-institution study, with suggestions for operational efficiency. Diagnostic pathology 2020; doi: 10.1186/s13000-020-01033-8.
- Kurt-Mangold ME, Grieme CV, Krasowski MD, et al. Clinical utility of ordered pathology blood smear reviews - an overused resource? Clinical Laboratory 2018; doi: 10.7754/Clin.Lab.2017.170703.
- Nagendra S, Mongillo J, Dodge K, et al. Clinician-ordered peripheral smear review by a pathologist has low clinical utility – a reference laboratory perspective. J Appl Lab Med 2024; doi: 10.1093/jalm/jfae101.