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Characterization of Hematology Consults for Complete Blood Count Abnormalities: A Single Center Experience in the Era of Electronic Consultation
Purpose: As patient volumes and complexity of hematology care increase, subspecialty provider efficiency is of utmost importance. We aim to improve efficiency by characterizing the nature and outcome of common hematology e-consults.
Background: Veterans Affairs Medical Centers pioneered electronic subspecialty consultation with the initiation of the e-consult system in 2011. An increase in number of hematology consultations at one VAMC from 391 in 2010 to 704 after e-consult implementation in 2013 was described by Cecchini et al (Blood, 2016).
Methods: A retrospective review of all hematology and oncology consults at one institution between April 1, 2016 and December 8, 2016 was performed. Cell counts, prior workup, diagnoses offered, age and comorbidities were determined for consults about complete blood count (CBC) abnormalities.
Results: 523 hematology/oncology consults were reviewed: 169 questioned CBC abnormalities, 76 consults were for anemia, and 38 consults were for thrombocytopenia. The most common diagnosis was iron-deficiency anemia (21.1% anemia consults). The most common hemoglobin value for anemia
consults was 9.0-9.9 g/dL (27.6% anemia consults). The most common platelet count for thrombocytopenia consults was 75k-100k (36.8% thrombocytopenia consults). Referring providers were significantly more likely to have initiated workup for anemia than for thrombocytopenia consults (71%
vs 29%, P < .0001). Consulting hematologists were significantly more likely to offer a diagnosis if basic workup had already been initiated (68% vs 39%, P = .0025). Age ≥ 70 years old had higher likelihood of 2-3 cell line abnormalities (RR 1.37, 95% CI, 1.02-1.82).
Conclusions: 169 consults about CBC abnormalities were reviewed. The most common reason for consult was anemia. Referring providers were significantly more likely to initiate a workup for anemia than for thrombocytopenia. There was a significantly greater likelihood of consultants offering a diagnosis if a basic workup had already been initiated. Increased education regarding mild anemia and basic workup of thrombocytopenia are areas of potential intervention to improve likelihood of diagnosis on initial consult and improve efficiency of the electronic consultation process.
Purpose: As patient volumes and complexity of hematology care increase, subspecialty provider efficiency is of utmost importance. We aim to improve efficiency by characterizing the nature and outcome of common hematology e-consults.
Background: Veterans Affairs Medical Centers pioneered electronic subspecialty consultation with the initiation of the e-consult system in 2011. An increase in number of hematology consultations at one VAMC from 391 in 2010 to 704 after e-consult implementation in 2013 was described by Cecchini et al (Blood, 2016).
Methods: A retrospective review of all hematology and oncology consults at one institution between April 1, 2016 and December 8, 2016 was performed. Cell counts, prior workup, diagnoses offered, age and comorbidities were determined for consults about complete blood count (CBC) abnormalities.
Results: 523 hematology/oncology consults were reviewed: 169 questioned CBC abnormalities, 76 consults were for anemia, and 38 consults were for thrombocytopenia. The most common diagnosis was iron-deficiency anemia (21.1% anemia consults). The most common hemoglobin value for anemia
consults was 9.0-9.9 g/dL (27.6% anemia consults). The most common platelet count for thrombocytopenia consults was 75k-100k (36.8% thrombocytopenia consults). Referring providers were significantly more likely to have initiated workup for anemia than for thrombocytopenia consults (71%
vs 29%, P < .0001). Consulting hematologists were significantly more likely to offer a diagnosis if basic workup had already been initiated (68% vs 39%, P = .0025). Age ≥ 70 years old had higher likelihood of 2-3 cell line abnormalities (RR 1.37, 95% CI, 1.02-1.82).
Conclusions: 169 consults about CBC abnormalities were reviewed. The most common reason for consult was anemia. Referring providers were significantly more likely to initiate a workup for anemia than for thrombocytopenia. There was a significantly greater likelihood of consultants offering a diagnosis if a basic workup had already been initiated. Increased education regarding mild anemia and basic workup of thrombocytopenia are areas of potential intervention to improve likelihood of diagnosis on initial consult and improve efficiency of the electronic consultation process.
Purpose: As patient volumes and complexity of hematology care increase, subspecialty provider efficiency is of utmost importance. We aim to improve efficiency by characterizing the nature and outcome of common hematology e-consults.
Background: Veterans Affairs Medical Centers pioneered electronic subspecialty consultation with the initiation of the e-consult system in 2011. An increase in number of hematology consultations at one VAMC from 391 in 2010 to 704 after e-consult implementation in 2013 was described by Cecchini et al (Blood, 2016).
Methods: A retrospective review of all hematology and oncology consults at one institution between April 1, 2016 and December 8, 2016 was performed. Cell counts, prior workup, diagnoses offered, age and comorbidities were determined for consults about complete blood count (CBC) abnormalities.
Results: 523 hematology/oncology consults were reviewed: 169 questioned CBC abnormalities, 76 consults were for anemia, and 38 consults were for thrombocytopenia. The most common diagnosis was iron-deficiency anemia (21.1% anemia consults). The most common hemoglobin value for anemia
consults was 9.0-9.9 g/dL (27.6% anemia consults). The most common platelet count for thrombocytopenia consults was 75k-100k (36.8% thrombocytopenia consults). Referring providers were significantly more likely to have initiated workup for anemia than for thrombocytopenia consults (71%
vs 29%, P < .0001). Consulting hematologists were significantly more likely to offer a diagnosis if basic workup had already been initiated (68% vs 39%, P = .0025). Age ≥ 70 years old had higher likelihood of 2-3 cell line abnormalities (RR 1.37, 95% CI, 1.02-1.82).
Conclusions: 169 consults about CBC abnormalities were reviewed. The most common reason for consult was anemia. Referring providers were significantly more likely to initiate a workup for anemia than for thrombocytopenia. There was a significantly greater likelihood of consultants offering a diagnosis if a basic workup had already been initiated. Increased education regarding mild anemia and basic workup of thrombocytopenia are areas of potential intervention to improve likelihood of diagnosis on initial consult and improve efficiency of the electronic consultation process.
The Buck Stops Here: Rational Oversight for Hematologic Testing
Complex hematological tests aid in establishing hematologic diagnoses, but can be quite costly. We hypothesized that certain diagnostic tests (specifically JAK2 at $175/test, BCR-ABL at $163/test, and flow cytometry at $275/test) that were being ordered without input from a hematologist were generally not indicated and expensive. We reviewed all of these tests sent between September 2013 and September 2015. 20/55 or 36% of JAK2 mutations, 19/37 or 51% of BCR-ABL mutations, and 47/74 or 63% of flow cytometry were completed without hematology input, primarily via primary care (72/86 or 84%). Tests that were ordered or recommended by hematology were excluded from the subsequent cost analysis. In total $19,500 was spent (without hematology input). One hematologist then reviewed the charts on every test that had been ordered not by hematology to determine if the test was clinically appropriate. 12/20 or 60% of JAK2 mutations, 19/19 or 100% of BCR mutations, and 44/47 or 94% of flow cytometry evaluations were felt to be unnecessary. Thus $17,300 of the $19,500 could have been saved had there been hematology input at the outset. This would have amounted to 86 e-consults over 2 years, which would be 1.2 extra consults/week; these consults generally take under 10 minutes, so less than 2 minutes/day. This all translates to ~$1,075 over 2 years of a hematologist’s salary, clearly more cost-effective than permitting everyone to be able to order these tests. We should consider recommending hematology input prior to allowing these tests (and perhaps other costly unusual hematology investigations) to be sent out, perhaps via a pop-up suggestion for a hematology e-consult when ordered; the e-consult would also be a tool to educate other providers on the appropriate use of these tests and may ultimately lead to a decrease in the ordering of these e-consults.
Complex hematological tests aid in establishing hematologic diagnoses, but can be quite costly. We hypothesized that certain diagnostic tests (specifically JAK2 at $175/test, BCR-ABL at $163/test, and flow cytometry at $275/test) that were being ordered without input from a hematologist were generally not indicated and expensive. We reviewed all of these tests sent between September 2013 and September 2015. 20/55 or 36% of JAK2 mutations, 19/37 or 51% of BCR-ABL mutations, and 47/74 or 63% of flow cytometry were completed without hematology input, primarily via primary care (72/86 or 84%). Tests that were ordered or recommended by hematology were excluded from the subsequent cost analysis. In total $19,500 was spent (without hematology input). One hematologist then reviewed the charts on every test that had been ordered not by hematology to determine if the test was clinically appropriate. 12/20 or 60% of JAK2 mutations, 19/19 or 100% of BCR mutations, and 44/47 or 94% of flow cytometry evaluations were felt to be unnecessary. Thus $17,300 of the $19,500 could have been saved had there been hematology input at the outset. This would have amounted to 86 e-consults over 2 years, which would be 1.2 extra consults/week; these consults generally take under 10 minutes, so less than 2 minutes/day. This all translates to ~$1,075 over 2 years of a hematologist’s salary, clearly more cost-effective than permitting everyone to be able to order these tests. We should consider recommending hematology input prior to allowing these tests (and perhaps other costly unusual hematology investigations) to be sent out, perhaps via a pop-up suggestion for a hematology e-consult when ordered; the e-consult would also be a tool to educate other providers on the appropriate use of these tests and may ultimately lead to a decrease in the ordering of these e-consults.
Complex hematological tests aid in establishing hematologic diagnoses, but can be quite costly. We hypothesized that certain diagnostic tests (specifically JAK2 at $175/test, BCR-ABL at $163/test, and flow cytometry at $275/test) that were being ordered without input from a hematologist were generally not indicated and expensive. We reviewed all of these tests sent between September 2013 and September 2015. 20/55 or 36% of JAK2 mutations, 19/37 or 51% of BCR-ABL mutations, and 47/74 or 63% of flow cytometry were completed without hematology input, primarily via primary care (72/86 or 84%). Tests that were ordered or recommended by hematology were excluded from the subsequent cost analysis. In total $19,500 was spent (without hematology input). One hematologist then reviewed the charts on every test that had been ordered not by hematology to determine if the test was clinically appropriate. 12/20 or 60% of JAK2 mutations, 19/19 or 100% of BCR mutations, and 44/47 or 94% of flow cytometry evaluations were felt to be unnecessary. Thus $17,300 of the $19,500 could have been saved had there been hematology input at the outset. This would have amounted to 86 e-consults over 2 years, which would be 1.2 extra consults/week; these consults generally take under 10 minutes, so less than 2 minutes/day. This all translates to ~$1,075 over 2 years of a hematologist’s salary, clearly more cost-effective than permitting everyone to be able to order these tests. We should consider recommending hematology input prior to allowing these tests (and perhaps other costly unusual hematology investigations) to be sent out, perhaps via a pop-up suggestion for a hematology e-consult when ordered; the e-consult would also be a tool to educate other providers on the appropriate use of these tests and may ultimately lead to a decrease in the ordering of these e-consults.
Hypercalcemia in Diffuse Large B-cell Lymphoma
Purpose: Review the clinical presentation and pathophysiology of hypercalcemia in diffuse large B-cell lymphoma.
Methods: Case study of a 59-year-old man with untreateddiffuse large B-cell lymphoma (DLBCL) who presented with anorexia, constipation, and weight loss in the setting of a fungating breast mass.
Results: The patient presented to an outside hospital 1.5 years prior for a left breast mass biopsy that was diagnosed as triple-hit DLBCL. However, he deferred treatment at that time. He subsequently experienced anorexia, nausea, vomiting, consti-pation, and a 20-pound unintentional weight loss. At hospital presentation, a physical examination revealed enlargement of the left breast mass measuring 8 x 14 cm with central ulceration and malodorous purulent discharge and a proximal 7 x 4 cm firm axillary mass. The patient reported no abdominal pain or fever. He was found to have acute kidney injury (creatinine 2.9 mg/dL); hyperuricemia (13.3 mg/dL); and corrected hypercalcemia (17.4 mg/dL). Empiric treatment for tumor lysis syndrome with rasburicase, allopurinol, and aggressive IV hydration was initiated. Further evaluation revealed normal lactate dehydrogenase and K+.The patient was found to have an elevated vitamin D 1,25-OH (244 pg/mL) but low parathyroid hormone (PTH) (6.4 pg/mL); normal PTH-rP; mild hyperphosphatemia (5.5 mg/dL); and negative serum protein electrophoresis/urine protein electrophoresis. Clinical presentation was suggestive of vitamin D-mediated hypercalcemia. The patient received pamidronate and aggressive IV hydration. Electrolyte abnormalities and renal function gradually improved. Computed tomography and positron emission tomography imaging revealed masses localized to the left chest wall with ipsilateral axillary lymphadenopathy. Surgical biopsy of the mass reconfirmed DLBCL ultimately staged as IIE. Following stabilization, the patient declined more aggressive chemotherapy and received R-CHOP with a complete response.
Conclusions: The patient presented with vitamin D-mediated hypercalcemia in the setting of aggressive triple-hit DLBCL. Vitamin D-mediated hypercalcemia occurs in < 1% of lymphomas, and < 0.5% of breast tumors are primary lymphomas. This case study presents a rare constellation of findings at diagnosis. The patient responded to IV hydration and pamidronate and subsequently received R-CHOP for stage IIE DLBCL. While hypercalcemia in the setting of malignancy is associated with poor prognosis, treatment of hypercalcemia does not improve survival.
Purpose: Review the clinical presentation and pathophysiology of hypercalcemia in diffuse large B-cell lymphoma.
Methods: Case study of a 59-year-old man with untreateddiffuse large B-cell lymphoma (DLBCL) who presented with anorexia, constipation, and weight loss in the setting of a fungating breast mass.
Results: The patient presented to an outside hospital 1.5 years prior for a left breast mass biopsy that was diagnosed as triple-hit DLBCL. However, he deferred treatment at that time. He subsequently experienced anorexia, nausea, vomiting, consti-pation, and a 20-pound unintentional weight loss. At hospital presentation, a physical examination revealed enlargement of the left breast mass measuring 8 x 14 cm with central ulceration and malodorous purulent discharge and a proximal 7 x 4 cm firm axillary mass. The patient reported no abdominal pain or fever. He was found to have acute kidney injury (creatinine 2.9 mg/dL); hyperuricemia (13.3 mg/dL); and corrected hypercalcemia (17.4 mg/dL). Empiric treatment for tumor lysis syndrome with rasburicase, allopurinol, and aggressive IV hydration was initiated. Further evaluation revealed normal lactate dehydrogenase and K+.The patient was found to have an elevated vitamin D 1,25-OH (244 pg/mL) but low parathyroid hormone (PTH) (6.4 pg/mL); normal PTH-rP; mild hyperphosphatemia (5.5 mg/dL); and negative serum protein electrophoresis/urine protein electrophoresis. Clinical presentation was suggestive of vitamin D-mediated hypercalcemia. The patient received pamidronate and aggressive IV hydration. Electrolyte abnormalities and renal function gradually improved. Computed tomography and positron emission tomography imaging revealed masses localized to the left chest wall with ipsilateral axillary lymphadenopathy. Surgical biopsy of the mass reconfirmed DLBCL ultimately staged as IIE. Following stabilization, the patient declined more aggressive chemotherapy and received R-CHOP with a complete response.
Conclusions: The patient presented with vitamin D-mediated hypercalcemia in the setting of aggressive triple-hit DLBCL. Vitamin D-mediated hypercalcemia occurs in < 1% of lymphomas, and < 0.5% of breast tumors are primary lymphomas. This case study presents a rare constellation of findings at diagnosis. The patient responded to IV hydration and pamidronate and subsequently received R-CHOP for stage IIE DLBCL. While hypercalcemia in the setting of malignancy is associated with poor prognosis, treatment of hypercalcemia does not improve survival.
Purpose: Review the clinical presentation and pathophysiology of hypercalcemia in diffuse large B-cell lymphoma.
Methods: Case study of a 59-year-old man with untreateddiffuse large B-cell lymphoma (DLBCL) who presented with anorexia, constipation, and weight loss in the setting of a fungating breast mass.
Results: The patient presented to an outside hospital 1.5 years prior for a left breast mass biopsy that was diagnosed as triple-hit DLBCL. However, he deferred treatment at that time. He subsequently experienced anorexia, nausea, vomiting, consti-pation, and a 20-pound unintentional weight loss. At hospital presentation, a physical examination revealed enlargement of the left breast mass measuring 8 x 14 cm with central ulceration and malodorous purulent discharge and a proximal 7 x 4 cm firm axillary mass. The patient reported no abdominal pain or fever. He was found to have acute kidney injury (creatinine 2.9 mg/dL); hyperuricemia (13.3 mg/dL); and corrected hypercalcemia (17.4 mg/dL). Empiric treatment for tumor lysis syndrome with rasburicase, allopurinol, and aggressive IV hydration was initiated. Further evaluation revealed normal lactate dehydrogenase and K+.The patient was found to have an elevated vitamin D 1,25-OH (244 pg/mL) but low parathyroid hormone (PTH) (6.4 pg/mL); normal PTH-rP; mild hyperphosphatemia (5.5 mg/dL); and negative serum protein electrophoresis/urine protein electrophoresis. Clinical presentation was suggestive of vitamin D-mediated hypercalcemia. The patient received pamidronate and aggressive IV hydration. Electrolyte abnormalities and renal function gradually improved. Computed tomography and positron emission tomography imaging revealed masses localized to the left chest wall with ipsilateral axillary lymphadenopathy. Surgical biopsy of the mass reconfirmed DLBCL ultimately staged as IIE. Following stabilization, the patient declined more aggressive chemotherapy and received R-CHOP with a complete response.
Conclusions: The patient presented with vitamin D-mediated hypercalcemia in the setting of aggressive triple-hit DLBCL. Vitamin D-mediated hypercalcemia occurs in < 1% of lymphomas, and < 0.5% of breast tumors are primary lymphomas. This case study presents a rare constellation of findings at diagnosis. The patient responded to IV hydration and pamidronate and subsequently received R-CHOP for stage IIE DLBCL. While hypercalcemia in the setting of malignancy is associated with poor prognosis, treatment of hypercalcemia does not improve survival.