George Lundberg is a pathologist and writer who was editor of JAMA for a number of years. He wrote the book, "Managing the Patient-Focused Laboratory" in 1975, decades before "patient-focused" became a ubiquitous term.
This week, I ran across some articles on his paradigm of a "brain to brain loop" in lab medicine and medical information. We often remark that lab results only can have "clinical utility" to the extent they are actionable and acted on, and Lundberg contributed to this framework.
The original article was Lundberg, JAMA 1981 245:1762 "Acting on significant laboratory results." He had a follow-up note almost twenty years later, JAMA 1998 280:565. [cited 166 and 85 times, respectively]
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| Plebani 2011 |
The 1981/1998 concept was revisited in a six-page article in 2011 by Plebani, Laposata, and Lundberg, AJCP 2011 136:829 (open access; cited 145 times). See also a follow-up short letter by Sandhaus, AJCP 2012 137:1012.
And finally, see also a 4-page article by Lundberg in 2014, titled "Adding Outcome as the Tenth Step in the Brain to Brain Laboratory Test Loop." AJCP 2014 141:767. (This plea for us to "add outcomes" was less popular, cited only 22 times!)
AI Corner
Here's a Chat GPT summary of Plebani and of Sandhaus.
Summary of Plebani, Laposata, & Lundberg 2011
In the article by Plebani and colleagues, the authors review the evolution of the brain-to-brain loop concept introduced by Lundberg 40 years ago. This concept outlines the steps involved in generating a laboratory test result, from ordering to the action taken based on the test. Over the past four decades, significant changes in medical practice have impacted this loop, leading to both improvements and challenges.
Key changes highlighted include:
Technological Advancements: Improvements in analytic techniques, reagents, instrumentation, and information technology have drastically reduced errors within the laboratory itself, particularly in the analytic phase.
Preanalytic and Postanalytic Phases: Despite improvements in the analytic phase, errors are still prevalent in the preanalytic and postanalytic phases, especially in steps not controlled by laboratory professionals.
Direct Laboratory Access (DLA): Programs allowing patients direct access to laboratory testing without clinician referral have benefits like time and cost savings but pose risks of misinterpretation and emotional distress from abnormal results.
Point-of-Care Testing (POCT): While POCT offers rapid results and can improve clinical outcomes in some scenarios, it introduces new challenges and potential errors, particularly in preanalytic and postanalytic phases.
Laboratory-Clinical Interface: There is a growing autonomy of clinical laboratories from the clinical context, leading to risks of inappropriate test requests and interpretation of results.
Declining Workforce: There is a notable decline in students entering laboratory medicine, leading to shortages in medical technologists and laboratory directors, impacting the quality of laboratory services.
Summary of Sandhaus' Comment re Plebani
In her comment, Sandhaus acknowledges the significant contributions of the brain-to-brain loop concept over the past 40 years, as outlined by Plebani and colleagues. She agrees with their identification of five major challenges to the future relevance of the loop. Sandhaus emphasizes the irony that despite recognizing the preanalytic phase as the source of most laboratory errors and introducing effective interventions, laboratory testing is increasingly being performed by non-laboratory personnel in point-of-care settings. This shift undermines the safeguards established by laboratory professionals to ensure accurate and reliable test results.
Here's an AI read of Lundberg 2014:
In the 2014 article in AJCP, George D. Lundberg reflects on the evolution of the brain-to-brain loop concept for laboratory testing, initially introduced 40 years ago. Lundberg highlights the importance of assessing outcomes as an additional, tenth step in the loop.
Key Points:
Introduction of the Brain-to-Brain Loop Concept:
- Lundberg introduced the brain-to-brain loop in 1981, which outlines the continuum of steps from ordering a laboratory test to acting on the results.
- The loop emphasizes the importance of minimizing errors at each step, particularly in preanalytic and postanalytic phases.
Historical Context and Evolution:
- The brain-to-brain loop was first published in JAMA and has been a recurring theme in Lundberg’s work.
- In 1969, the critical value reporting system was introduced to ensure significant lab results are promptly communicated, which became standard practice.
Challenges in Laboratory Testing:
- Despite advancements, inappropriate laboratory utilization remains a challenge. Misbah et al. and others have highlighted the need for clinical audits to improve test appropriateness.
- Historically, efforts to educate physicians on appropriate test usage through algorithms and decision trees have had mixed success.
Adding Outcomes as the Tenth Step:
- Lundberg proposes adding outcomes as the tenth step in the brain-to-brain loop to emphasize the importance of actionable results that benefit patients.
- Laboratory tests should not only produce data but also lead to positive clinical actions and outcomes.
Contemporary Issues in Laboratory Medicine:
- Lundberg reflects on past and current challenges in laboratory medicine, including the difficulty in defining inappropriate utilization and the need for an outcomes research agenda.
- He notes the ongoing need to address questions about the appropriateness, benefits, and economics of laboratory tests.
Impact on Clinical Practice:
- Effective laboratory testing should lead to actionable results, improving patient care and outcomes.
- The article underscores the necessity of considering the final outcomes of laboratory tests to ensure their clinical relevance and utility.
In summary, Lundberg (2014) emphasizes the critical need to integrate outcomes as a fundamental part of the laboratory testing process, building on decades of work to enhance the appropriateness and effectiveness of laboratory diagnostics.
