Great, you have finally managed to develop that in-house multiplex PCR to diagnose disease Y, and thus you can provide the clinicians with a “real-time” result on the same day. Previously you had to send the sample off to a “reference lab”, and a result was not forthcoming for what seemed like an age…
Even better, your in-house PCR has primers for an increased number of target pathogens, thus increasing its clinical usefulness.
And best of all, its cheaper than the price of the Reference Lab equivalent!
Hold on a minute.
The problem with tests that are better or faster than their predecessors is that they are almost inevitably more popular. You may end up with twice the amount of requests than before, obviating any cost savings per individual test. You may also find the requests becoming increasingly dubious in their validity.
I have seen this happen in practice and it is something that microbiology managers and funders need to be very wary of.
How to counteract it? The obvious way is to place appropriate restrictions on test requesting. This can either be by insisting on certain clinical conditions being met, or requiring “authorisation” from an expert in the condition before the test request is approved.
As the range, speed and quality of microbiology testing improves, I suspect that you are going to see more and more algorhythms, guidelines and evidence based restrictions around test requesting. Indeed I see this as being one of the primary roles of a Clinical/Medical Microbiologist.
You have been made aware of a new PCR test X. It seems to work very well, and diagnoses disease Y with high sensitivity and specificity, and with a decrease in turnaround time compared to what you have been doing previously. You are confident that it will decrease length of admission, reduce unnecessary investigations and will save your local hospital a lot of money.
It’s not even that expensive. Sure it costs more than your old style test but surely that will be compensated for by the above….
There are certainly plenty of Test Xs out there these days. A new one seems to come on the market every other week.
So why can it be so difficult to get funding for Test X?
A large part of the reason is that the savings made may occur in a different budget to the one where the extra costs are incurred, even if the central funder for both budgets is the same body. In other words the funding is siloed.
Funding silos are of course not unique to microbiology, laboratory medicine, or even healthcare. They are a ubiquitous problem, but can be frustrating nevertheless. And silos, as we are aware, are notoriously difficult to break down. They are much more of a problem with the system, rather than any individuals involved. Silos are the end result of society’s inability to look beyond the immediate environment and I believe they are culturally engrained in all of us.
If I knew of an easy way to break down the funding silos and get test x funded, I would divulge them, but I don’t think there are any easy solutions. Persistence is key, backing your argument up with as much evidence as possible, focusing on clinical risk, and extending empathy with your funder’s predicament are all good starting points, but does not guarantee success!
Silos of course do not just apply to funding but can even occur in departments in a laboratory! It is always worthwhile reviewing the good things that happen in your department and considering whether they can apply to other departments as well. Click here for a nice article on silos (about a 5 min read)
Over the years I have been used to teaching everyone that MRSA is resistant to all cephalosporins, or indeed, all beta-lactams.
However I have been having to revise that statement recently with the advent of the new “5th generation” cephalosporins, ceftaroline and ceftobiprole.
These broad spectrum antibiotics have activity against MRSA by having enhanced affinity for the PBP2A binding protein. As new antibiotics go, they are not overly expensive. Their main downside is that they both need to be given intra-venously.
They have actually been around for a while now, but only more recently available in New Zealand.
So will I use these “new” antibiotics in clinical practice?
Possibly, although I always think that new broad spectrum antibiotics such as these should be protected from widespread use in order to minimise resistance selection.
However if they are not used at all, they will be commercially unviable and be withdrawn from the market. A catch 22 situation.
I now have to revise my lectures. MRSA is resistant to most beta-lactams, with a couple of exceptions….”