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A lab-driven program for cholesterol testing.

A lab-driven program for cholesterol testing

Intense public interest in the dangers of high blood cholesterol levels has led to a proliferation of cholesterol screening programs throughout the United States. In the Ohio area, as elsewhere, too many such programs are run by personnel with no clinical laboratory training. That's too bad, because labs can easily offer superb programs that become easier to accomplish with each screening session.

It was just this situation that prompted the laboratory at Union Hospital in Dover, Ohio, to develop a cholesterol screening program of its own. The motivation was simple: As laboratory professionals, we believed we could provide more accurate results (1-3) and interpret the numbers more meaningfully than some of the other local programs were doing. Our credibility, we believed, would enhance post-testing counseling sessions. (4) Furthermore, physicians would be more likely to accept laboratory-generated test results than those from certain other sources. (5) Physicians' greater confidence in the data, we hoped, would encourage their involvement in follow-up activities.

Since our first screening program, held in April 1987, more than 6,600 people have dropped in at one of our sites - the hospital, shopping malls, pharmacies, and even a large grocery store - to have their cholesterol checked. This article looks at planning considerations, shares the wisdom gained from nine separate screening programs, and examines benefits to the laboratory, the hospital, and the physician.

Screening programs have three common stages: planning the program, conducting the screening sessions, and analyzing the program after it has been completed. Accompanying all these stages are various benefits and draw-backs that require consideration. Each of these aspects is important to the program's overall success. * Pre-program planning. We have found that choosing a theme helps define the program. At various times we have linked screening programs with National Heart Month and National Medical Laboratory Week. National Hospital Week and local health fairs are other possibilities for labs to consider. A theme enhances advertising and allows the hospital to promote other programs or services.

Timing is everything. Summer programs complete with vacations and myriad fair-weather activities. Fall programs get lostt in the back-to school rush. Turnout at midwinter programs is generally disappointing, since sensible eating habits aren't a high priority during the holidays. In northern climates, the weather keeps many prospective participants at home. That leaves the spring.

The public tends to be health conscious after months of winter inertia. The imminent approach of swimsuit season awakens the dormant desire to get in shape. Of the screening programs our hospital now offers quarterly - more often if a sponsor is especially eager - we invariably get the greatest turnout in the spring.

Location is important, particularly in terms of access, parking, cost, and crowd control. In the hospital itself, the lobby and auditorium are a logical choice and provide a chance to showcase the hospital's facilities. Many people age 20 to 25, however, tend to avoid hospitals. Affiliated service areas, such as a new or recently renovated medical office building, are other effective sites.

Convention centers are a popular locale for large-scale health fairs. Rental fees are high, however, and other contractual obligations may be involved - some as amazing as having to use (read: rent) the center's tables or extension cords. The possibility of using medical office complexes, clinics, and pharmacies is worth investigating. There is also an increasing demand for testing at worksites.

In our experience, local shopping malls are by far the finest choice. Malls meet all site requirements listed above, charge little or nothing for the space, and offer distractions before, during, and after the screening.

The time of day dictates the demographics. (6) To accommodate all work schedule, programs should be offered from approximately 8 a.m. to 9 p.m. The day or days of the week makes a difference as well. Events held for more than one day usually draw a bigger crowd, especially if a Saturday or Sunday is included. When we are limited to a single day, we have found that Wednesday works best, although we aren't sure just why.

The programs shouldn't run longer than three days. After that, the public loses interest and dail9 attendance plummets. We seem to get our biggest crowds during two-day programs that begin or end on a weekend.

Because the event is intended as a public service and good public relations, rather than to make money, any fee charged should equal or run only slightly more than the cost of providing the service. offering the screen at cost fosters goodwill between the hospital and the community.

Our direct cost for a cholesterol test, following a fairly standard pattern nationwide, is $2.46. This amount includes $1 for technical time, 15 cents for fingerstick supplies, $1.10 for the analyzer's reagent tab, 10 cents for the registration form, and 11 cents for educational materials. Advertising costs, which vary according to the types of media used, are paid by the sponsor.

It is not unreasonable to add a modest handling charge. A fee of $5 seems to satisfy both the public and the hospital administrators. It's a nice round number that everyone accepts; any profit goes right back into the program. We tried charging $7 once, but people resisted paying the extra couple of dollars. * The event. Each screening program has a sponsor. It may be the pharmacy across the street from the hospital, or a large grocery store, or the hospital itself. We start publicizing each program two weeks in advance. The sponsor places newspaper ads and runs radio spots and public service announcements. The hospital public relations representative and I often participate in radio and television interviews. We alert local bookstores to expect a rush of requests for books on cholesterol.

Depending on the locale, site preparation and setup can begin the night before or first thing in the morning. If the screening program will be held at a mall, we begin as soon as the stores in the mall have closed the night before. If a local store is donating the space, we allow about half an hour before it opens.

The brand of portable analyzer that we selected requires only a small blood specimen, uses whole blood rather than serum, provides results quickly, costs little per test, and is easy to use. (7) Other supplies include tables, chairs, and a source of electricity; re-agents, registration forms, and phlebotomy paraphernalia; and educational handouts. Pamphlets are donated by the manufacturer of the analyzer, prepared by the hospital's dietary department, or purchased from the American Heart Association. If testing will be done off hospital grounds, we make sure plenty of extra supplies are on hand to prevent shortages if turnout is higher than expected.

The screening staff includes cashiers, technicians and technologists, interviewers for counseling and education, and circulators to maintain an orderly traffic flow. Depending on the projected turnout, we bring four to six portable analyzers. The hospital owns two, and we borrow the rest from labs outside our service area. A courier picks up and returns the borrowed equipment.

Since one person can run two analyzers - and an experienced technologist can easily run three - we usually schedule at least two laboratorians to be on hand at all times. We also tap technologists or technicians to cover rest and meal breaks and to act as circulators. The laboratory secretary fills in as cashier, while the lab's administrative director or a senior technologist does counseling. For a large program, six to eight of our lab's 35 FTEs might work on their days off at one of the workstations. * Work areas. To keep the crowd flowing through comfortably, we set up three work areas. In the future, we hope to institute a fourth.

[paragraph] Registration. Participants start at the registration table, where they receive a registration form, in triplicate, on a clipboard. A circulator stands by to keep the line orderly and to answer questions from those about to be screened. Typical queries are "What will I have to do?" and "How long will it take?" The cashier checks the form and collects the fee, if any. When our hospital is the sponsor, we charge no fee at all.

(*)Blood sampling and analysis. Registration form in hand, participants move to an available chemistry analyzer. A technologist does a fingerstick and draws 30[mu]l of whole blood. Supplies include an alcohol swab, lancet, gauze swab, and capillary tube. Fasting specimens are not necessary, since we analyze only total cholesterol, not LDL or HDL cholesterol. (8)

The specimen is applied to the cholesterol reagent tab and analyzed with the procedure recommended by the manufacturer. Each analysis takes 175 seconds; we can perform 20 tests per hour. A circulator is assigned to the testing area to keep the lines at the analyzer tables moving. Results are recorded on the registration form, which participants take with them to the next area.

(*)Counseling. At the third area, veteran laboratorians review test results, explain their implications, and discuss options. Each participant is encouraged to ask questions and to review the educational materials provided with the registration form. If the cholesterol level is high, he or she is urged to consult a physician for follow-up.

Participants keep one copy of the form. The counselor pulls the remaining two pages. One is filed at the laboratory; the other is mailed directly to the participant's physician, if one has been named on the form.

(*)Miscellaneous. As our program grows, we hope to institute a fourth work area staffed by non-laboratorians offering miscellaneous services. Participants might have their blood pressure checked by a nurse, pick up tips on nutrition from hospital dietitians, or discuss an exercise program with a staff member from the cardiac rehabilitation department. * Post-program analysis. Rush hour begins as soon as the doors open. Other peak periods are lunch hour and late afternoon to early evening, when people leave school and work - from 3 to 7 p.m. Waiting time may be as long as 50 minutes in the registration area and 20 minutes at the blood sampling/analysis workstation. Even so, people accept the inconvenience of long lines if they know results will be available immediately. That's better, many feel, than faster turnaround with results mailed later. (9)

Our program is strictly cash and carry. After-the-fact paperwork would be a logistical nightmare for the lab. In addition, ever-rising postage costs would make the effort prohibitive for us, to say the least.

Participants' complaints have increased as cholesterol screening programs of many types have sprung up in our community. The major gripe is that results are not comparable from one program to another. This isn't surprising, given the different kinds of desktop analyzers used, the lack of a standardized calibration material, and the extreme variation in the training and expertise of testers.

The chief complainers are those who feel compelled to have their cholesterol checked at every screening program. Despite having diligently followed the advice they received in the educational handouts and counseling suggestions at previous screenings, some become disheartened when they fail to see any improvement.

A few physicians have been irked because they were unprepared to handle the volume of patients calling for follow-up of tests they had not ordered. We have heard of situations in which doctors have entered their offices to find 200 lab reports stacked in their in-boxes. They usually calm down after we point out that many of these patients will need an office visit for follow-up. * Benefits. Cholesterol screening programs help everyone involved. Local residents pursue wellness at little or no cost. The hospital community stands to gain as well:

(*)The hospital. By responding to the public's needs, the hospital receives priceless goodwill at minimal cost. The hospital shares center stage with the laboratory, reaping the benefits of increased exposure via local newspapers and cable TV stations both before and during the event. The hospital also gains invaluable marketing survey data in terms of demographics, the efficacy of various advertising media, and assessment of the service area. To our surprise, for example, a ZIP code review showed that our highest response rate comes from a community 12 to 15 miles away that has its own hospital right in town.

(*)The laboratory. The up-close-and-personal approach is an ideal way to enhance the lab's visibility and image. The technical staff's morale is boosted when they have a chance to interact with the population they usually serve behind the laboratory walls.

The screening program helps the lab formulate marketing strategies. We can show that the public obviously wants cholesterol screening and that our hospital offers such programs, but other hospitals don't. Cholesterol screening programs enable the laboratory to develop an outpatient consumer base directly, without physician assistance, and to market our services to prospective patients. The volume of other lab work increases as a result of follow-up test referrals from participants' physicians.

(*)The physician. The screening program provides direct referrals when technologists suggest that high-risk candidates seek a physician's advice. Indirect referrals result when test results are mailed to participants' physicians.

Best of all, the program bonds the hospital, laboratory, and medical offices more closely by developing a common patient base. * Demographics. The 6,600 people who sought cholesterol screens during our program's first two years constitute a track record comparable to what has been reported in other screening programs. (10,11) During that period, 6,423 people returned completed registration data sheets. The rest decided to bypass the screen at the last minute.

Sixty-two per cent of our screenees were female. Sixty-seven per cent of all screenees said they were participating in a cholesterol screening program for the first time. Nearly two-thirds (65 per cent) were at least 50 years old. Those in the single largest age group - 29 per cent of all participants screened - were 60 to 69 years old.

The demographic profile indicates that our typical participant is a married Caucasian woman, aged 60 to 69 years, who has not been tested in any previous screening program. We would like to increase participation among persons aged 20 to 49 years, who have so far been harder to reach. The results would be worthwhile; younger people can incorporate dietary and exercise changes into their daily routine more easily than older ones. Reducing high cholesterol levels during the early adult years is likely to have the greatest impact on decreasing the incidence of atherosclerosis. * Results and analysis. We categorized the cholesterol levels of all participants according to 1987 National Institutes of Health Consensus Conference criteria. The mean cholesterol level for all participants (male and female) was 232.2 mg/dl. One-third of those screened tested at "desirable" levels ([less than]200 mg/dl); one-third were "borderline high" (200 to 239 mg/dl); and one-third tested "high" ([greater than]240 mg/dl). * Anticipation. Pre-program planning is the key to a successful effort. It is essential to anticipate any problems that might occur during screening, such as a spate of phone calls from annoyed physicians when all those lab slips arrive. A successful screening program not only satisfies the participants but also enables the hospital, lab, and physicians to share their resources.

Our data indicate that the cholesterol levels of two-thirds of our community are borderline high or high. We hope that the laboratory, by continuing to provide screening and education programs, will help improve the situation.

(1.) Belsey, R.; Goitein, R.K.; and Baer, D.M. Evaluation of a laboratory system intended for use in physicians' offices: I. Reliability of results produced by trained laboratory technologists. JAMA 258: 353-356, 1987.

(2.) Belsey, R.; Vandenbark, M.; Goitein, R.K.; et al. Evaluation of a laboratory system intended for use in physicians' offices: II. Reliability of results produced by health care workers without formal or professional laboratory training. JAMA 258: 357-361, 1987.

(3.) Sontrop, M.E.; Peake, M.J.; and Fraser, C.G. Assessment of the Beckman oxygen rate analyzer for the enzymatic assay of cholesterol. Clin. Biochem. 12: 40-42, 1979.

(4.) Lefebvre, R.C.; Hursey, K.G.; and Carleton, R.A. Labeling of participants in high blood pressure screening programs: Implications for blood cholesterol screenings. Arch. Intern. Med. 148: 1993-1997, 1988.

(5.) Schucker, B., and Bradford, R.H. Screening for high blood cholesterol. Clin. Lab. Med. 9: 29-36, 1989.

(6.) Wynder, E.L.; Field, F.; and Haley, N.J. Population screening for cholesterol determination: A pilot study. JAMA 256: 2839-2842, 1986.

(7.) James, R.; Tyler, C.; and Henrikson, D. An evaluation of the accuracy of the Reflotron system in the field. Med. J. Aust. 149: 130-131, 1988.

(8.) Garber, A.M.; Sox, H.C. Jr.; and Littenberg, B. Screening asymptomatic adults for cardiac risk factors: The serum cholesterol level. Ann. Intern. Med. 110: 622-639, 1989.

(9.) Fraser, C.G.; Peake, M.J.; and Calvert, G.D. Rapid cholesterol measurement: Patient classification in heart risk evaluation clinics. Med. J. Aust. 1: 465-466, 1979.

(10.) Greenland, P.; Levenkron, J.C.; Radley, M.G.; et al. Feasibility of large-scale cholesterol screening: Experience with a portable capillary-blood testing device. Am. J. Public Health 77: 73-75, 1987.

(11.) Meyerson, D.A., and Santanello, N.C. Family-oriented cardiovascular risk screening and intervention. Md. Med. J. 37: 395-398, 1988.

The author is director of laboratory operations at Akron (Ohio) City Hospital. At the time this article was written, he was administrative director of laboratory services at Union Hospital in Dover, Ohio.
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Title Annotation:part 3
Author:Bennett, W. David
Publication:Medical Laboratory Observer
Date:Apr 1, 1990
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