In-house blood work can boost veterinary clinic profits but only if practitioners treat it as a major capital investment and do their homework, say veterinary clinical pathologists.
“Many people only look at the cost of the instrument, but there is so much more to understand,” said Craig Tockman, DVM, director of Abaxis North American Animal Health of Union City, Calif. “We must look at the cost and value of time. Veterinarians must look at the value of investment in capital equipment as part of the value of their business and what they provide their patients. The cost of running a test at the point of care is actually less expensive for the practice, and provides the ability to actually grow the business.”
Kendal Harr, DVM, MS, a diplomate of the American College of Veterinary Pathologists, is owner and clinical pathologist of Mukilteo, Wash.-based URIKA LLC, a private pathology consortium of boarded consultants. A member of the Abaxis Scientific Advisory Board, she has written extensively about issues surrounding her field, particularly the assurance of quality, accurate test results.
“Especially in the more normal patients, in-house complete blood count and biochemical analyzers can improve turnaround time and diagnostic results when appropriate quality assurance has been implemented,” Dr. Harr said.
Time saved by an on-site blood analyzing machine can be crucial for an after-hours clinic, and decreased transport and handling of samples also cuts down opportunity for artifacts, she said.
“Additionally, certain analyses, such as coagulation factors and urinalysis, are temperature and time-dependent, and results would benefit from high-quality, well-validated in-clinic assays,” Harr said. “The hope in the clinics is that the purchase of laboratory equipment also increases revenue by keeping laboratory work in the clinic revenue stream.”
However, a survey Harr co-authored for the online Veterinary Information Network (VIN.com) showed that “While the vast majority of practitioners (who responded) recognized the importance of quality assurance in their laboratories, only about half of them have instituted any form of a prospective quality assurance program.”
Practitioners should carefully assess their practice goals and make a list of questions to ask the manufacturer, said Leslie Sharkey, DVM, Ph.D., Dipl. ACVP and president of the American Society for Veterinary Clinical Pathology.
“Is the priority turnaround time, or is this a financially driven decision?” Dr. Sharkey said. “They need to consider the cost of the machines, the reagents, the quality control materials—if these are even available—and the resources that will be required to train staff and maintain the equipment.”
Practitioners should ask about a maintenance agreement in case the machine breaks, Sharkey advised.
“Be sure to have a complete understanding of the limitations of the analyzers, including how the machine signals that a problem may have occurred that could produce erroneous results,” Sharkey said. “Practice owners will need to figure out how long it takes a tech to run the blood work, perform the maintenance, and do reagent inventory and quality assurance, so they should consider that cost in their accounting.”
When issues have arisen with in-house blood equipment, the major problem observed by one veterinary consultant for a major manufacturer has been the clinic’s failure to maintain it according to the manufacturer’s directions, and lack of regular use of the machine, said Kristen Friedrichs, DVM, Dipl. ACVP, clinical assistant professor of clinical pathology at the University of Wisconsin School of Veterinary Medicine.
“The more often an analyzer is used, the better it is,” she said. “Staff and clinicians are much more familiar with a piece of equipment if they use it frequently. The equipment will be better maintained, and when problems do occur they will be more readily recognized and dealt with in a timely manner.”
Rather than limiting their search to the brand carried by their major equipment supplier, Dr. Friedrichs said, practitioners should look at multiple analyzers.
“They need to make sure they are comparing the features and capabilities equally,” she said.
“Ease of use, sample volume, single or panel/rotor test availability, species capabilities and equipment cost may be of more immediate interest,” she added. “But cost of reagents and maintenance, shelf-life of reagents, updates from the manufacturer, technical and consultation support, ease of trouble-shooting, waste handling, water and electrical requirements, and reputation and longevity of the company should all be considered.”
The amount of maintenance depends on the particular analyzer, explained Dr. Tockman.
“The Abaxis Vetscan VS2 analyzer incorporates a system called Intelligent Quality Control. Part of that system is an automatic calibration procedure each time a blood sample is performed, and there is no work necessary by the user,” he said. “In addition, the system performs more than 150 internal quality assessment procedures to ensure accurate and precise results.”
Because hematology instruments have blood running through their mechanisms so as to count cells, Tockman said you need to be able to clean them.
“Instruments that cannot be cleaned in the practice must be sent in for regular service, adding cost and down time,” he said. “The Abaxis Vetscan hematology instruments should be cleaned about every 100 complete blood counts (CBCs), and this takes only about 10 to 15 minutes.”
Harr recommended seeking scientific and budgetary advice from an objective third party not involved in sales with the manufacturer in question.
“Once they know what they need, they can compare that to revenue generated from samples sent to the reference lab,” she said. “ If the decision to purchase is made, I recommend bringing the equipment in-house for at least two weeks, if not a month, prior to purchase.”
The veterinary clinical pathology society has a written set of external quality assurance recommendations using allowable total error, currently pending review, that should be used to test each piece of equipment, Harr said.
“There are laboratory lemons similar to that found in the car world,” she said. “The practitioner should run an external quality assessment on every piece of equipment while it is still under warranty, so that they don’t wind up paying a significant amount of money for a headache which results in misdiagnosis.”
Tockman reinforced that idea.
“You wouldn’t buy a car without driving it. Why would you not test out the ease of use of a veterinary lab?” he said.
“Secondly, it is important to ask about warranty and service costs,” he continued. “Many analyzers come with a one-year warranty, but then the practice is charged thousands of dollars per year in maintenance contracts. Check out the company’s customer service department, and whether you can get clinical help from board-certified experts when using your point-of-care analyzers.”
While reference laboratories might make the most sense for delicate and sophisticated blood tests, Tockman said if blood work can reliably be performed on-site, it should be.
“It is simply better medicine, better customer service and more cost-effective to do it that way,” he said. “Even tests performed in the hospital can be backed up at the reference lab.”
Which can combine the best of both worlds: “The client does what the doctor recommends, the immediate information is highly valuable to the veterinarian and the client, and the veterinarian has the clinical pathologist’s evaluation of the blood smear in the same time as it would have taken to get the entire CBC result anyway,” Tockman said.