Laboratory quality control for all. Can this be achieved?

Visiting hospitals in Africa and meeting with clinicians, pathologists, and laboratory directors, it rapidly becomes apparent that confidence in any diagnostic services is lacking. Clinicians cite many reasons. Some days complete blood cell counts and chemistries are available, while on other days, because there are no reagents available, physicians have no results to guide treatment for their patients. Blood cultures, when available, are frequently contaminated by fungi and bacteria and you cannot be sure if the organism identified is the cause of the patient's fever. Turnaround times are incredibly long, and by the time a result is available , it is too late to be clinically relevant. Consequently, clinicians continue to practice medicine using a syndromic approach rather than defining a specific diagnosis. Unfortunately , this happens routinely, even in large African academic centers and in much of the developing world. One of the things that clinicians in developed countries take for granted are efficient laboratories that deliver credible results. For example, clinicians order blood work as the patient is leaving their office, and the results appear in the electronic medical record that afternoon. They get a call from the laboratory when budding yeasts show up in a blood culture obtained 2 days ago in a patient with a transplant who had been admitted with fever and treat the patient accordingly; they know blood culture contamination rates in the hospital are low and are confident that there is little likelihood that these yeasts are a contaminant. Two days after a patient with a gastric ulcer undergoes an endoscopic biopsy, a pathologist's report shows adenocarcinoma, and thus staging and treatment can be started. Having reagents daily in the laboratory and working with well-maintained instruments allow for dependable turnaround times. Using internal and external quality controls is indispensable for consistency of laboratory results. These activities are completely invisible to clinicians but they provide confidence and credibility to the laboratory results in our environment. Thus, it is not surprising that physicians depend on laboratory results to diagnose and guide treatment. The article by Amukele et al 1 in this issue demonstrates that given the opportunity and resources, multiple centers in Africa are capable of taking the necessary steps to establish confidence in laboratory results. In the context of research, the authors have implemented good laboratory practices in African institutions collaborating under the auspices of the US President's Emergency Plan for AIDS Relief (PEPFAR). …