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Appropriateness of laboratory tests in the diagnosis of inflammatory rheumatic diseases among patients newly referred to rheumatologists. Joint Bone Spine 2020; 87:588-595. [PMID: 32522598 DOI: 10.1016/j.jbspin.2020.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/14/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Autoantibody tests are commonly ordered when screening for rheumatic diseases. Rheumatoid factor (RF) and antinuclear antibody (ANA) have low positive predictive values in general practice. Overuse of diagnostic tests can result in an increase in unnecessary referrals, patient anxiety, and further costs. OBJECTIVE The objective was to evaluate the utilization patterns, appropriateness, and associated costs of tests including ANA, extractable nuclear antibodies (ENA), anti-double stranded DNA (anti-dsDNA), RF, and HLA-B27 in patients referred to rheumatologists. METHODS A review was conducted of consecutive referrals (accepted and rejected) using university rheumatologists' practices over one year. Inappropriate investigations, and associated costs were analyzed. Tests were considered appropriate if at least one criterion for a specific disease was provided. RESULTS Of 638 referrals the most common reported reasons for referral were: spondyloarthropathies (SpA), rheumatoid arthritis (RA), and lupus (SLE). Prior to referral: 61% had undergone ANA testing at least once, ANA was repeated in one third; 19% had ENA and 21% had anti-dsDNA. 20% had ANA testing with no clinical indication. Half of ENA and anti-dsDNA testing was in the context of a negative ANA. RF was requested in 65% and in close to one third, there was no clinical suspicion of inflammatory arthritis. CONCLUSION Despite the recommendations by CRA Choosing Wisely Campaign, at least 50% of laboratory investigations, including RF, ANA, ENA, and anti-dsDNA, are inappropriately ordered. More selective ordering of the above tests would lead to marked cost reduction.
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Barrett BJ, Randell EW, Mariathas HH, Mohammadi A, Darcy S, Wilson R, Brian Johnston K, Parfrey PS. The effect of laboratory requisition modification, audit and feedback with academic detailing or both on utilization of blood urea testing in family practice in Newfoundland, Canada. Clin Biochem 2020; 83:21-27. [PMID: 32450078 DOI: 10.1016/j.clinbiochem.2020.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 05/15/2020] [Accepted: 05/16/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Measuring blood urea at the same time as serum creatinine in stable ambulatory patients in family practice is largely unnecessary. The objective was to assess the relative impact of changing the laboratory requisition versus audit and feedback and academic detailing on the volume of orders for blood urea. DESIGN AND METHODS A natural experiment was observed over the period April 2015 to March 2018 in the Canadian province of Newfoundland where three health regions had different approaches to trying to reduce such urea testing. The Eastern and Western regions removed urea from the standard laboratory requisition but the test could still be ordered by writing it on the requisition. Central region requisitions continued to list urea. Audit and feedback was undertaken with family doctors in Eastern region after the requisition change and that was followed by academic detailing. A nephrologist gave presentations to groups of family doctors on one occasion in Central region. RESULTS The volume of serum creatinine testing was largely unchanged over time in each region. The volume of urea testing reduced by 73%, 48% and 28% in Eastern, Western and central regions. Interrupted time series analysis showed significant changes in test volume after requisition change in Eastern and Western regions as well as after audit and feedback in Eastern and the presentations in Central region. The incremental impact of academic detailing was not statistically significant. CONCLUSION We conclude that removing urea from standard test order menus was the most effective in reducing test volumes, but combination with audit and feedback augmented the impact.
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Affiliation(s)
- Brendan J Barrett
- Clinical Epidemiology & Nephrology, Faculty of Medicine, Memorial University of Newfoundland, Canada.
| | - Edward W Randell
- Discipline of Laboratory Medicine, Faculty of Medicine, Memorial University of Newfoundland, Canada.
| | - Hensley H Mariathas
- NL SUPPORT, Faculty of Medicine, Memorial University of Newfoundland, Canada.
| | - Asghar Mohammadi
- NL SUPPORT, Faculty of Medicine, Memorial University of Newfoundland, Canada.
| | - Stephen Darcy
- Discipline of Family Medicine, Faculty of Medicine, Memorial University of Newfoundland, Canada.
| | - Robert Wilson
- NL SUPPORT, Faculty of Medicine, Memorial University of Newfoundland, Canada.
| | - K Brian Johnston
- Patient Partner affiliated with NL SUPPORT, St. John's, NL, Canada.
| | - Patrick S Parfrey
- Clinical Epidemiology & Nephrology, Faculty of Medicine, Memorial University of Newfoundland, Canada.
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Meidani Z, Mousavi GA, Kheirkhah D, Benar N, Maleki MR, Sharifi M, Farrokhian A. Going beyond audit and feedback: towards behaviour-based interventions to change physician laboratory test ordering behaviour. J R Coll Physicians Edinb 2019. [PMID: 29537404 DOI: 10.4997/jrcpe.2017.407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Studies indicate there are a variety of contributing factors affecting physician test ordering behaviour. Identifying these behaviours allows development of behaviour-based interventions. Methods Through a pilot study, the list of contributing factors in laboratory tests ordering, and the most ordered tests, were identified, and given to 50 medical students, interns, residents and paediatricians in questionnaire form. The results showed routine tests and peer or supervisor pressure as the most influential factors affecting physician ordering behaviour. An audit and feedback mechanism was selected as an appropriate intervention to improve physician ordering behaviour. The intervention was carried out at two intervals over a three-month period. Findings There was a large reduction in the number of laboratory tests ordered; from 908 before intervention to 389 and 361 after first and second intervention, respectively. There was a significant relationship between audit and feedback and the meaningful reduction of 7 out of 15 laboratory tests including complete blood count (p = 0.002), erythrocyte sedimentation rate (p = 0.01), C-reactive protein (p = 0.01), venous blood gas (p = 0.016), urine analysis (p = 0.005), blood culture (p = 0.045) and stool examination (p = 0.001). Conclusion The audit and feedback intervention, even in short duration, affects physician ordering behaviour. It should be designed in terms of behaviour-based intervention and diagnosis of the contributing factors in physicians' behaviour. Further studies are required to substantiate the effectiveness of such behaviour-based intervention strategies in changing physician behaviour.
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Affiliation(s)
- Z Meidani
- D Kheirkhah, Infectious Diseases Research Centre, Kashan University of Medical Sciences, Kashan, Iran.
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Ma I, Lau CK, Ramdas Z, Jackson R, Naugler C. Estimated costs of 51 commonly ordered laboratory tests in Canada. Clin Biochem 2019; 65:58-60. [PMID: 30615855 DOI: 10.1016/j.clinbiochem.2018.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/03/2018] [Accepted: 12/27/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Test cost display has been shown to reduce inappropriate laboratory test ordering practices in the United States. Unfortunately, such a system is limited in the Canadian publically funded healthcare environment. Many Canadian physicians inaccurately estimate the cost of laboratory tests, which may contribute to mis-utilization. Here, we provide an estimated cost of over 50 commonly ordered laboratory tests in Canada as an educational tool for physicians. METHODS Test volume data was collected from Calgary Laboratory Services' Laboratory Information System in order to determine which laboratory and diagnostic tests are most commonly ordered in Calgary and its surrounding area. Reference median cost (RMC) of fifty one commonly ordered test was calculated by determining the price list of all-inclusive indirect costs from six different clinical laboratories across Canada. RESULTS Of the 51 laboratory tests included, the minimum RMC was $5 CAD (eg: albumin, calcium, urea), and the maximum RMC was $300 (surgical pathology report). CONCLUSIONS A caveat to the provided list of test costs is that it is only an estimate and may differ from what each individual clinical laboratories charges to third parties or for research purposes. However, this list can serve as an educational tool and raise awareness for Canadian physicians on the relative costs of laboratory tests.
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Affiliation(s)
- Irene Ma
- Department of Pathology and Laboratory Medicine, Calgary, Alberta, Canada
| | - Cheryl K Lau
- Department of Pathology and Laboratory Medicine, Calgary, Alberta, Canada
| | - Zane Ramdas
- Calgary Laboratory Services, Calgary, Alberta, Canada
| | | | - Christopher Naugler
- Department of Pathology and Laboratory Medicine, Calgary, Alberta, Canada; Family Medicine, Calgary, Alberta, Canada; Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Naugler C, Hemmelgarn B, Quan H, Clement F, Sajobi T, Thomas R, Turin TC, Hnydyk W, Chin A, Wesenberg J. Implementation of an intervention to reduce population-based screening for vitamin D deficiency: a cross-sectional study. CMAJ Open 2017; 5:E36-E39. [PMID: 28401116 PMCID: PMC5378529 DOI: 10.9778/cmajo.20160073] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND We describe the implementation of an intervention in Alberta in support of the Choosing Wisely Canada recommendation against population screening for vitamin D deficiency (as determined by serum total 25-hydroxyvitamin D testing). We hypothesized that the introduction of a specialized requisition for vitamin D testing would reduce the annual number of vitamin D tests performed. METHODS We performed a cross-sectional observational study that included all vitamin D tests ordered in Alberta between Apr. 1, 2015, and Mar. 31, 2016. There were no exclusion criteria. A special requisition for ordering vitamin D tests in Alberta was introduced on Apr. 1, 2015. Using an interrupted time series model, we compared predicted versus observed vitamin D test volumes for the 12-month period following the introduction of the new requisition. The sole outcome measure was the monthly change in volume of vitamin D testing. In addition, we calculated any cost savings as a result of reduced testing. RESULTS Over the first 12 months of the intervention, there was a reduction in the number of tests ordered from a predicted 342 477 tests to 29 525 tests (91.4% reduction). This decrease represented a direct spending decrease of Can$938 856-$1 564 760 per year in Alberta. INTERPRETATION A provincially led implementation of a Choosing Wisely Canada recommendation resulted in a large and sustained reduction in serum total 25-hydroxyvitamin D testing in Alberta. This study shows that provincially led interventions based on Choosing Wisely Canada recommendations can result in substantial reductions in laboratory tests.
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Affiliation(s)
- Christopher Naugler
- Departments of Pathology and Laboratory Medicine (Naugler, Chin), Family Medicine (Naugler, Thomas, Turin), Community Health Sciences (Hemmelgarn, Quan, Clement, Sajobi), Cumming School of Medicine, University of Calgary, Calgary, Alta; Alberta Medical Association (Hnydyk), Edmonton, Alta; Red Deer Regional Hospital Centre (Wesenberg), Clinical Laboratory, Red Deer, Alta
| | - Brenda Hemmelgarn
- Departments of Pathology and Laboratory Medicine (Naugler, Chin), Family Medicine (Naugler, Thomas, Turin), Community Health Sciences (Hemmelgarn, Quan, Clement, Sajobi), Cumming School of Medicine, University of Calgary, Calgary, Alta; Alberta Medical Association (Hnydyk), Edmonton, Alta; Red Deer Regional Hospital Centre (Wesenberg), Clinical Laboratory, Red Deer, Alta
| | - Hude Quan
- Departments of Pathology and Laboratory Medicine (Naugler, Chin), Family Medicine (Naugler, Thomas, Turin), Community Health Sciences (Hemmelgarn, Quan, Clement, Sajobi), Cumming School of Medicine, University of Calgary, Calgary, Alta; Alberta Medical Association (Hnydyk), Edmonton, Alta; Red Deer Regional Hospital Centre (Wesenberg), Clinical Laboratory, Red Deer, Alta
| | - Fiona Clement
- Departments of Pathology and Laboratory Medicine (Naugler, Chin), Family Medicine (Naugler, Thomas, Turin), Community Health Sciences (Hemmelgarn, Quan, Clement, Sajobi), Cumming School of Medicine, University of Calgary, Calgary, Alta; Alberta Medical Association (Hnydyk), Edmonton, Alta; Red Deer Regional Hospital Centre (Wesenberg), Clinical Laboratory, Red Deer, Alta
| | - Tolulope Sajobi
- Departments of Pathology and Laboratory Medicine (Naugler, Chin), Family Medicine (Naugler, Thomas, Turin), Community Health Sciences (Hemmelgarn, Quan, Clement, Sajobi), Cumming School of Medicine, University of Calgary, Calgary, Alta; Alberta Medical Association (Hnydyk), Edmonton, Alta; Red Deer Regional Hospital Centre (Wesenberg), Clinical Laboratory, Red Deer, Alta
| | - Roger Thomas
- Departments of Pathology and Laboratory Medicine (Naugler, Chin), Family Medicine (Naugler, Thomas, Turin), Community Health Sciences (Hemmelgarn, Quan, Clement, Sajobi), Cumming School of Medicine, University of Calgary, Calgary, Alta; Alberta Medical Association (Hnydyk), Edmonton, Alta; Red Deer Regional Hospital Centre (Wesenberg), Clinical Laboratory, Red Deer, Alta
| | - Tanvir C Turin
- Departments of Pathology and Laboratory Medicine (Naugler, Chin), Family Medicine (Naugler, Thomas, Turin), Community Health Sciences (Hemmelgarn, Quan, Clement, Sajobi), Cumming School of Medicine, University of Calgary, Calgary, Alta; Alberta Medical Association (Hnydyk), Edmonton, Alta; Red Deer Regional Hospital Centre (Wesenberg), Clinical Laboratory, Red Deer, Alta
| | - William Hnydyk
- Departments of Pathology and Laboratory Medicine (Naugler, Chin), Family Medicine (Naugler, Thomas, Turin), Community Health Sciences (Hemmelgarn, Quan, Clement, Sajobi), Cumming School of Medicine, University of Calgary, Calgary, Alta; Alberta Medical Association (Hnydyk), Edmonton, Alta; Red Deer Regional Hospital Centre (Wesenberg), Clinical Laboratory, Red Deer, Alta
| | - Alex Chin
- Departments of Pathology and Laboratory Medicine (Naugler, Chin), Family Medicine (Naugler, Thomas, Turin), Community Health Sciences (Hemmelgarn, Quan, Clement, Sajobi), Cumming School of Medicine, University of Calgary, Calgary, Alta; Alberta Medical Association (Hnydyk), Edmonton, Alta; Red Deer Regional Hospital Centre (Wesenberg), Clinical Laboratory, Red Deer, Alta
| | - James Wesenberg
- Departments of Pathology and Laboratory Medicine (Naugler, Chin), Family Medicine (Naugler, Thomas, Turin), Community Health Sciences (Hemmelgarn, Quan, Clement, Sajobi), Cumming School of Medicine, University of Calgary, Calgary, Alta; Alberta Medical Association (Hnydyk), Edmonton, Alta; Red Deer Regional Hospital Centre (Wesenberg), Clinical Laboratory, Red Deer, Alta
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