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VanSpronsen AD, Zychla L, Turley E, Villatoro V, Yuan Y, Ohinmaa A. Causes of Inappropriate Laboratory Test Ordering from the Perspective of Medical Laboratory Technical Professionals: Implications for Research and Education. Lab Med 2023; 54:e18-e23. [PMID: 35801961 DOI: 10.1093/labmed/lmac076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Inappropriate laboratory test ordering is a significant and persistent problem. Many causes have been identified and studied. Medical laboratory professionals (MLPs) are technical staff within clinical laboratories who are uniquely positioned to comment on why inappropriate ordering occurs. We aimed to characterize existing MLP perceptions in this domain to reveal new or underemphasized interventional targets. METHODS We developed and disseminated a self-administered survey to MLPs in Canada, including open-ended responses to questions about the causes of inappropriate laboratory test ordering. RESULTS Four primary themes were identified from qualitative analysis: ordering-provider factors, communication factors, existing test-ordering processes, and patient factors. Although these factors can largely be found in previous literature, some are under-studied. CONCLUSION MLP insights into nonphysician triage ordering and poor result communication provide targets for further investigation. A heavy focus on individual clinician factors suggests that current understandings and interprofessional skills in the MLP population can be improved.
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Affiliation(s)
- Amanda D VanSpronsen
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Laura Zychla
- Research, Canadian Association for Medical Radiation Technologists, Ottawa, Ontario, Canada
| | - Elona Turley
- Coagulation Medicine, Alberta Precision Laboratories, Edmonton, Alberta, Canada
| | - Valentin Villatoro
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Yan Yuan
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Arto Ohinmaa
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Laohavisudhi K, Phinyo P, Wittayachamnankul B, Chenthanakij B, Tangsuwanaruk T, Tianwibool P, Laohakul P, Wongtanasarasin W. Symptoms and comorbidities associated with abnormal levels of serum calcium, magnesium, and phosphate in the emergency department: a prospective observational study. World J Emerg Med 2023; 14:59-61. [PMID: 36713345 PMCID: PMC9842460 DOI: 10.5847/wjem.j.1920-8642.2023.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/20/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Korsin Laohavisudhi
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand,Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Borwon Wittayachamnankul
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Boriboon Chenthanakij
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Theerapon Tangsuwanaruk
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Parinya Tianwibool
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Pavita Laohakul
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Wachira Wongtanasarasin
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand,Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California 95817, USA,Corresponding Author: Wachira Wongtanasarasin,
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Lin DC, Parakati I, Haymond S. The Impact of COVID-19 on Laboratory Test Utilization at a Pediatric Medical Center. J Appl Lab Med 2022; 7:1076-1087. [PMID: 35723285 PMCID: PMC9384293 DOI: 10.1093/jalm/jfac048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/17/2022] [Indexed: 11/13/2022]
Abstract
Abstract
Background
The epidemiology and clinical manifestation of coronavirus disease 2019 (COVID-19) in the pediatric population is different from the adult population. The purpose of this study is to identify effects of the COVID-19 pandemic on laboratory test utilization in a pediatric hospital.
Methods
We performed retrospective analysis on test utilization data from Ann & Robert H. Lurie Children’s Hospital of Chicago, an academic pediatric medical center. Data between two 100-day periods prior to (prepandemic) and during the pandemic (mid-pandemic) were analyzed to evaluate changes in test volume, lab utilization, and test positivity rate. We also evaluated these metrics based on in- vs outpatient testing and performed modeling to determine what variables significantly impact the test positivity rate.
Results
During the pandemic period, there was an expected surge in COVID-19 testing, while over 84% of lab tests studied decreased in ordering volume. The average number of tests ordered per patient was not significantly different during the pandemic for any of the laboratories (adjusted P value > 0.05). Thirty-three studied tests showed significant change in positivity rate during the pandemic. Linear modeling revealed test volume and inpatient status as the key variables associated with change in test positivity rate.
Conclusions
Excluding severe acute respiratory syndrome coronavirus 2 tests, the COVID-19 pandemic has generally led to decreased test ordering volume and laboratory utilization. However, at this pediatric hospital, the average number of tests performed per patient and test positivity rates were comparable between pre- and mid-pandemic periods. These results suggest that, overall, clinical test utilization at this site remained consistent during the pandemic.
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Affiliation(s)
- David C Lin
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago , Chicago, IL , USA
- Northwestern University, Feinberg School of Medicine, Department of Pathology , Chicago, IL , USA
| | - Isaac Parakati
- Data Analytics and Reporting, Ann & Robert H. Lurie Children's Hospital of Chicago , Chicago, IL , USA
| | - Shannon Haymond
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago , Chicago, IL , USA
- Northwestern University, Feinberg School of Medicine, Department of Pathology , Chicago, IL , USA
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Sajid IM, Frost K, Paul AK. 'Diagnostic downshift': clinical and system consequences of extrapolating secondary care testing tactics to primary care. BMJ Evid Based Med 2022; 27:141-148. [PMID: 34099498 DOI: 10.1136/bmjebm-2020-111629] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2021] [Indexed: 12/21/2022]
Abstract
Numerous drivers push specialist diagnostic approaches down to primary care ('diagnostic downshift'), intuitively welcomed by clinicians and patients. However, primary care's different population and processes result in under-recognised, unintended consequences. Testing performs poorer in primary care, with indication creep due to earlier, more undifferentiated presentation and reduced accuracy due to spectrum bias and the 'false-positive paradox'. In low-prevalence settings, tests without near-100% specificity have their useful yield eclipsed by greater incidental or false-positive findings. Ensuing cascades and multiplier effects can generate clinician workload, patient anxiety, further low-value tests, referrals, treatments and a potentially nocebic population 'disease' burden of unclear benefit. Increased diagnostics earlier in pathways can burden patients and stretch general practice (GP) workloads, inducing downstream service utilisation and unintended 'market failure' effects. Evidence is tenuous for reducing secondary care referrals, providing patient reassurance or meaningfully improving clinical outcomes. Subsequently, inflated investment in per capita testing, at a lower level in a healthcare system, may deliver diminishing or even negative economic returns. Test cost poorly represents 'value', neglecting under-recognised downstream consequences, which must be balanced against therapeutic yield. With lower positive predictive values, more tests are required per true diagnosis and cost-effectiveness is rarely robust. With fixed secondary care capacity, novel primary care testing is an added cost pressure, rarely reducing hospital activity. GP testing strategies require real-world evaluation, in primary care populations, of all downstream consequences. Test formularies should be scrutinised in view of the setting of care, with interventions to focus rational testing towards those with higher pretest probabilities, while improving interpretation and communication of results.
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Affiliation(s)
- Imran Mohammed Sajid
- NHS West London Clinical Commissioning Group, London, UK
- University of Global Health Equity, Kigali, Rwanda
| | - Kathleen Frost
- NHS Central London Clinical Commissioning Group, London, UK
| | - Ash K Paul
- NHS South West London Health and Care Partnership STP, London, UK
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5
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Almenar Bonet L, Blasco Peiró MT, Laiz Marro B, Camafort Babkowski M, Buño Soto A, Crespo-Leiro MG. Specific test panels for patients with heart failure: implementation and use in the Spanish National Health System. ADVANCES IN LABORATORY MEDICINE 2022; 3:65-78. [PMID: 37359437 PMCID: PMC10197348 DOI: 10.1515/almed-2022-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/17/2021] [Indexed: 06/28/2023]
Abstract
Objectives The use of specific test panels (STP) for heart failure (HF) could help improve the management of this condition. The purpose of this study is to gain an insight into the level of implementation of STPs in the management of HF in Spain and gather the opinions of experts, with a special focus on parameters related to iron metabolism. Methods The opinions of experts in HF were gathered in three stages STAGE 1 as follows: level of implementation of STPs (n=40). STAGE 2: advantages and disadvantages of STPs (n=12). STAGE 3: level of agreement with the composition of three specific STPs for HF: initial evaluation panel, monitoring panel, and de novo panel (n=16). Results In total, 62.5% of hospitals used STPs for the clinical management of HF, with no association found between the use of STPs and the level of health care (p=0.132) and location of the center (p=0.486) or the availability of a Heart Failure Unit in the center (p=0.737). According to experts, the use of STPs in clinical practice has more advantages than disadvantages (8 vs. 3), with a notable positive impact on diagnostics. Experts gave three motivations and found three limitations to the implementation of STPs. The composition of the three specific STPs for HF was viewed positively by experts. Conclusions Although the experts interviewed advocate the use of diagnostic and monitoring STPs for HF, efforts are still necessary to achieve the standardization and homogenization of test panels for HF in Spanish hospitals.
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Affiliation(s)
- Luis Almenar Bonet
- Unit of Heart Failure and Transplant, Service of Cardiology, University and Polytechnic La Fe Hospital of Valencia, Valencia, Spain
- University of Valencia, Valencia, Spain
- Spanish Network-Center for Cardiovascular Biomedical Research (CIBERCV), Madrid, Spain
| | - Mᵃ Teresa Blasco Peiró
- Unit of Heart Failure and Transplant, Service of Cardiology, Miguel Servet University Hospital, Zaragoza, Spain
- University of Zaragoza, Zaragoza, Spain
| | - Begoña Laiz Marro
- Laboratory Analysis Service, University and Polytechnic La Fe Hospital of Valencia, Valencia, Spain
| | - Miguel Camafort Babkowski
- Service of Internal Medicine, ICMiD, Hospital Clínic, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Antonio Buño Soto
- Laboratory Analysis Service, La Paz University Hospital, Madrid, Spain
| | - Maria Generosa Crespo-Leiro
- Unit of Heart Failure and Heart Transplant, Service of Cardiology, A Coruña Hospital Complex, CHUAC, A Coruña (UDC), Spain
- Biomedical Research Institute of A Coruña (INIBIC), A Coruña, Spain
- University of A Coruña, A Coruña, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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6
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Sri-Ganeshan M, Walker KP, Lines TJ, Neal-Williams TJ, Sheffield ER, Yeoh MJ, Taylor DM. Evaluation of a calcium, magnesium and phosphate clinical ordering tool in the emergency department. Am J Emerg Med 2022; 53:163-167. [DOI: 10.1016/j.ajem.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/22/2021] [Accepted: 01/07/2022] [Indexed: 10/19/2022] Open
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Jesus APSD, Okuno MFP, Campanharo CRV, Lopes MCBT, Batista REA. Manchester Triage System: assessment in an emergency hospital service. Rev Bras Enferm 2021; 74:e20201361. [PMID: 34287496 DOI: 10.1590/0034-7167-2020-1361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/03/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES to analyze demographic data, clinical profile and outcomes of patients in emergency services according to Manchester Triage System's priority level. METHODS a cross-sectional, analytical study, carried out with 3,624 medical records. For statistical analysis, the Chi-Square Test was used. RESULTS white individuals were more advanced in age. In the red and white categories, there was a higher percentage of men when compared to women (p=0.0018) and higher prevalence of personal history. Yellow priority patients had higher percentage of pain (p<0.0001). Those in red category had a higher frequency of altered vital signs, external causes, and death outcome. There was a higher percentage of exams performed and hospitalization in the orange category. Blue priority patients had a higher percentage of non-specific complaints and dismissal after risk stratification. CONCLUSIONS a higher percentage of altered vital signs, number of tests performed, hospitalization and death were evidenced in Manchester protocol's high priority categories.
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8
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Lapić I, Rogić D. Frequency of repetitive laboratory testing in patients transferred from the Emergency Department to hospital wards: a 3-month observational study. Diagnosis (Berl) 2021; 8:121-124. [PMID: 32549124 DOI: 10.1515/dx-2020-0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Ivana Lapić
- Department of Laboratory Diagnostics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Dunja Rogić
- Department of Laboratory Diagnostics, University Hospital Center Zagreb, Zagreb, Croatia
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Bai L, Gao S, Burstein F, Kerr D, Buntine P, Law N. A systematic literature review on unnecessary diagnostic testing: The role of ICT use. Int J Med Inform 2020; 143:104269. [PMID: 32927268 DOI: 10.1016/j.ijmedinf.2020.104269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/10/2020] [Accepted: 09/02/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The negative impact of unnecessary diagnostic tests on healthcare systems and patients has been widely recognized. Medical researchers in various countries have been devoting effort to reduce unnecessary diagnostic tests by using different types of interventions, including information and communications technology-based (ICT-based) intervention, educational intervention, audit and feedback, the introduction of guidelines or protocols, and the reward and punishment of staff. We conducted a review of ICT based interventions and a comparative analysis of their relative effectiveness in reducing unnecessary tests. METHOD A systematic Boolean search in PubMed, EMBase and EBSCOhost research databases was performed. Keyword search and citation analysis were also conducted. Empirical studies reporting ICT based interventions, and their implications on relative effectiveness in reducing unnecessary diagnostic tests (pathology tests or medical imaging) were evaluated independently by two reviewers based on a rigorously developed coding protocol. RESULTS 92 research articles from peer-reviewed journals were identified as eligible. 47 studies involved a single-method intervention and 45 involved multi-method interventions. Regardless of the number of interventions involved in the studies, ICT-based interventions were utilized by 71 studies and 59 of them were shown to be effective in reducing unnecessary testing. A clinical decision support (CDS) tool appeared to be the most adopted ICT approach, with 46 out of 71 studies using CDS tools. The CDS tool showed effectiveness in reducing test volume in 38 studies and reducing cost in 24 studies. CONCLUSIONS This review investigated five frequently utilized intervention methods, ICT-based, education, introduction of guidelines or protocols, audit and feedback, and reward and punishment. It provides in-depth analysis of the efficacy of different types of interventions and sheds insights about the benefits of ICT based interventions, especially those utilising CDS tools, to reduce unnecessary diagnostic testing. The replicability of the studies is limited due to the heterogeneity of the studies in terms of context, study design, and targeted types of tests.
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Affiliation(s)
- Lu Bai
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Shijia Gao
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Frada Burstein
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia.
| | - Donald Kerr
- USC Business School, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Paul Buntine
- Emergency Department, Box Hill Hospital, Melbourne, VIC, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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10
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Munk JK, Bathum L, Jørgensen HL, Lind BS. A compulsory pop-up form reduces the number of vitamin D requests from general practitioners by 25 percent. Scand J Prim Health Care 2020; 38:308-314. [PMID: 32686978 PMCID: PMC7470087 DOI: 10.1080/02813432.2020.1794399] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 05/27/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Healthcare costs, including costs for laboratory tests, are increasing worldwide. One example is the measurement of vitamin D. General practitioners in the Capital Region of Denmark include a vitamin D status in approximately 20% of all laboratory requisitions. This study intended to examine the effect of a compulsory pop-up form in the electronic request system on the number of vitamin D tests and to monitor the indications. DESIGN From 1 January 2017, we introduced a compulsory pop-up form in which the general practitioners had to state the indication for measuring vitamin D, choosing from a predefined set of indications. Intervention practitioners were compared with control practitioners before and after the intervention. SETTING General practices in the Capital Region of Denmark. SUBJECTS In total, 572 general practitioners and 383,964 patients were included in the period from 1 January 2016 to 31 December 2018. MAIN OUTCOME MEASURES Number of vitamin D tests and distribution of indications. RESULTS We observed a drop in number of vitamin D requisitions to 70% (in 2017) and 75% (in 2018) relative to 2016. During the same period, the number of requisitions increased by 33% in a non-intervention group of practitioners. The indication 'Monitoring of treatment with vitamin D' was the most frequently used indication, recorded in 121,475 patients. CONCLUSION A compulsory pop-up form reduces the number of vitamin D requests from general practitioners by 25%. The implication is that pop-up forms can be used to decrease healthcare costs.
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Affiliation(s)
- Jens K. Munk
- Department of Clinical Biochemistry, Hvidovre University Hospital, Hvidovre, Denmark
| | - Lise Bathum
- Department of Clinical Biochemistry, Hvidovre University Hospital, Hvidovre, Denmark
| | - Henrik L. Jørgensen
- Department of Clinical Biochemistry, Hvidovre University Hospital, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Bent S. Lind
- Department of Clinical Biochemistry, Hvidovre University Hospital, Hvidovre, Denmark
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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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Date PA, Smith JL, Spencer WS, de Tonnerre EJ, Yeoh MJ, Taylor DM. Utility of calcium, magnesium and phosphate testing in the emergency department. Emerg Med Australas 2019; 32:39-44. [PMID: 31155837 DOI: 10.1111/1742-6723.13332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/14/2019] [Accepted: 05/15/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine how frequently calcium (Ca), magnesium (Mg) and phosphate (PO4 ) tests change ED patient management. METHODS We undertook a retrospective observational study in an Australian tertiary referral ED. We enrolled adult patients (aged ≥18 years) who presented between 1 January and 30 June 2017 and who had a serum Ca, Mg or PO4 test ordered and completed during their ED stay. Patient symptoms, medical history, electrolyte levels and ED management changes were extracted from the electronic medical record. RESULTS Of the 33 120 adults presented during the study period, 1716 (5.2%, 95% confidence interval [CI] 5.0-5.4) had at least one Ca, Mg or PO4 test completed in the ED. This included 4776 individual electrolyte tests, of which 776 (16.2%, 95% CI 15.2-17.3) were abnormal. Fifty-six (7.2% [95% CI 5.5-9.3] of patients with abnormal tests, 1.2% [95% CI 0.9-1.5] of all tests) tests were associated with a change in ED management. Twenty-six out of 1683 (1.5%) Ca levels were low with six (23.1%) management changes; 203 (12.1%) were high with 10 (4.9%) management changes. One hundred and twenty-eight out of 1579 (8.1%) Mg levels were low with 33 (25.8%) management changes; 30 (1.9%) were high with no management changes. Two hundred and twenty-five out of 1514 (14.9%) PO4 levels were low with six (2.7%) management changes; 164 (10.8%) were high with one (0.6%) management change. Fifty (2.9%) patients had management changes despite normal electrolyte levels. CONCLUSION Ca, Mg and PO4 testing is common. However, the yield of clinically significant abnormal levels is low and patient management is rarely changed. Testing of these electrolytes needs to be rationalised.
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Affiliation(s)
| | | | | | - Erik J de Tonnerre
- Northern Sydney Local Health District, NSW Health, Sydney, New South Wales, Australia
| | - Michael J Yeoh
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia
| | - David McD Taylor
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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Munk JK, Lind BS, Jørgensen HL. Change in HbA 1c concentration as decision parameter for frequency of HbA 1c measurement. Scandinavian Journal of Clinical and Laboratory Investigation 2019; 79:320-324. [PMID: 31140320 DOI: 10.1080/00365513.2019.1622032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hemoglobin A1c (HbA1c) is a long-term measure for glucose concentration in plasma. Since its introduction as a diabetes monitoring tool, and its more recent application as a diagnostic tool, the number of measurements of HbA1c have risen dramatically. However, HbA1c change is slow, so repeating measurements should not be done too often. We use a large, unfiltered dataset from 52,017 patients to determine the possible rate of change in HbA1c concentration. In our laboratory, the critical difference between HbA1c measurements is 8.5%. Our data show that a 1-unit HbA1c rise takes 4 weeks to occur, hence, at a HbA1c concentration around 50 mmol/mol Hgb, a critically increased HbA1c concentration cannot be determined until after 16 weeks. Conversely a critically lower HbA1c can manifest itself after 2 weeks, but after 7 weeks the dropping tendency stops. The amount of measurements that can be cancelled because they were taken sooner than 16 weeks is 23 percent.
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Affiliation(s)
- Jens K Munk
- a Department of Clinical Biochemistry, Hvidovre University Hospital , Hvidovre , Denmark
| | - Bent S Lind
- a Department of Clinical Biochemistry, Hvidovre University Hospital , Hvidovre , Denmark
| | - Henrik L Jørgensen
- a Department of Clinical Biochemistry, Hvidovre University Hospital , Hvidovre , Denmark.,b Department of Clinical Medicine, University of Copenhagen , Copenhagen N , Denmark
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14
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Chloride validity in Emergency Department settings. Am J Emerg Med 2018; 36:1501-1502. [DOI: 10.1016/j.ajem.2017.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 12/01/2017] [Indexed: 11/17/2022] Open
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