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Claeys KC, Morgan DJ, Johnson MD. The importance of pharmacist engagement in diagnostic stewardship. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e43. [PMID: 38628377 PMCID: PMC11019581 DOI: 10.1017/ash.2024.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 04/19/2024]
Abstract
Diagnostic stewardship is increasingly recognized as a powerful tool to improve patient safety. Given the close relationship between diagnostic testing and antimicrobial misuse, antimicrobial stewardship (AMS) pharmacists should be key members of the diagnostic team. Pharmacists practicing in AMS already frequently engage with clinicians to improve the diagnostic process and have many skills needed for the implementation of diagnostic stewardship initiatives. As diagnostic stewardship becomes more broadly used, all infectious disease clinicians, including pharmacists, must collaborate to optimize patient care.
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Affiliation(s)
- Kimberly C. Claeys
- Associate Professor Infectious Diseases, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Veterans’ Affairs Maryland Healthcare System, Baltimore, MD, USA
| | - Melissa D. Johnson
- Professor in Medicine, Division of Infectious Diseases & International Health, Duke University School of Medicine, Durham, NC, USA
- Liaison Clinical Pharmacist, Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC, USA
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Abstract
Diagnostic stewardship refers to the responsible and judicious use of diagnostic tests to reduce low value care and improve patient outcomes. This article provides an overview of behavioral strategies, their relevance to diagnostic stewardship and highlights behavioral determinants that drive diagnostic testing behavior, drawing on theoretic frameworks. Additionally, we provide concrete examples of evidence-based behavioral strategies for promoting appropriate diagnostic testing while acknowledging associated challenges. Finally, we highlight the significance of evaluating these strategies and provide an overview of evaluation frameworks and methods.
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Affiliation(s)
- Sonali D Advani
- Department of Internal Medicine-Infectious Diseases, Duke University School of Medicine, 315 Trent Drive, Hanes House, Suite 154, Durham, NC 27710, USA.
| | - Kimberly Claeys
- Department of Pharmacy Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
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A Multimodal Intervention for Reducing Unnecessary Repeat Glycated Hemoglobin Testing. Can J Diabetes 2023; 47:19-24. [PMID: 36008251 DOI: 10.1016/j.jcjd.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 05/07/2022] [Accepted: 06/15/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Reducing unnecessary tests that do not enhance quality can promote health-care value. Glycated hemoglobin (A1C) is often ordered at a frequency exceeding the recommendation of once every 3 months. We conducted a quality improvement (QI) initiative aimed to reduce unnecessary repeat testing by 75% at a tertiary care academic hospital. METHODS A retrospective baseline analysis was conducted on laboratory data from 2019 that enumerated unnecessary A1C tests, defined as repeat tests ordered within 60 days. A multifaceted change intervention with iterative plan-do-study-act cycles was introduced in March 2019 to educate providers and to automatically cancel A1C tests requested within 60 days. Monthly totals of A1C testing processed were plotted on statistical process control charts. RESULTS In 2019, 11% of all A1C tests ordered were unnecessary. Between March 2020 and January 2021, 11% of the tests (N=14,247 tests) were unnecessary, of which 84% were cancelled with our intervention. Providers in cardiology and nephrology accounted for over half (55%) of the unnecessary tests ordered. CONCLUSIONS A 2-pronged approach informed by root-cause analysis, and comprised of gatekeeping and provider education, can effectively promote resource stewardship for reducing unnecessary A1C testing.
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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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Canceled Air Ambulance Trauma Scene Calls: A Prospective Observational Study of Causes and Outcomes of Trauma Auto-launch Cancellations. Air Med J 2022; 41:435-441. [PMID: 36153139 DOI: 10.1016/j.amj.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/20/2022] [Accepted: 07/15/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Direct transport, occasionally by helicopter, to a trauma hospital for severely injured patients is associated with decreased mortality. This study sought to determine causes for air ambulance trauma response cancellations and secondarily to identify patients who underwent secondary transfer to a trauma center after a canceled air ambulance dispatch. METHODS This prospective cohort study used administrative databases from August 2020 to August 2021 to collect data related to canceled trauma calls. Frequencies of cancellation reasons and transferred patients were summarized, and the estimated delay to trauma center arrival was calculated. Subsequent probabilistic matching was performed to identify patients who underwent secondary transfer. RESULTS Of 3,232 trauma calls, 1,924 were canceled for reasons including the trauma bypass criteria not being met, patient brought to trauma center, and patient refused transfer. Of the 1,117 patients for whom an air ambulance was canceled because they did not meet the trauma bypass criteria, 184 (16.5%) were later transferred to a lead trauma hospital, with a median delay of 4.12 hours (interquartile range = 2.57-7.35 hours). CONCLUSIONS Most scene call cancellations were due to patients not meeting the trauma bypass criteria; yet, 16.5% of these patients were later transported to a trauma center. Interventions are needed in education, adherence, and modification of the trauma bypass criteria.
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Panteghini M, Dolci A, Birindelli S, Szoke D, Aloisio E, Caruso S. Pursuing appropriateness of laboratory tests: a 15-year experience in an academic medical institution. Clin Chem Lab Med 2022; 60:1706-1718. [PMID: 35998662 DOI: 10.1515/cclm-2022-0683] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/08/2022] [Indexed: 02/04/2023]
Abstract
Appropriateness in Laboratory Medicine has been the object of various types of interventions. From published experiences, it is now clear that to effectively manage the laboratory test demand it is recommended to activate evidence-based preventative strategies stopping inappropriate requests before they can reach the laboratory. To guarantee appropriate laboratory test utilization, healthcare institutions should implement and optimize a computerized provider order entry (CPOE), exploiting the potential of electronic requesting as "enabling factor" for reinforcing appropriateness and sustaining its effects over time. In our academic institution, over the last 15 years, our medical laboratory has enforced various interventions to improve test appropriateness, all directly or indirectly based on CPOE use. The following types of intervention were implemented: (1) applying specific recommendations supported by monitoring by CPOE as well as a continuous consultation with clinicians (tumour markers); (2) removing outdated tests and avoiding redundant duplications (cardiac markers, pancreatic enzymes); (3) order restraints to selected wards and gating policy (procalcitonin, B-type natriuretic peptide, homocysteine); (4) reflex testing (bilirubin fractions, free prostate-specific antigen, aminotransferases, magnesium in hypocalcemia); and (5) minimum retesting interval (D-Dimer, vitamin B12, C-reactive protein, γ-glutamyltranspeptidase). In this paper, we reviewed these interventions and summarized their outcomes primarily related to the changes in total test volumes and cost savings, without neglecting patient safety. Our experience confirmed that laboratory professionals have an irreplaceable role as "stewards" in designing, implementing, evaluating, and maintaining interventions focused to improving test appropriateness.
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Affiliation(s)
- Mauro Panteghini
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy.,Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi, Milan, Italy
| | - Alberto Dolci
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy.,Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi, Milan, Italy
| | - Sarah Birindelli
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Dominika Szoke
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Elena Aloisio
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Simone Caruso
- UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milan, Italy
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Hueth KD, Prinzi AM, Timbrook TT. Diagnostic Stewardship as a Team Sport: Interdisciplinary Perspectives on Improved Implementation of Interventions and Effect Measurement. Antibiotics (Basel) 2022; 11:250. [PMID: 35203852 PMCID: PMC8868553 DOI: 10.3390/antibiotics11020250] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/03/2022] [Accepted: 02/11/2022] [Indexed: 02/06/2023] Open
Abstract
Diagnostic stewardship aims to deliver the right test to the right patient at the right time and is optimally combined with antimicrobial stewardship to allow for the right interpretation to translate into the right antimicrobial at the right time. Laboratorians, physicians, pharmacists, and other healthcare providers have an opportunity to improve the effectiveness of diagnostics through collaborative activities around pre-analytical and post-analytical periods of diagnostic testing. Additionally, special considerations should be given to measuring the effectiveness of diagnostics over time. Herein, we perform a narrative review of the literature on these potential optimization opportunities and the temporal factors that can yield changes in diagnostic effectiveness. Our objective is to inform on these considerations to ensure enhanced value through improved implementation and measurement of effectiveness for local stakeholder metrics and/or clinical outcomes research.
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Affiliation(s)
- Kyle D. Hueth
- BioMérieux, Salt Lake City, UT 84104, USA; (K.D.H.); (A.M.P.)
| | | | - Tristan T. Timbrook
- BioMérieux, Salt Lake City, UT 84104, USA; (K.D.H.); (A.M.P.)
- College of Pharmacy, University of Utah, Salt Lake City, UT 84112, USA
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Lang T. Minimum retesting intervals in practice: 10 years experience. ACTA ACUST UNITED AC 2020; 59:39-50. [DOI: 10.1515/cclm-2020-0660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/22/2020] [Indexed: 12/27/2022]
Abstract
Abstract
Background
Minimum retesting intervals (MRI) are a popular demand management solution for the identification and reduction of over-utilized tests. In 2011 Association of Clinical Biochemistry and Laboratory Medicines (ACB) published evidence-based recommendations for the use of MRI.
Aim
The aim of the paper was to review the use of MRI over the period since the introduction of these recommendations in 2011 to 2020 and compare it to previous published data between 2000-2010.
Methods
A multi-source literature search was performed to identify studies that reported the use of a MRI in the management or identification of inappropriate testing between the years prior to (2000–2010) and after implementation (2011–2020) of these recommendations.
Results
31 studies were identified which met the acceptance criteria (2000–2010 n=4, 2011–2020 n=27). Between 2000 and 2010 4.6% of tests (203,104/4,425,311) were identified as failing a defined MRI which rose to 11.8% of tests (2,691,591/22,777,288) in the 2011–2020 period. For those studies between 2011 and 2020 reporting predicted savings (n=20), 14.3% of tests (1,079,972/750,580) were cancelled, representing a total saving of 2.9 M Euros or 2.77 Euro/test. The most popular rejected test was Haemoglobin A1c which accounted for nearly a quarter of the total number of rejected tests. 13 out 27 studies used the ACB recommendations.
Conclusions
MRI are now an established, safe and sustainable demand management tool for the identification and management of inappropriate testing. Evidence based consensus recommendations have supported the adoption of this demand management tool into practice across multiple healthcare settings globally and harmonizing laboratory practice.
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Affiliation(s)
- Tim Lang
- Department of Clinical Biochemistry , University Hospital of North Durham , North Road , Durham , County Durham , DH1 5TW , UK
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Yu L, Zhang Q, Bernstam EV, Jiang X. Predict or draw blood: An integrated method to reduce lab tests. J Biomed Inform 2020; 104:103394. [DOI: 10.1016/j.jbi.2020.103394] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 01/16/2023]
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