Why is there variation in test ordering practices for patients presenting to the emergency department with undifferentiated chest pain? A qualitative study

IntroductionUp to one-third of laboratory tests ordered in the ED for adults presenting with undifferentiated chest pain are generally not indicated by current Australian guidelines. This study set out to undertake a qualitative investigation of clinician perceptions to identify the reasons for variations in pathology requesting.MethodsFor this study, we draw on data from semistructured interviews (n=38) conducted in the EDs and laboratories across three hospitals as part of a larger study on the test result management process from test request to result follow-up. Thematic analysis was conducted to determine what aspects of the clinical routines and environment might contribute to variations in pathology requesting. Informed by the findings from the analysis, targeted questions were developed and further focus groups (n=5) were held with clinicians, hospital management and electronic medical record (eMR) analysts to investigate in more detail the reasons for requesting outside of guidelines.ResultsParticipants cited four main reasons for ordering outside of guidelines. Clinicians requested tests outside of guidelines and the ED scope of practice to facilitate the patient journey along the broader continuum of care, including admission to hospital or transfer to another site. Clinicians were also faced with multiple and inconsistent guidelines regarding appropriate test selection. Limited access to in-house specialty and diagnostic services also influenced ordering patterns in smaller non-referral hospitals. Finally, certain features of the current electronic ordering framework within the eMR facilitated overordering and failed to impose any real restrictions on ordering inappropriately or outside of scope of practice.ConclusionBeyond the standardisation of pathology requesting advice across electronic decision support, order sets and guidelines, attempts to address issues related to the appropriateness and variation of laboratory test ordering should consider local and systemic factors which also shape the ordering process.

Assessment of laboratory test request forms for completeness

Background: Laboratory test request forms usually accompany patient’s samples to the laboratory, providing biodata and clinical details of the patient. This information is for purposes of identification and guiding pathologists to accurately interpret patient’s result. Clinicians however do not usually provide all the required information, thus making interpretation difficult. The frequency of such incompleteness is assessed in this study.Methods: Laboratory request forms received at the Chemical Pathology laboratory between July and September 2020 were assessed for completeness of all the required parameters. Parameters analyzed in this study included age, gender, hospital number, location, clinical information, name of requesting physician and the date of request. Frequency of missing parameters were expressed as proportions (%) of the total omissions.Results: There were 1906 request forms received during the course of this study and 789 (41.4%) of them had at least one missing parameter. Apart from patients’ names, nature of sample and the requested investigation, all other parameters were omitted at one time or the other making a total of 1117 omissions. Age (287; 25.7%) hospital number (264; 23.6%) and clinical information (246; 22%) were the most commonly omitted parameters. Majority of the omissions (69%) were from the outpatient clinics, 20% were from the wards while 10% of the forms had no ward or clinic indicated.Conclusion: Incomplete filling of laboratory test request forms is a regular occurrence among clinicians. Effort must be made to continually sensitize them of the importance of each of the required parameters to ensure a visible improvement.

Appropriateness of test request and clinical outcome: the case of autoimmune diseases

Objectives: To improve the appropriateness in the autoantibody test requests for proper diagnosis of systemic rheumatic autoimmune diseases, celiac disease and anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitides. Methodology: Review of recommendations proposed by the Study Group in Autoimmunology (GDS-AI) of the Italian Society of Clinical Pathology and Laboratory Medicine (SIPMeL) and the European Society For Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHaN) Results: This document aims to bring to the attention of general practitioners the recommendations proposed by National and International study group to improve the appropriateness in the autoantibody test requests expecially in sytemic autoimmune and celiac disease. Conclusions: Autoimmunity is a specialistic laboratory area where the costs are extremely high compared to other diagnostics: it would therefore be very helpful and economically advantageous to align the clinicians on appropriate requests and the laboratory on useful diagnostics. In Autoimmunology, diagnostic appropriateness remains a complex and debated topic from the management, professional and economic point of view.

Teleregulation in Neurology: A decision-making process for neurology evaluation in a large Brazilian city

Background: There is an increasing demand for neurological consultations. However, geographical and economic barriers and the long waiting lines limit the access. Teleregulation (TR), an asynchronous evaluation made by the neurologist, could optimize the need for presential evaluation. Objectives: The aim of this study was to analyze TR for neurological referral of patients, regarding the information provided, the main reasons for consultation, and the teleneurologist’s final decision. Design and setting: Observational cross-sectional study in Complexo Hospital de Clínicas in Curitiba-PR. Methods: The study selected neurological referrals for evaluation by TR between October 2018 and February 2020. The referrals who had incomplete information were excluded. The main variables analyzed were age, sex, reasons for TR, and final decision by the teleneurologist. Results: Of the 1035 included referrals, 56% were women and the mean age was 50±19.6 years old. The main reasons for TR were therapeutic conduct (32%), diagnosis (31%), and test request (13%) and the main specific clinical reasons were headache (30%), epilepsy (19%), dementia (16%), cerebrovascular diseases (11%), and neuromuscular disorders (10%). More information was requested in 427 (41%) of the consults and no need for in-person consultation occurred in 713 (68%) of cases. Conclusions: The main reasons for TR were management and diagnosis. The study showed that TR can reduce the need for presential assessment by a neurologist in more than two-thirds of cases. However, a great part of the consultations needed additional data. Thus, the optimization of the referrals could further improve this system, reducing its overhead.

Assessment of regulation on vitamin D test requesting in terms of the rational laboratory use

ObjectivesThe aim of this study is to identify the possible effects of the Ministry of Health regulation on Vitamin D testing and vitamin D deficiency detection and to investigate the effect of the reflex test algorithm implementation.Materials and methodsA total of requested 78,919 25(OH)D and 5,653 1,25(OH)2D test results were examined. Test requests were classified in 3 groups according to the Regulation; Group 1: Requests from inpatients and intensive care units, Group 2: Requests from outpatients of non-restricted departments, Group 3: Requests from outpatients of restricted departments. In addition, the reflex test algorithm was simulated and the name of the 1,25-dihydroxyvitamin D test request was changed to 1,25-dihydroxycholecalciferol.ResultsChanging the test name as 1,25 dihydroxycholecalciferol reduced the number of monthly test requests (−71.7%). The hypovitaminous detection rate was similar in Group 1, 2, and 3 in the 25(OH)D requests and was higher in the reflex test algorithm. In 1,25(OH)2D requests, the rate of hypovitaminous detection was higher in Group 1 than in Group 2 and 3.DiscussionWith simple acts like using structured test ordering forms, reflex test algorithms applied in the clinic-laboratory-interface involving Medical Biochemistry Specialists, bigger impact with less underdiagnosis might be possible in test demand management.

Inadequate clinical data on Pap test request form: Where are we headed in the era of precision medicine?

The request form accompanying any sample to a clinical laboratory constitutes an important communication tool between the clinician and the laboratory personnel. Much has been written about the inadequacy of pertinent clinical data on the request slips for hematology and biochemistry tests and its impact on the subsequent test interpretation and error liability. Although the cytology laboratories, including those performing cervical cytology, have to deal with a similar problem of lack of clinical information critical to the proper interpretation of cytomorphologic features, the issue has not been attended to or reported adequately in the literature. This article attempts to explore this topic of inadequate clinical data on Pap test request form from multiple perspectives and suggest possible ways to circumvent this age-old problem. These recommendations may be tailor-made and adopted as per the individual laboratory’s logistics.

Free online chlamydia and gonorrhoea urine test request in Queensland: sexually transmissible infections testing can be hard for young people even if the process is easy

Online options to request sexually transmissible infections testing are increasingly popular and a free online chlamydia and gonorrhoea urine testing service is available for people living in Queensland, Australia. Data from 3 August 2017 to 31 August 2019 provide information for 1316 reminder calls to young people (aged 16–29 years) to encourage sample submission. The reminder calls generated few additional samples for testing, suggesting young people may have changed their mind about using the service, sought testing elsewhere or were reluctant to talk further about their original decision to request a test online.

Effects of a demand optimization intervention on laboratory test utilization in primary care

There is evidence of increasing use of laboratory tests with substantial variation between clinical teams which is difficult to justify on clinical grounds. The aim of this project was to assess the effect of a demand optimisation intervention project on laboratory test requesting by general practitioners (GPs) in an area of Northern Ireland supported by the Clinical Chemistry Laboratory service of Western Health and Social Care Trust (WHSCT). The intervention package was developed in conjunction with the Western Local Commissioning Group and consisted of educational initiatives, feedback to 55 individual practices on test request rates with ranking relative to other practices, and a small financial incentive for practices to reflect on their test requesting activity. Overall test utilization rates of profile tests, HbA1c, and PSA one year before, during, and one year after the intervention were measured using laboratory databases of the Altnagelvin Area Hospital, Tyrone County Hospital, and the Erne (South West Acute Hospital. The intervention was associated with mixed effects. First, we observed a reduction of 5.1% in the median profile test request rates and a decrease in their between practice variability. The overall downward trend in variability of profile test request rates was found statistically significant (p = 0.03). Second, we found a significant increase in both the volume (p < 0.0001) and between practice variability (p = 0.0001) of HbA1c requests per patient with diabetes. The increase in HbA1c requests may reflect a more appropriate rate of diabetes monitoring and also the adoption of HbA1c as a diagnostic test. Yet, the subsequent 600% increase in between practice variability of HbA1c ordering rates may imply an inconsistent implementation of recommended guidelines by GPs. Finally, there was a 29.3% increase in the median and 35% increase in between practice variability of request rates for PSA, the reasons for which are unclear.

Indicator condition-guided HIV testing with an electronic prompt in primary healthcare: a before and after evaluation of an intervention

ObjectiveIndicator condition (IC)-guided HIV testing is a strategy for the diagnosis of patients with HIV. The aim of this study was to assess the impact on the proportion of HIV tests requested after the introduction of an electronic prompt instructing primary healthcare (PHC) physicians to request an HIV test when diagnosing predefined IC.MethodsA prospective interventional study was conducted in 2015 in three PHC centres in Barcelona to assess the number of HIV test requests made during the implementation of an electronic prompt. Patients aged 18–65 years without HIV infection and with a new diagnosis of predefined IC were included. The results were compared with preprompt (2013) and postprompt data (2016).ResultsDuring the prompt period, 832 patients presented an IC (median age 41.6 years [IQR 30–54], 48.2% female). HIV tests were requested in 296 individuals (35, 6%) and blood tests made in 238. Four HIV infections were diagnosed (positivity rate 1.7%, 95% CI 0.5% to 4.4%). The number of HIV tests requested based on IC increased from 12.6% in 2013 to 35.6% in 2015 (p<0.001) and fell to 17.9% after removal of the prompt in 2016 (p<0.001). Younger patient age (OR 0.97, 95% CI 0.96 to 0.98), birth outside Spain (OR 1.53, 95% CI 1.06 to 2.21) and younger physician age (OR 0.97, 95% CI 0.96 to 0.99) were independent predictive factors for an HIV test request during the prompt period. The electronic prompt (OR 3.36, 95% CI 2.70 to 4.18) was the factor most closely associated with HIV test requests. It was estimated that 10 (95% CI 3.0 to 26.2) additional new cases would have been diagnosed if an HIV test had been performed in all patients presenting an IC.ConclusionsA significant increase in HIV test requests was observed during the implementation of the electronic prompt. The results suggest that this strategy could be useful in increasing IC-guided HIV testing in PHC centres.