1
|
Buss LF, Spitzer D, Watson JC. Can I have blood tests to check everything is alright? BMJ 2023; 382:e075728. [PMID: 37407075 DOI: 10.1136/bmj-2023-075728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Affiliation(s)
- Lewis F Buss
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol BS8 2PS, UK
| | - David Spitzer
- Cranwich Road Surgery, 62 Cranwich Road, London N16 5JF, UK
| | - Jessica C Watson
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol BS8 2PS, UK
| |
Collapse
|
2
|
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
|
3
|
Kamzan AD, Ng E. When Less is More: The Role of Overdiagnosis and Overtreatment in Patient Safety. Adv Pediatr 2021; 68:21-35. [PMID: 34243853 DOI: 10.1016/j.yapd.2021.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Audrey D Kamzan
- Division of Pediatric Hospital Medicine, Mattel Children's Hospital, 10833 LeConte Avenue, A2-383 MDCC, Los Angeles, CA 90095, USA; David Geffen School of Medicine at the University of California, Los Angeles, 10833 Le Conte Avenue, A2-383 MDCC, Los Angeles, CA 90095, USA.
| | - Elayna Ng
- Division of Pediatric Hospital Medicine, Mattel Children's Hospital, 10833 LeConte Avenue, A2-383 MDCC, Los Angeles, CA 90095, USA; David Geffen School of Medicine at the University of California, Los Angeles, 10833 Le Conte Avenue, A2-383 MDCC, Los Angeles, CA 90095, USA
| |
Collapse
|
4
|
Jatoi I, Sah S. Clinical practice guidelines and the overuse of health care services: need for reform. CMAJ 2019; 191:E297-E298. [PMID: 30885967 DOI: 10.1503/cmaj.181496] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ismail Jatoi
- Division of Surgical Oncology and Endocrine Surgery (Jatoi), University of Texas Health, San Antonio, Tex.; Samuel Curtis Johnson Graduate School of Management (Sah), Cornell SC Johnson College of Business, Cornell University, Ithaca, NY
| | - Sunita Sah
- Division of Surgical Oncology and Endocrine Surgery (Jatoi), University of Texas Health, San Antonio, Tex.; Samuel Curtis Johnson Graduate School of Management (Sah), Cornell SC Johnson College of Business, Cornell University, Ithaca, NY
| |
Collapse
|
5
|
Taylor DM, Date PA, Ugoni A, Smith JL, Spencer WS, de Tonnerre EJ, Yeoh MJ. Risk variables associated with abnormal calcium, magnesium and phosphate levels among emergency department patients. Emerg Med Australas 2019; 32:303-312. [PMID: 31847050 DOI: 10.1111/1742-6723.13411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 10/09/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The utility of calcium, magnesium and phosphate measurement in the ED is limited. We aimed to determine clinical risk variables for abnormal levels of these electrolytes in order to inform the development of an ordering guideline. METHODS We performed a retrospective, observational study of patients who presented to a tertiary referral ED between January and June 2017. Adult patients who had serum calcium, magnesium or phosphate tests completed during their ED stay were included. Presenting symptoms and signs, comorbidities, medication use and laboratory values were extracted from the medical record. Patients with missing data items were excluded. Logistic regression models determined clinical risk variables associated with low and high levels of each electrolyte. RESULTS A total of 33 120 adults presented during the study period. Of the 1679 calcium, 1576 magnesium and 1511 phosphate tests, 228 (13.6%), 158 (10.0%) and 387 (25.6%) were abnormal, respectively. Significant risk variables (P < 0.05) for abnormal levels were: hypocalcaemia - vomiting, perioral numbness, hand/foot spasm, calcium and phosphate supplements and chemotherapy (odds ratio [OR] range 5.9-17.3); hypercalcaemia - female sex, vomiting, polyuria, confusion, hyperparathyroidism, cancer and type 1 diabetes (OR range 2.3-9.7); hypomagnesemia - female sex, proton pump inhibitor use, tacrolimus use, alcohol abuse and type 2 diabetes (OR range 2.2-13.1); hypermagnesemia - lethargy, thiazide use and chronic kidney disease (OR range 4.3-4.5); hypophosphatemia - nausea, seizure and glucocorticoid use (OR range 1.7-2.1); and hyperphosphataemia - polyuria, diuretics and chronic kidney disease (OR range 1.9-5.0). CONCLUSION A range of demographic, comorbid, medication and clinical variables are associated with abnormal calcium, magnesium and phosphate levels. These findings will inform the development of clinical guidelines to rationalise calcium, magnesium and phosphate testing. Justification may be required for testing patients with no risk variables.
Collapse
Affiliation(s)
- David McD Taylor
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Patrick A Date
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia
| | - Antony Ugoni
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - 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
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Watson J, de Salis I, Banks J, Salisbury C. What do tests do for doctors? A qualitative study of blood testing in UK primary care. Fam Pract 2017; 34:735-739. [PMID: 28985303 DOI: 10.1093/fampra/cmx051] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Rates of blood testing are rising with significant geographical variability. Most research into diagnostic testing focuses on the role of tests in diagnostic decision-making. OBJECTIVE The aim of this study was to explore the non-medical motives for blood testing by considering what tests do for doctors, through qualitative interviews with general practitioners (GPs). METHODS We undertook 23 in-depth semi-structured interviews with UK GPs. Reasons for performing recent inflammatory marker blood tests were explored by reviewing GPs pathology inboxes to ground discussions in real-life clinical practice. Interviews were transcribed verbatim and analysed using a grounded theory approach. RESULTS Blood tests offer doctors a tool to manage uncertainty; within a context of increased litigation, risk aversion and reduced continuity of care. Tests can also be offered as a 'gift' for patients, a way to be seen to be 'doing something'; in the social context of time pressures and perceived patient pressures. There was a tension however. On the one hand, doctors talked about using tests for reassurance and as a 'gift' offering 'truth'. Yet paradoxically, they also discussed the challenges of uncertainty and anxiety from inconclusive test results. CONCLUSION Our study emphasises that defining 'unnecessary' blood testing may not be as simple as determining medical criteria for testing; psychosocial reasons may be equally valid and interlinked. Further research is needed to help GPs manage uncertainty within the context of a risk averse society, and to explore the congruence and dissonance between doctors' and patients' perceptions of testing.
Collapse
Affiliation(s)
- Jessica Watson
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.,Collaboration for Leadership in Applied Health Research and Care West (CLAHRC West), Bristol, UK
| | - Isabel de Salis
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jonathan Banks
- Collaboration for Leadership in Applied Health Research and Care West (CLAHRC West), Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.,Collaboration for Leadership in Applied Health Research and Care West (CLAHRC West), Bristol, UK
| |
Collapse
|
8
|
Morgan DJ, Leppin A, Smith CD, Korenstein D. A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction. J Hosp Med 2017; 12:346-351. [PMID: 28459906 PMCID: PMC5570540 DOI: 10.12788/jhm.2738] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Overuse of medical services is an increasingly recognized driver of poor-quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert-informed, evidence-based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient-clinician interaction as the nexus of decisions regarding inappropriate care. This interaction is influenced by other utilization drivers, including healthcare system factors, the practice environment, the culture of professional medicine, the culture of healthcare consumption, and individual patient and clinician factors. The variable strength of the evidence supporting these domains highlights important areas for further investigation. Journal of Hospital Medicine 2017;12:346-351.
Collapse
Affiliation(s)
- Daniel J. Morgan
- VA Maryland Healthcare System, University of Maryland School of Medicine and Centers for Disease Dynamics, Economics and Policy, Baltimore, MD, USA
| | - Aaron Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester MN, USA
| | | | - Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
9
|
|
10
|
Ducatman AM, Tacker DH, Ducatman BS, Long D, Perrotta PL, Lawther H, Pennington K, Lander O, Warden M, Failinger C, Halbritter K, Pellegrino R, Treese M, Stead JA, Glass E, Cianciaruso L, Nau KC. Quality Improvement Intervention for Reduction of Redundant Testing. Acad Pathol 2017; 4:2374289517707506. [PMID: 28725791 PMCID: PMC5497914 DOI: 10.1177/2374289517707506] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/05/2017] [Accepted: 04/07/2017] [Indexed: 01/09/2023] Open
Abstract
Laboratory data are critical to analyzing and improving clinical quality. In the setting of residual use of creatine kinase M and B isoenzyme testing for myocardial infarction, we assessed disease outcomes of discordant creatine kinase M and B isoenzyme +/troponin I (-) test pairs in order to address anticipated clinician concerns about potential loss of case-finding sensitivity following proposed discontinuation of routine creatine kinase and creatine kinase M and B isoenzyme testing. Time-sequenced interventions were introduced. The main outcome was the percentage of cardiac marker studies performed within guidelines. Nonguideline orders dominated at baseline. Creatine kinase M and B isoenzyme testing in 7496 order sets failed to detect additional myocardial infarctions but was associated with 42 potentially preventable admissions/quarter. Interruptive computerized soft stops improved guideline compliance from 32.3% to 58% (P < .001) in services not receiving peer leader intervention and to >80% (P < .001) with peer leadership that featured dashboard feedback about test order performance. This successful experience was recapitulated in interrupted time series within 2 additional services within facility 1 and then in 2 external hospitals (including a critical access facility). Improvements have been sustained postintervention. Laboratory cost savings at the academic facility were estimated to be ≥US$635 000 per year. National collaborative data indicated that facility 1 improved its order patterns from fourth to first quartile compared to peer norms and imply that nonguideline orders persist elsewhere. This example illustrates how pathologists can provide leadership in assisting clinicians in changing laboratory ordering practices. We found that clinicians respond to local laboratory data about their own test performance and that evidence suggesting harm is more compelling to clinicians than evidence of cost savings. Our experience indicates that interventions done at an academic facility can be readily instituted by private practitioners at external facilities. The intervention data also supplement existing literature that electronic order interruptions are more successful when combined with modalities that rely on peer education combined with dashboard feedback about laboratory order performance. The findings may have implications for the role of the pathology laboratory in the ongoing pivot from quantity-based to value-based health care.
Collapse
Affiliation(s)
- Alan M. Ducatman
- School of Public Health, West Virginia University, Morgantown, WV, USA
| | - Danyel H. Tacker
- Department of Pathology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Barbara S. Ducatman
- Department of Pathology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Dustin Long
- University of Alabama School of Public Health, Birmingham, AL, USA
| | - Peter L. Perrotta
- Department of Pathology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Hannah Lawther
- Department of Radiology, Mayo School of Graduate Medical Education, Scottsdale, AZ, USA
| | - Kelly Pennington
- Department of Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN, USA
| | - Owen Lander
- Department of Emergency Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Mary Warden
- Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Conard Failinger
- Heart Institute, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Kevin Halbritter
- Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Ronald Pellegrino
- Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Marney Treese
- Department of Emergency Medicine, Jefferson Medical Center, Ranson, WV, USA
| | - Jeffrey A. Stead
- Department of Pathology, Jefferson Medical Center Medical Center, Ranson, WV, USA
- Department of Pathology, Berkeley Medical Center, Martinsburg, WV, USA
| | - Eric Glass
- Department of Emergency Medicine, Berkeley Medical Center, Martinsburg, WV, USA
| | | | - Konrad C. Nau
- Department of Family Medicine and Office of the Dean, Robert C Byrd Health Sciences Center-Eastern campus, Harpers Ferry, WV, USA
| |
Collapse
|
11
|
Appropriate pathology ordering? Troponin testing within an Australian Emergency Department. Ir J Med Sci 2016; 186:213-218. [DOI: 10.1007/s11845-016-1476-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 06/14/2016] [Indexed: 12/12/2022]
|
12
|
'I'm fishing really'--inflammatory marker testing in primary care: a qualitative study. Br J Gen Pract 2016; 66:e200-6. [PMID: 26852797 PMCID: PMC4758500 DOI: 10.3399/bjgp16x683857] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 11/24/2015] [Indexed: 12/17/2022] Open
Abstract
Background Inflammatory markers can be helpful as part of the diagnostic workup for specific diseases or for monitoring disease activity. A third use is as a screening and/or triage tool to differentiate between the presence or absence of disease. Most research into inflammatory markers looks at diagnosis of specific diseases and comes from secondary care. Qualitative studies to explore when and why clinicians use these tests in primary care are lacking. Aim To identify clinicians’ approaches to inflammatory marker testing in primary care. Design and setting Qualitative study with 26 GPs and nurse practitioners. Method Interviews were conducted using a semi-structured topic guide. Clinicians reviewed recent cases of inflammatory marker testing in their pathology inbox. Interviews were audiorecorded and transcribed. Qualitative analysis was conducted by two of the authors. Results Clinicians are uncertain about the appropriate use of inflammatory markers and differ in their approach to testing patients with undifferentiated symptoms. Normal or significantly elevated inflammatory markers are seen as helpful, but mildly raised inflammatory markers in the context of non-specific symptoms are difficult to interpret. Clinicians describe a tension between not wanting to ‘miss anything’ and, on the other hand, being wary of picking up borderline abnormalities that can lead to cascades of further tests. Diagnostic uncertainty is a common reason for inflammatory marker testing, with the aim to reassure; however, paradoxically, inconclusive results can generate a cycle of uncertainty and anxiety. Conclusion Further research is needed to define when inflammatory marker testing is useful in primary care and how to interpret results.
Collapse
|
13
|
Morgan S, Henderson KM, Tapley A, Scott J, Van Driel ML, Spike NA, Mcarthur LA, Davey AR, Oldmeadow C, Ball J, Magin PJ. Pathology test-ordering behaviour of Australian general practice trainees: a cross-sectional analysis. Int J Qual Health Care 2015; 27:528-35. [DOI: 10.1093/intqhc/mzv086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2015] [Indexed: 12/16/2022] Open
|
14
|
Test in peace. Br J Gen Pract 2015; 65:371. [DOI: 10.3399/bjgp15x685885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
|
15
|
Brashers DE, Hogan TP. The appraisal and management of uncertainty: Implications for information-retrieval systems. Inf Process Manag 2013. [DOI: 10.1016/j.ipm.2013.06.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|