Indications for laboratory tests in primary care: assessment of the most frequent indications and requests with blank clinical information

Alopecia and Iron Deficiency: An Interventional Pilot Study in Primary Care to Improve the Request of Ferritin

BACKGROUND

The aim was to study the demographic and laboratory pattern of primary care patients with alopecia undergoing laboratory testing, more specifically, the request of hemoglobin and ferritin and values showing anemia and iron deficiency, and to evaluate the effects of an intervention involving automatic ferritin registration and measurement when not requested.

METHODS

Retrospective and prospective observational cross-sectional studies were conducted, as well as an intervention to automatically register and measure ferritin when not requested by the general practitioner.

RESULTS

There were 343 and 1032 primary care laboratory requests prompted by alopecia in the retrospective and prospective studies. Hemoglobin was requested in almost every patient and ferritin in 88%. 5% of the cohort had anemia, and 25% had iron deficiency. The intervention registered and measured that 123 ferritin and 24 iron deficiencies were detected in patients with alopecia, all women, at a cost of 10.6€.

CONCLUSION

Primary care patients with alopecia and laboratory tests request were mainly young female. Our intervention added ferritin when not requested, detecting iron deficiency in 27.9% of women, potentially avoiding the adverse effects of iron deficiency on hair loss.

Laboratory Computer-Based Interventions for Better Adherence to Guidelines in the Diagnosis and Monitoring of Type 2 Diabetes

INTRODUCTION

The aim was to present two automated laboratory strategies designed to detect new cases of type 2 diabetes and prediabetes and improve their monitoring.

METHODS

To improve diabetes diagnosis, we automatically registered the glycated hemoglobin (HbA1c) levels of every primary care patient between 25 and 46 years old in case of abnormal lipid testing when an HbA1c test had not been requested in the current order or during the previous year and when fasting glucose was > 100 mg/dl. We counted the number of detected cases of diabetes and prediabetes and calculated the cost per identified patient. To improve diabetes monitoring, the levels of HbA1c, total cholesterol, high- and low-density lipoprotein cholesterol and triglycerides and the spot urinary albumin-to-creatinine ratios (ACRs) were automatically registered in patients with diabetes when not ordered according to guidelines. We calculated the total economic costs according to the total number of additional registered tests and reagent cost.

RESULTS

Of 103,425 requests, 224 (0.22%) met the inclusion criteria. Seventeen (7.6%) patients were identified as having new cases of diabetes and 149 (66.5%) of prediabetes, at a cost of €15.2 and €2.3, respectively, per case detected. From 13,874 requests in patients with diabetes, 91 HbA1c and 708 lipid tests and 862 ACRs were automatically registered to comply with guidelines, resulting in expenses of €1948.90.

CONCLUSIONS

Making use of laboratory technology, it is possible to detect new cases of type 2 diabetes and prediabetes and to improve disease monitoring.

Automated Requests for Thyroid-Stimulating Hormone and Ferretin Tests in Young Primary Care Patients with Anorexia as an Intervention to Improve Detection of Underlying Conditions

Objective

To improve clinical laboratory contribution to the treatment of primary care patients with anorexia through automated computerized strategies.

Methods

We recorded the number of laboratory requests due to anorexia; the demographic data, laboratory values, and presence of pathological values for the applicable patients. In a prospective study, the laboratory information management system (LIMS) automatically added thyroid-stimulating hormone (TSH) and/or ferritin testing when it was not requested by general practitioners for all primary care patients with anorexia who were younger than 16 years.

Results

A total of 3562 patients underwent laboratory testing due to anorexia, of whom 47% were younger than 16 years. The tests in which the results most frequently were abnormal were hemoglobin, ferritin, and TSH. TSH results were abnormal in 20% of patients younger than 16 years. Through the intervention, we detected 3 low ferritin values and 7 cases of pathological TSH levels.

Conclusions

The LIMS required TSH and ferritin testing in young patients even when not requested, potentially avoiding the adverse effects of iron deficiency and thyroid disorders on neurological development and cognition in those patients.

Urinary albumin strip assay as a screening test to replace quantitative technology in certain conditions

Background The clinical laboratory plays a crucial role in the diagnosis and monitoring of chronic kidney disease. The quantitative measurement of urine albumin in a spot sample, expressed as ratio per creatinine (ACR) is the most frequently used biomarker for such a purpose. Our aim was to evaluate the diagnostic performances of a strip for measuring ACR for differentiating patients who are candidates for subsequent albumin quantification, and to evaluate the economic effects of its implementation. Methods We systematically measured strip analysis when quantitative urinary albumin was requested. Semiquantitative urinary albumin was measured using a UC-3500 (Sysmex, Kobe, Japan), based on the protein error of a pH indicator. We collected and reviewed all the values of quantified urinary albumin and their corresponding results in ACR strip tests. We calculated the diagnostic indicators for ACR at different albumin and creatinine values using the quantitative ACR measurement as a "gold standard". We also studied the economic effects based on both tests prices (€1.31 for quantitative albumin plus creatinine, and €0.04 for an albumin strip). Results The study included 9148 patients (mean age 63, 46.3% men). The results at different albumin and creatinine cutoffs showed the best performance when 10 mg/L and above 50 mg/dL, respectively. Based on our results, we would have saved 3506 urine albumin and creatinine tests in the study period, corresponding to €4226.94. Conclusions The present study supports the use of the ACR strip test to identify pathological albuminuria values to be measured through quantitative methods. Considerable economic savings are possible.

Serum Uric Acid Laboratory Test Request Patterns in Primary Care: How Panels May Contribute to Overutilization and Treatment of Asymptomatic Patients

Background

To study the variability in the request of serum uric acid (SUA) in primary care.

Method

A cross-sectional study was designed and conducted at a main core laboratory. Spanish laboratories were invited to report their number of serum glucose (SG) and SUA tests requested from primary care during 2014. A survey was sent to every participant in November 2016 regarding the inclusion of SUA in order profiles/panels. The ratio of SUA/SG requests (SUA/SG) was calculated and compared between regions, and laboratories depending on whether SUA was included or not in a health check profile.

Results

110 laboratories participated in the study (59.8% Spanish population). The median SUA/SG ratio was 0.82 (IQR: 0.25), and 41 laboratories had a ratio over 0.9. There was a significant regional variability (P = .008). Laboratories where SUA was not included in the "health check profile" had lower SUA/SG indicators (P = .003).

Conclusion

There was significant regional variability in the request of SUA, and an overall over-request. Different regional customs or habits and the inclusion of SUA in the health check profile were probable causes behind the observed over-request.

Urinary albumin: a risk marker under-requested in primary care in Spain

Background

To study the inter-practice regional variation in the request of urinary albumin by general practitioners and compare to guideline recommendations.

Methods

A cross-sectional study enrolled laboratories from different Spanish autonomous communities. Laboratories were invited to report the number of urinary albumin requested by general practitioners during 2012 and 2014. Urinary albumin requested per 1000 inhabitants and the index of variability (90th centile/10th centile) was calculated, and compared between autonomous communities and time periods. To investigate potential inappropriate requesting in the management of diabetes and arterial hypertension, the actual number of requests was compared to the theoretical, based on prevalence and guideline recommendations.

Results

Urinary albumin requested per 1000 inhabitants was similar for years 2012 and 2014 (78.2 (60.1) to 85.4 (55.4); P = 0.235), as was the variability index (4.6 for both). There were significant differences between autonomous communities, with the indicator ranging from 46.0 (33.1) to 125.8 (64.3) ( P < 0.05). The theoretical cut-off ratios of urinary albumin per 1000 inhabitants to manage patients with diabetes and arterial hypertension were, respectively, 78 and 159; no laboratory reached both values.

Conclusions

Requesting of urinary albumin showed a significant regional variability in primary care in Spain, and was insufficient to correctly monitor patients with diabetes and arterial hypertension.