National High Value Performance Improvement Campaign
With the mission of delivering measurable improvements in health care value, the High Value Practice Academic Alliance announces a new campaign entitled “4 Tests to Target“. All medical centers are invited to participate, by making a commitment to reduce unnecessary ordering of 4 lab tests have been safely decreased in many institutions without compromising patient care quality or safety. Join the charge to demonstrate accountability for value-based care. Together we can move the needle!
Rationale: Folate testing has no utility in Western countries because of ubiquitous folic acid fortification. Additionally, it is not reliable for identifying folate deficiency. For the rare patient suspected of having folate deficiency, treating with folic acid is more cost effective than testing.
- Serum and red blood cell folate testing on hospitalized patients J Hosp Med 2015; 10:753-755
- Johns Hopkins DOM One Minute Guide
Clinical decision support message: Folate deficiency occurs in <1% of the US population. Consider empirically treating high-risk patients with folic acid.
Fecal Occult Blood Testing in Inpatients
Rationale: Fecal occult blood testing is not reliable to detect GI bleeding, false-positives occur in up to 10% of patients and false-negatives in up to 50%. The test is designed to screen outpatients for colorectal cancer and should not be used to guide the management of inpatients with suspected GI bleeding.
- Inappropriate Use of Fecal Occult Blood Testing: JAMA IM Teachable Moment, JAMA IM
- Eliminating In-Hospital Fecal Occult Blood Testing: Our Experience with Disinvestment, AJM
Clinical decision support intervention: Remove FOBT from inpatient order entry.
CK-MB in Suspected Acute Coronary Syndrome
Rationale: Diagnosing patients with acute coronary syndrome (ACS) is crucial to initiating treatment earlier. In addition, knowing which patients do not have acute coronary syndrome reduces unnecessary downstream testing. While CK-MB was traditionally used to diagnose ACS, troponin has much better test performing characteristics for accurate diagnosis and is the gold standard according to American College of Cardiology guidelines.
- Eliminating Creatine Kinase–Myocardial Band Testing in Suspected Acute Coronary Syndrome: A Value-Based Quality Improvement
Clinical decision support intervention: Remove CK-MB from Emergency Department order entry.
Amylase in Acute Pancreatitis
Rationale: The most sensitive and specific test for acute pancreatitis is lipase. Addition of amylase adds no incremental diagnostic efficacy. Furthermore, repeat testing should be avoided after diagnosis of acute pancreatitis.
- Tenner S, Baillie J, DeWitt J, Vege SS.; American College of Gastroenterology. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013; 108:1400–1415.
- Amylase testing for abdominal pain and suspected acute pancreatitis J. Hosp. Med. 2016; 11:366-368
Clinical decision support intervention: Remove amylase from Emergency Department order sets.