From the 2024 HVPA National Conference
Kelly Szymanski MD (Lankenau Medical Center), Samuel Laiacona MD, Aleena Shah MD, Eseoghene Kevu MD, Matthew Koury DO, Karthik Shankar DO, Arezoo Ghaneie MD, Zonera Ali MD
Background
Hypercoagulable testing is frequently ordered to investigate the etiology of venous or arterial thrombosis despite the lack of clinical significance in most cases. In the setting of an acute thrombosis or active anticoagulation use, hypercoagulable testing will yield results that are confounding and difficult to interpret. Unnecessary and inappropriate testing ultimately leads to poor utilization of hospital financial resources without impacting patient treatment. One retrospective study conducted at Emory University Hospitals in 2015 showed direct costs of hypercoagulable testing to be $2,364 per patient, $12,331.55 per positive diagnosis, and $19,653 per diagnosis that led to a change in management. Durham et al. conducted a trial at Baylor University Medical Center that showed a tangible decrease in both volume and cost of inappropriate testing after establishing a hard stop mechanism into the electronic medical record (EMR) prior to ordering.
Objective
The objective of this quality improvement project is to assess frequency of correct hypercoagulable testing and its impact on management, analyze the financial ramifications of incorrect testing, and ultimately create institutional guidelines paired with an alert within the EMR to improve the hypercoagulable testing process and interpretation.
Methods
A retrospective data analysis was performed of patients aged 18 to 75 years who presented to Main Line Health facilities with an acute thrombotic event between January 1, 2019, and January 1, 2024, and underwent hypercoagulability testing. Eligible patients were identified via the Main Line Health patient database and charts were reviewed using Epic EMR. Tests of interest included lupus anticoagulant, beta 2 glycoprotein antibody, anti-cardiolipin antibody, protein S, protein C, antithrombin III, factor V Leiden, and prothrombin gene mutation. The incidence of inappropriate testing was measured among eligible patients who had a panel of all eight tests ordered. Testing was deemed to be inappropriate if the panel was ordered for patients older than 50 years with first diagnosed provoked venous thromboembolism, patients with active thrombus (within 30 days of diagnosis), or those on current anticoagulation therapy. Charts were then reviewed to determine if results of testing precipitated a change in medical management.
Results
Preliminary results analyzed prior to intervention implementation showed that of 86 patients, 68 (79%) had testing ordered inappropriately and only 8 (9%) had testing that resulted in a change in management. Further data for the remainder of eligible patients and financial implications for our institution are pending.
Conclusions
The preliminary results prove hypercoagulable testing has been frequently ordered in inappropriate clinical contexts without routinely impacting patient management.
Clinical Implications
Unnecessary testing rarely benefits patients and carries a significant financial burden for health systems. Although preliminary data showed results of testing infrequently affected patient management, patients could be erroneously placed on indefinite anticoagulation therapy when it is not truly indicated. Providers would benefit from education to inform proper hypercoagulable testing. At our institution, we aim to create institutional guidelines and tools within the EMR to increase the validity, clinical significance, and financial efficiency of testing.