Redundant Inflammatory Marker Use on a Pediatric Hospital Medicine (PHM) Service

From the 2022 HVPA National Conference

Kathryn Bakkum MD (Akron Children’s Hospital), Prabi Rajbhandari MD, FAAP

Background

Due to their widespread availability, inflammatory markers are used with increasing frequency, often concurrently, without adding any diagnostic or clinical benefit1, 2. Each additional blood draw raises the potential for patient discomfort, further testing, and prolonged hospital stays, ultimately increasing the cost for the patient3. In an era that emphasizes high-value, low cost-care medical providers play an integral role in promoting evidence-based practices and avoiding unnecessary laboratory testing.

Objective

To identify the baseline use of inflammatory markers (C-reactive protein (CRP), procalcitonin (PCAL), and Erythrocyte Sedimentation Rate (ESR)) in patients admitted to the PHM serviceTo reduce the percentage of use of multiple inflammatory markers using a quality improvement process

Methods

This quality improvement initiative was conducted with patients admitted to the PHM service at our institution. Baseline ordering rates of CRP, PCAL, and ESR for patients admitted to the PHM service was extracted using our electronic health record (EHR). The use of any two or more inflammatory markers within a single 24-hour period was defined as “redundant”. Ordering provider was identified and each order was associated with the corresponding ‘Primary Encounter Diagnosis’ sorted into one of the following categories: 1) COVID-19/MIS-C 2) Bacterial pneumonia 3) Fever 4) Non-infectious 5) Sepsis 6) Viral respiratory illness 7) Other infections and 8) Other respiratory diagnoses.

Results

From September 2021-February 2022 a total of 821 inflammatory markers were ordered by the PHM service, 41% (n = 337) of which were classified as “redundant.” Approximately half (n=397, 49.1%) of orders were accounted for by 8 out of a total of 27 hospitalists. Inflammatory markers were most frequently obtained for COVID-19/MIS-C (n=238, 29%) followed by other infections (n=158, 19.2%), non-infectious diagnoses (n=105, 12.8%), sepsis (n=91, 11.1%), viral respiratory illnesses (n = 76, 9.3%), other respiratory diagnoses (n=71, 8.6%), bacterial pneumonia (n=49, 6.0%) and fever (n=33, 4.0%).

Conclusions

Multiple inflammatory markers are often being obtained in less than 24 hours despite evidence showing it provides no benefit to patient diagnosis or management. Ordering rates for inflammatory markers were variable between providers. There was also variation based on patient diagnosis with highest rates amongst COVID-19/MIS-C.

Clinical Implications

Use of multiple inflammatory markers does not improve diagnostic accuracy but rather provides low value care and adds to healthcare expenditure. Our initial study identified a potential area to impart high value care and provide guideline consistent care for our patients. A multidisciplinary team consisting of hospitalists, pathologists, data analysts, and quality improvement specialists has been formed. A key driver diagram has been developed to aide in design and implementation of interventions to decrease unnecessary use of inflammatory markers.

References

1. Zhi M, Ding EL, Theisen-Toupal J, Whelan J, Arnaout R. The landscape of inappropriate laboratory testing: a 15-year meta-analysis. PLoS One. 2013;8(11):e78962. Published 2013 Nov 15. doi:10.1371/journal.pone.0078962
2. Watson J, Jones HE, Banks J, Whiting P, Salisbury C, Hamilton W. Use of multiple inflammatory marker tests in primary care: using Clinical Practice Research Datalink to evaluate accuracy. Br J Gen Pract. 2019;69(684):e462-e469. doi:10.3399/bjgp19X704309
3. Jha AK, Chan DC, Ridgway AB, Franz C, Bates DW. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood). 2009;28(5):1475-1484. doi:10.1377/hlthaff.28.5.1475

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