Value-based quality improvement projects for residents: Reducing unnecessary laboratory testing


Table 1. Proposed laboratory tests with appropriateness improvement targets.
Laboratory test Appropriateness Improvement Target
Amylase Replace with lipase for diagnosis of acute pancreatitis.
Antinuclear Antibody and Sub-Serologies Do not test for ANA sub-serologies in the setting of negative ANA and low pretest probability of autoimmune disease.
Basic Metabolic Panel Eliminate repeated testing in the setting of clinical and laboratory stability.
Complete Blood Count Eliminate repeated testing in the setting of clinical and laboratory stability.
CK-MB Eliminate in favor of troponin for diagnosis of acute coronary syndrome.
Clostridiodes difficile Testing Do not test asymptomatic patients and do not perform test of cure. Routine testing in infants is not recommended.
Erythrocyte Sedimentation Rate Eliminate in favor of C-reactive protein in most cases of acute inflammation, except low-grade bone and joint infections and some autoimmune diseases.
Fecal Lactoferrin Do not use both fecal lactoferrin and calprotection routinely given similar test characteristics.
Fecal Occult Blood Testing Eliminate use in the evaluation of suspected acute gastrointestinal bleeding.
Folic acid Favor empiric supplementation over testing. If testing is necessary, serum folate is favored over RBC folate.
Gastrointestinal Pathogen Nucleic Acid Amplification Panels Limit use to those with a recent travel history, those with increased risk of severe disease and those with symptoms persisting beyond seven days.
Helicobacter pylori Serology Eliminate use of H. pylori serology in the evaluation of active infection.
Heparin-Induced Thrombocytopenia Avoid testing for patients with low probability for HIT.
Hepatitis A virus screening In otherwise healthy individuals known to be immune, avoid measuring HAV antibodies in the diagnosis of acute hepatitis.
Hepatitis B virus screening Screen high risk individuals with Hepatitis B surface antigen, surface antibody, and core antibody only.
Hepatitis C viral load and genotype Limit HCV viral load testing to diagnosis of acute and chronic HCV infection and monitoring of an antiviral regimen. Genotypes are only necessary when treatment with a non-pan-genotypic agent is planned.
Legionella pneumophila Urinary Antigen Testing Avoid use in typical community-acquired pneumonia.
Paraneoplastic panel Avoid in cases with low pretest probability of paraneoplastic encephalitis.
Peripheral Blood Smear Optimize automated systems to avoid unnecessary triggers for hematopathologist review.
Rapid Antigen Testing for Group A Streptococcal Pharyngitis Avoid testing in the setting of obvious viral illness. In adults, routine back-up culture is not recommended. Test of cure not routinely recommended.
Tacrolimus Level Optimize timing of drug levels in the inpatient setting.
Thrombophilia Work-up Eliminate for most inpatients, for those with provoked venous thromboembolism, and among those for whom indefinite anticoagulation is otherwise indicated.
Total Serum Triiodothyronine and Free T3 Not recommended for diagnosis of thyroid disorders except in pregnancy, TSH-secreting pituitary adenoma or follow up after administering medications or radioactive iodine ablation.
Type and Screen Avoid retesting in < 3 months (unless pregnant or transfused) and reduce use in the perioperative setting for non-anemic patients undergoing low-risk procedures.
Vitamin D Deficiency Screening Screen only high risk patients with 25-hydroxyvitamin D. Avoid 1,25-dihydroxyvitamin D in the absence of hypercalcemia or renal insufficiency.

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