Home Value-based quality improvement projects for residents

Value-based quality improvement projects for residents

Reducing unnecessary laboratory testing

Download PDF

Authors

  • Jessica S. Tischendorf, MD, MS1,2
  • The High Value Practice Academic Alliance Future Leaders Program3
  • Brad Karon, MD, PhD4
  • George Hoke, MD5
  • Christopher Petrilli, MD6
  • Jennifer M. Schmidt, MD7
  • Pamela T. Johnson, MD8
  • Nasia Safdar, MD, PhD1,2

Affiliations

  • 1William S. Middleton Memorial VA Hospital, Madison, Wisconsin
  • 2University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
  • 3Contributing authors below
  • 4Mayo Clinic College of Medicine, Rochester, Minnesota
  • 5University of Virginia Medical Center, Charlottesville, Virginia
  • 6Michigan Medicine, Ann Arbor, Michigan
  • 7 Saint Louis University School of Medicine, Saint Louis, Missouri
  • 8Johns Hopkins Medicine, Baltimore, Maryland

3Contributing authors:

  • Oluwasayo Adeyemo, MD, Saint Louis University, Saint Louis, Missouri
  • Clarice Bunag, MD, University of California Riverside School of Medicine, Riverside, California
  • Stephanie Carr, MD, MBA, VA Puget Sound Health Care System, Seattle, Washington
  • Mike Kai-Wick Cheng, MD, University of Chicago, Chicago, Illinois
  • Abimbola Chris-Olaiya, MD, MPH, Grand Strand Medical Center, Myrtle Beach, South Carolina
  • Shirley Cohen-Mekelburg, MD, Weill Cornell Medicine, New York, New York
  • Carl V. Crawford, MD, Weill Cornell Medicine, New York, New York
  • Christopher Grondin, MD, Michigan Medicine, Ann Arbor, Michigan
  • Arjun Gupta, MD, University of Texas Southwestern Medical Center, Dallas, Texas
  • Kevin Hsu, MD, Cedars-Sinai Medical Center, Los Angeles, California
  • Charity Huang, MD, University of California Riverside School of Medicine, Riverside, California
  • Ashley Kosier, MD, Our Lady of the Lake Children’s Hospital, Baton Rouge, Louisiana
  • Benjamin O. Lawson, MD, Honor Health Internal Medicine Residency Program, Scottsdale, Arizona
  • Kasey Little, MD, University of Virginia Medical Center, Charlottesville, Virginia
  • Joshua D. Newman, MD, Loyola University Medical Center, Maywood, Illinois
  • Michelle Ogunwole, MD, UT Health San Antonio, San Antonio, Texas
  • Ariella Pratzer, MD, New York University, New York, New York
  • Rachna Rawal, MD, Saint Louis University, Saint Louis, Missouri
  • Javad Savoj, MD, University of California Riverside School of Medicine, Riverside, California
  • Christopher Steele, MD, MPH, MS, Johns Hopkins Medicine, Baltimore, Maryland
  • Garth W. Strohbehn, MD, MPhil, Michigan Medicine, Ann Arbor, Michigan
  • Jian Liang Tan, MD, Crozer-Chester Medical Center, Upland, Pennsylvania
  • Branden Tarlow, MD, PhD, University of Texas Southwestern Medical Center, Dallas, Texas
  • Foram Thakkar, MD, University of Texas Health Northeast/CHRISTUS Good Shepard Medical Center, Longview, Texas

Corresponding author:

  • Jessica S. Tischendorf, MD, MS
  • University of Wisconsin Hospital and Clinics
  • UWMF Centennial Building
  • 1685 Highland Avenue
  • Madison, WI 53705
  • email: jtischendorf@wisc.edu

Jessica Tischendorf’s work was supported with resources and the use of facilities at the William S. Middleton Memorial VA Hospital in Madison, Wisconsin in academic year 2017-2018.

There are no relevant conflicts of interest for any contributing author. All authors had a role in writing the manuscript.

This work has not been published previously.

Key Words: utilization, healthcare costs, practice patterns, quality of healthcare                                                                 

************************************

Abstract

Background: Medical costs are a leading financial concern for Americans, and medical providers must play an integral role in reducing cost of care by avoiding inappropriate laboratory testing. Residents and fellows can champion value-based quality improvement work to promote high quality patient care and reduce costs associated with unnecessary laboratory testing in their institutions. This narrative review of appropriate use of laboratory testing can direct trainee value-based quality improvement initiatives to reduce inappropriate testing in the inpatient, outpatient and emergency department setting.

Methods: In the 2017-2018 academic year, faculty mentors from the High Value Practice Academic Alliance compiled a list of laboratory tests to target for value-based quality improvement work. Under faculty mentorship, trainees contributed to this narrative review by reviewing relevant literature and providing recommendations for quality improvement targets for each of the proposed target laboratory tests.

Results: High Value Practice Academic Alliance faculty mentors identified 25 laboratory tests to target for value-based quality improvement work. These tests range the inpatient, outpatient and emergency settings and span several medical specialties.

Discussion: Trainees are poised to lead impactful value-based quality improvement initiatives. The present review provides trainees interested in this work with an actionable list of laboratory tests to target for optimization.

****************************************** 

Introduction

The United States healthcare system is fraught with inefficiencies, with reports of $750 billion worth of waste contributing to poor quality, disparities, and patient harm1. Healthcare costs are a leading concern for families2 and many adults forgo recommended care or avoid seeking care when ill due to cost3. To deliver higher value healthcare, many institutions are implementing quality improvement initiatives to reduce unnecessary tests, treatments and procedures. In academic medical centers, nearly two-thirds of laboratory testing in the inpatient setting does not affect patient management4. In addition to unnecessary costs and patient discomfort, inappropriate laboratory testing contributes to anemia, misguided management and unnecessary downstream testing.

As the front line providers in academic medical centers, trainees are especially poised to lead initiatives to reduce costs by reducing unnecessary laboratory testing across disciplines and care settings. The purpose of this narrative review is to provide trainees with an actionable list of laboratory studies to target for optimization as part of quality improvement efforts in the inpatient, outpatient and emergency department settings.

Methods

This narrative review is a collaborative effort among the faculty leaders and trainees engaged in the High Value Practice Academic Alliance in the 2017-2018 academic year. The High Value Practice Academic Alliance is an organization of faculty from 90 United States academic institutions with a mission to improve the quality and safety of patient care while reducing costs5.

Participants collaborate on quality improvement, education and research in value-based care. Faculty leaders direct a trainee mentorship program, the Future Leaders Program6.

To engage trainees in value-based scholarship in the 2017-2018 academic year, faculty compiled a list of laboratory tests to target for quality improvement. The list was generated through an emailed faculty survey conducted by a senior author (P.J.). Alongside a faculty mentor, trainees authored a synopsis for one or more of the targeted laboratory tests. Trainees reviewed relevant primary literature and existing guideline statements to inform a brief synopsis on overuse and appropriate indications for each laboratory test. Content experts reviewed synopses where necessary and three authors (J.T., P.J., and N.S.) compiled the review.

Results

High Value Practice Academic Alliance faculty leaders identified 25 laboratory tests as targets for optimization (Table 1). These tests crossed medical specialties and spanned the care continuum.

Chemistry

Basic and Comprehensive Metabolic Panel

The basic and comprehensive metabolic panels are frequently ordered for hospitalized patients without clear indication4. Repeated ordering of chemistries in the setting of clinical stability is recommended against7. In patients without clinical suspicion for hepatobiliary disease, carefully consider whether the additional data a comprehensive metabolic panel provides is necessary given the added cost.

Amylase in Pancreatitis

Combined with clinical features or characteristic imaging, elevated serum amylase or lipase can establish a diagnosis of acute pancreatitis. Amylase is less specific than lipase and can be falsely normal, particularly in alcohol- and hypertriglyceridemia-induced pancreatitis8, limiting its utility. Testing both serum lipase and amylase in pancreatitis is discouraged because of increased cost without clinical benefit9.

CK-MB

CK-MB was widely used before introduction of Troponin T and I, the current gold standard cardiac biomarker given high sensitivity and specificity for myocardial necrosis10. Previously, CK-MB was advocated to help diagnose reinfarction and used by some for diagnosis of peri-procedural infarction though troponin has subsumed that role. Routine use of CK-MB is not recommended9,11–13.

Hematology

Complete Blood Count (CBC)

Ordering repetitive CBCs (with and without differential) in hospitalized patients in the setting of clinical and laboratory stability is not recommended7. Studies show reduction of routine use saves costs without negatively impacting quality of care14,15.

Type and screen (TS)

There is currently no standard for determining the safe duration or validity of TS results in patients not pregnant or recently transfused16. For these patients, reordering a TS is likely unnecessary if ordered within the past three months. If a patient has received a transfusion, their history is unknown, or they have been pregnant in the past three months, the TS is valid only for three days17.

Perioperative TS is often ordered inappropriately for minimally invasive or low-intermediate risk surgery. For operations with minimal anticipated blood loss, TS is likely unnecessary18. Implementation of a validated model to guide TS ordering for non-anemic pre-surgical patients could reduce unnecessary TS orders by up to 35%, without causing significant harm19,20.

Peripheral blood smear

Manual review of peripheral blood smears by hematopathologists prompted by abnormalities detected on automated equipment is costly due to provider fees, volume and technician time21,22. The evolution of automated analyzers and middleware systems have reduced the volume of manual reviews23 and efforts to improve accuracy of these systems to cut costs associated with manual reviews should be pursued24. International consensus criteria for manual peripheral blood smear review have been attempted, however, there is great variability in the accuracy of these machines and each hospital should set their own standards for when hematopathologist review is required25,26.

Thrombophilia Testing

In 2014, at least $300 million was spent on inpatient thrombophilia testing, which typically includes evaluating for Factor V Leiden, prothrombin gene mutation, and deficiencies of antithrombin, protein C, and protein S27. Identification of a heritable thrombophilia does not predict or reduce the risk of recurrent venous thromboembolism (VTE)28. Additionally, thrombophilia testing is difficult to interpret in acute VTE and while on anticoagulation29. Thrombophilia testing is recommended only in select patients with a first episode of unprovoked VTE in whom there is a plan to stop anticoagulation30,31 and is not recommended for adults with a provoked VTE32. If indefinite anticoagulation is planned, testing is of limited utility27.

Heparin-induced Thrombocytopenia (HIT) Testing

HIT is an immune-mediated reaction to heparin that can lead to thromboembolism. Inappropriate testing for HIT in low risk patients is performed frequently in US hospitals; up to 60% of tests were not appropriate in one retrospective study33. The 4 T’s score is a well-validated tool to classify patients as low, intermediate, and high risk for HIT. Intermediate and high-risk groups warrant further laboratory testing34,35.

Folic acid

Folic acid levels are often measured in anemia36 and in the workup of dementia, delirium, and peripheral neuropathy37,38 despite the dramatic decline in folate deficiency in the US since mandatory fortification of processed grains was instituted. Multiple studies have documented the overuse of folic acid testing38–40. Empiric supplementation for suspected folate deficiency is more cost effective than a test-and-treat strategy. If testing is required, serum folic acid is recommended over RBC folate9.

Endocrine

Triiodothyronine (T3)

Nearly 60% of total serum T3 and free T3 (FT3) levels orders are inappropriate41. For a host of biochemical reasons, measuring T3 is of limited utility and indicated only in select diagnostic circumstances including along with TSH and FT4 for diagnosing hyperthyroidism in pregnancy, diagnosing TSH-secreting pituitary adenoma, and follow-up after initiation of anti-thyroid drugs or radioactive iodine ablation42,43. T3 should not be ordered as initial testing for suspected thyroid disease or to monitor levothyroxine dosing44. Employing algorithms that reflex thyroid hormone testing only when the TSH is abnormal present an additional opportunity for cost savings45.

Vitamin D Screening

There is insufficient evidence to recommend screening asymptomatic adults for vitamin D deficiency because no consensus exists regarding a level at which replacement provides clinical benefit46. Among those at high risk for deficiency, namely those with osteoporosis, chronic kidney disease, malabsorption, obesity and some infections, screening with 25-hydroxyvitamin D is recommended9. There are few indications for measuring 1,25-dihydroxyvitamin D and testing in the absence of hypercalcemia or renal insufficiency is not recommended44.

Gastroenterology

Fecal Lactoferrin

Fecal lactoferrin is a highly sensitive biomarker of active neutrophils and is useful to distinguish intestinal inflammation from non-inflammatory bowel disease, such as irritable bowel syndrome, though is not specific for exact cause of intestinal inflammation47–49. In patients with inflammatory bowel disease, fecal lactoferrin can assess disease activity and degree of mucosal healing non-invasively and can predict relapse and response to therapy48. Fecal calprotectin is used similarly and may offer better test characteristics50. As they often provide the same clinical information, routine testing of both fecal lactoferrin and calprotectin is not indicated.

Fecal Occult Blood Testing (FOBT)

FOBT is a validated outpatient colorectal cancer screening tool but is often misused in the acute setting to evaluate gastrointestinal bleeding (GIB)51. They are of two types: guaiac-based tests measuring heme (gFOBT), and immunochemical tests (FIT) measuring globin. FOBT cannot identify bleeding acuity and can be positive with clinically insignificant esophagitis, epistaxis, or certain foods. FIT testing is more specific for GIB, but is less sensitive for upper GIB since globin becomes denatured in the upper tract51. When used inappropriately in the acute setting, the indirect costs of delay in care, unnecessary testing and prolonged hospitalization are high51. Instead of FOBT, GIB should be evaluated with history, physical exam including digital rectal exam, hemoglobin, BUN, and iron store measurement52,53.

Helicobacter pylori Serology

Helicobacter pylori infection is common, particularly in the developing world, and can lead to peptic ulcer disease, GIB, and gastric malignancy. Available diagnostics include serology, endoscopy, breath tests, and fecal antigen tests. Serology is the least effective owing to poor test characteristics and inability to determine chronicity of infection54 and is not recommended for diagnosis of H. pylori infection9. Fecal antigen testing is the preferred testing strategy54.

Infectious Diseases

Hepatitis A Virus (HAV) Serology

Routine infant vaccination has reduced HAV incidence in the US. Vaccination of high risk adults is also recommended55 and some advocate pre-vaccination screening in high-prevalence groups as a cost-effective approach to HAV prevention, assuming the cost of a single test is not greater than the vaccine series56. Testing for HAV in acute hepatitis among otherwise healthy, previously vaccinated patients is unlikely to aid diagnosis because immunity persists for 15-25 years following vaccination57. In patients without known immunity, anti-HAV IgM antibody could be considered in the evaluation of severe acute liver injury58.

Hepatitis B Virus (HBV) Serology

Screening for HBV is cost effective given the burdens associated with reactivation of chronic infection, cirrhosis and hepatocellular carcinoma59. Screening high-risk individuals, including vulnerable healthcare personnel, with hepatitis B surface antigen, surface antibody and core antibody is recommended59. Hepatitis B serologic testing is complex, and inappropriate testing is frequently performed. One study found a substantial number of laboratory orders for anti-HBe antibody and HBeAg, which have no role in the routine screening for HBV immunity or infection60.

Hepatitis C Virus (HCV) Viral Load and Genotype

HCV viral load can diagnose acute infection, establish chronic infection in antibody-positive patients, and monitor response to treatment. A viral load is not an appropriate screening test for chronic HCV. For patients with chronic HCV, viral load testing is indicated at diagnosis and to monitor response to treatment, however, is not recommended at other times. In patients with sustained virologic response after treatment, a viral load is only necessary for a new exposure or unexplained hepatic dysfunction. Genotype testing is only indicated if treatment with a non-pan-genotypic regimen is planned61.

Gastrointestinal Pathogen Nucleic Acid Amplification Test (NAAT) Panels

Most cases of acute infectious diarrhea are self-limited and routine diagnostics are discouraged unless Clostridioides (Clostridium) difficile infection (CDI) is suspected62. Gastrointestinal-specific NAAT panels rapidly identify pathogens including viruses, bacteria and parasites with sensitivity and specificity of >90% and >97%, respectively, though can pose high cost to patients and institutions. These panels do not distinguish between colonization and infection, so clinically irrelevant pathogens can be detected62,63. Without concern for CDI, testing should be reserved for patients with a history of recent travel, those at risk for severe disease, and those with greater than seven days of symptoms64. Understanding the consequences of testing is important, as treating a generally self-limited process comes at additional cost and side effects62. 

CDI Testing

C. difficile is the leading cause of nosocomial infectious diarrhea among adults and is rising in children. CDI testing is recommended for unexplained, new-onset diarrhea of three or more unformed stools in 24 hours. In settings without established criteria for patient stool submission, an initial stool toxin test as part of a multistep diagnostic algorithm is preferred over NAAT alone owing to the high rate of false positives for NAAT, though both are acceptable. Testing asymptomatic patients and tests of cure are not recommended. Due to high rate of colonization, infants under 12 months should not be tested. Among children 1 to 2 years of age, testing can be considered after excluding other causes of diarrhea. After age 2, testing should be performed as it would be for adults65.

Rapid Antigen Testing and Culture for Group A Streptococcal Pharyngitis

Viruses cause the majority of outpatient cases of pharyngitis. Group A Streptococcus (GAS) accounts for 10%-30% of pharyngitis in children and 5-15% in adults66. GAS pharyngitis is treated to prevent acute rheumatic fever (ARF). GAS testing is not indicated for children <3 years old without risk factors, such as sibling contact, due to the extremely rare occurrence of ARF in this age group. Due to risk of ARF in children, back-up throat culture when RAT is negative is indicated. Among adults, routine use of back-up culture is not recommended due to lower incidence of GAS and lower risk of ARF66. It is not necessary to submit a positive swab for confirmatory culture at any age given high specificity of RAT. Follow-up post treatment throat cultures are not routinely recommended66.

Legionella pneumophila Urinary Antigen Testing (UAT)

Legionella pneumophila causes fewer than 2% of non-epidemic community acquired pneumonia cases annually67. Legionella pneumonia is clinically differentiated through its extrapulmonary manifestations, including relative bradycardia, headache, confusion, diarrhea, transaminitis, and hyponatremia68. While the sensitivity and specificity of Legionella UAT, which detects 80% of serogroup 1, is improving, the low pretest probability of Legionella pneumonia limits its utility69. Legionella UAT should be limited to severe pneumonia, immunocompromise, characteristic extrapulmonary manifestations, critical illness, failure of outpatient antibiotic therapy, active alcohol abuse, travel within the past two weeks or presence of a pleural effusion70.

Inflammatory Conditions

C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR)

CRP is an acute phase reactant that responds quickly to inflammation. The ESR is a surrogate marker of the acute phase reaction but is affected by plasma albumin concentration, size, shape and number of red blood cells, and non-acute phase reaction proteins71. ESR can be negative in minor inflammation, takes longer to become elevated during an inflammatory process, and takes longer to clear once inflammation resolves9. CRP is a better marker of the acute phase reaction in nearly all inflammatory processes, with some exceptions such as low-grade musculoskeletal infections and some autoimmune diseases. CRP is preferred over ESR to detect acute phase inflammation9.

Antinuclear Antibody (ANA) and Sub-Serologies

ANA testing is used to evaluate suspected autoimmune disease, however, is falsely positive in up to 15% of healthy adults72. With few exceptions, if ANA is negative, ANA sub-serologies are also negative. Despite this, one U.S. medical center found 6.6% of ANA tests had at least one sub-serology tested simultaneously73. The financial implications of indiscriminate ANA testing are significant74. Testing ANA sub-serologies with a negative ANA and low pretest probability of immune-mediated disease is not recommended72.

Paraneoplastic Panel

Paraneoplastic encephalitis typically manifests acutely or subacutely, can precede cancer diagnosis by weeks to months, is often associated with cerebrospinal fluid pleocytosis, elevated protein, oligoclonal bands and elevated immunoglobulins75,76. Serum and cerebrospinal fluid panels are available to measure several antibodies associated with paraneoplastic encephalitis syndromes but inappropriate ordering results in a high number of false positives and unnecessary costs related to follow-up care75. Positive antibody tests in the absence of clinical features of paraneoplastic encephalitis is of limited utility and the absence of these antibodies does not preclude the diagnosis in the appropriate clinical situation75,76.

Drug monitoring

Tacrolimus level

Tacrolimus is used in nearly all solid organ transplants77. Inpatient tacrolimus drug monitoring (TDM) is standard of care but variable pharmacokinetics, absorption, and medication interactions limit the utility and reliability of inpatient monitoring77. Further, the timing of inpatient TDM is unreliable, resulting in an estimated $22 million dollars in waste each year78. The impact of inpatient TDM needs to be clarified and inpatient-specific guidelines developed.

Discussion

In this review, we identify 25 target laboratory tests for ordering optimization that span medical specialties and the care continuum. By improving appropriate use of laboratory tests across the clinical spectrum, medical providers can reduce waste and improve healthcare value. While our review is limited by the informal methodology, we have compiled an actionable summary to inform value-based quality improvement work in academic medical centers across the nation.

Implementing value-based quality improvement and education to reduce the unnecessary ordering of laboratory tests among housestaff has been successful79–81 and is a focus of nationwide campaigns including Choosing Wisely®82 and specialty-specific initiatives, such as the American College of Physicians and Alliance for Academic Internal Medicine High Value Care Curriculum83.

Engaging housestaff in the leading these initiatives is beneficial to patient care, institutions and to trainee career development. The involvement of residents in the planning, implementation and evaluation process of value-based quality improvement work has been successful in optimizing care while providing the trainee with valuable experience leading this work84,85. Aligning trainee value-based quality improvement projects with institutional priorities supports high quality patient care and the educational mission of academic medical centers85,86. Further, trainee involvement in value-based initiatives fulfills the Accreditation Council for Graduate Medical Education’s requirement for quality improvement work87.

Medical providers must improve ordering appropriateness as part of the national imperative to reduce waste and increase healthcare value. Engaging trainees in this work facilitates successful implementation and serves to ingrain principles of high value care into their practice. Our review is a resource for trainees interested in championing this vital work in their own institutions by providing actionable targets for quality improvement projects.

References

  1. Institute of Medicine (US) Roundtable on Evidence-Based Medicine. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. (Yong PL, Saunders RS, Olsen L, eds.). Washington (DC): National Academies Press (US); 2010. http://www.ncbi.nlm.nih.gov/books/NBK53920/. Accessed January 16, 2020.
  2. Inc G. Cost of Healthcare Is Americans’ Top Financial Concern. Gallup.com. https://news.gallup.com/poll/212780/cost-healthcare-americans-top-financial-concern.aspx. Published June 23, 2017. Accessed January 16, 2020.
  3. Osborn R, Squires D, Doty MM, Sarnak DO, Schneider EC. In New Survey Of Eleven Countries, US Adults Still Struggle With Access To And Affordability Of Health Care. Health Aff Proj Hope. 2016;35(12):2327-2336. doi:10.1377/hlthaff.2016.1088
  4. Miyakis S, Karamanof G, Liontos M, Mountokalakis TD. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J. 2006;82(974):823-829. doi:10.1136/pgmj.2006.049551
  5. HVPAA • High Value Practice Academic Alliance. High Value Practice Academic Alliance. https://hvpaa.org/. Accessed January 16, 2020.
  6. Future leaders program • High Value Practice Academic Alliance. High Value Pract Acad Alliance. https://hvpaa.org/future-leaders/. Accessed January 16, 2020.
  7. Society of Hospital Medicine – Adult Hospital Medicine | Choosing Wisely. https://www.choosingwisely.org/societies/society-of-hospital-medicine-adult/. Accessed January 16, 2020.
  8. 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(9):1400-1415; 1416. doi:10.1038/ajg.2013.218
  9. American Society for Clinical Pathology | Choosing Wisely. http://www.choosingwisely.org/societies/american-society-for-clinical-pathology/. Accessed January 16, 2020.
  10. Jaffe AS, Ravkilde J, Roberts R, et al. It’s time for a change to a troponin standard. Circulation. 2000;102(11):1216-1220. doi:10.1161/01.cir.102.11.1216
  11. Januzzi JL, Lewandrowski K, MacGillivray TE, et al. A comparison of cardiac troponin T and creatine kinase-MB for patient evaluation after cardiac surgery. J Am Coll Cardiol. 2002;39(9):1518-1523. doi:10.1016/s0735-1097(02)01789-8
  12. Apple FS, Murakami MM. Cardiac troponin and creatine kinase MB monitoring during in-hospital myocardial reinfarction. Clin Chem. 2005;51(2):460-463. doi:10.1373/clinchem.2004.042887
  13. Alvin MD, Jaffe AS, Ziegelstein RC, Trost JC. Eliminating Creatine Kinase-Myocardial Band Testing in Suspected Acute Coronary Syndrome: A Value-Based Quality Improvement. JAMA Intern Med. 2017;177(10):1508-1512. doi:10.1001/jamainternmed.2017.3597
  14. Corson AH, Fan VS, White T, et al. A multifaceted hospitalist quality improvement intervention: Decreased frequency of common labs. J Hosp Med. 2015;10(6):390-395. doi:10.1002/jhm.2354
  15. Gupta SS, Voleti R, Nyemba V, et al. Results of a Quality Improvement Project Aimed at Eliminating Healthcare Waste by Changing Medical Resident Test Ordering Behavior. J Clin Med Res. 2017;9(12):965-969. doi:10.14740/jocmr3210w
  16. Yazer MH. The blood bank “black box” debunked: pretransfusion testing explained. CMAJ Can Med Assoc J J Assoc Medicale Can. 2006;174(1):29-32. doi:10.1503/cmaj.050919
  17. American Association of Blood Banks. Technical Manual. Washington, D.C.; Philadelphia: American Association of Blood Banks ; Lippincott; 2005.
  18. Dexter F, Ledolter J, Davis E, Witkowski TA, Herman JH, Epstein RH. Systematic criteria for type and screen based on procedure’s probability of erythrocyte transfusion. Anesthesiology. 2012;116(4):768-778. doi:10.1097/ALN.0b013e31824a88f5
  19. Hadler R. When Should a Type and Screen not be Ordered Preoperatively? J Anesth Clin Res. 2013;04. doi:10.4172/2155-6148.1000272
  20. van Klei WA, Moons KG, Leyssius AT, Knape JT, Rutten CL, Grobbee DE. A reduction in type and screen: preoperative prediction of RBC transfusions in surgery procedures with intermediate transfusion risks. Br J Anaesth. 2001;87(2):250-257. doi:10.1093/bja/87.2.250
  21. Kurt-Mangold ME, Grieme CV, Krasowski MD, Rosenthal NS. Clinical Utility of Ordered Pathology Blood Smear Reviews – an Overused Resource? Clin Lab. 2018;64(1):99-104. doi:10.7754/Clin.Lab.2017.170703
  22. Gulati G, Song J, Florea AD, Gong J. Purpose and Criteria for Blood Smear Scan, Blood Smear Examination, and Blood Smear Review. Ann Lab Med. 2013;33(1):1-7. doi:10.3343/alm.2013.33.1.1
  23. Allou K, Vial J-P, Béné MC, Lacombe F. The routine leukocyte differential flow cytometry HematoFlowTM method: A new flagging system for automatic validation. Cytometry B Clin Cytom. 2015;88(6):375-384. doi:10.1002/cyto.b.21242
  24. Pratumvinit B, Wongkrajang P, Reesukumal K, Klinbua C, Niamjoy P. Validation and optimization of criteria for manual smear review following automated blood cell analysis in a large university hospital. Arch Pathol Lab Med. 2013;137(3):408-414. doi:10.5858/arpa.2011-0535-OA
  25. Comar SR, Malvezzi M, Pasquini R. Are the review criteria for automated complete blood counts of the International Society of Laboratory Hematology suitable for all hematology laboratories? Rev Bras Hematol E Hemoter. 2014;36(3):219-225. doi:10.1016/j.bjhh.2014.03.011
  26. International Society for Laboratory Hematology. https://www.islh.org/web/index.php. Accessed January 16, 2020.
  27. Petrilli CM, Heidemann L, Mack M, Durance P, Chopra V. Inpatient inherited thrombophilia testing. J Hosp Med. 2016;11(11):801-804. doi:10.1002/jhm.2616
  28. Coppens M, Reijnders JH, Middeldorp S, Doggen CJM, Rosendaal FR. Testing for inherited thrombophilia does not reduce the recurrence of venous thrombosis. J Thromb Haemost JTH. 2008;6(9):1474-1477. doi:10.1111/j.1538-7836.2008.03055.x
  29. Gupta A, Sarode R, Nagalla S. Thrombophilia Testing in Provoked Venous Thromboembolism: A Teachable Moment. JAMA Intern Med. 2017;177(8):1195-1196. doi:10.1001/jamainternmed.2017.1815
  30. Baglin T, Gray E, Greaves M, et al. Clinical guidelines for testing for heritable thrombophilia. Br J Haematol. 2010;149(2):209-220. doi:10.1111/j.1365-2141.2009.08022.x
  31. Overview | Venous thromboembolic diseases: diagnosis, management and thrombophilia testing | Guidance | NICE. https://www.nice.org.uk/guidance/cg144. Accessed January 16, 2020.
  32. American Society of Hematology | Choosing Wisely. http://www.choosingwisely.org/societies/american-society-of-hematology/. Accessed January 16, 2020.
  33. Cuker A, Arepally GM, Chong BH, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia. Blood Adv. 2018;2(22):3360-3392. doi:10.1182/bloodadvances.2018024489
  34. Cuker A, Arepally G, Crowther MA, et al. The HIT Expert Probability (HEP) Score: a novel pre-test probability model for heparin-induced thrombocytopenia based on broad expert opinion. J Thromb Haemost JTH. 2010;8(12):2642-2650. doi:10.1111/j.1538-7836.2010.04059.x
  35. Linkins L-A, Dans AL, Moores LK, et al. Treatment and prevention of heparin-induced thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e495S-e530S. doi:10.1378/chest.11-2303
  36. Breu AC, Theisen-Toupal J, Feldman LS. Serum and red blood cell folate testing on hospitalized patients. J Hosp Med. 2015;10(11):753-755. doi:10.1002/jhm.2385
  37. Ashraf MJ, Cook JR, Rothberg MB. Clinical utility of folic acid testing for patients with anemia or dementia. J Gen Intern Med. 2008;23(6):824-826. doi:10.1007/s11606-008-0615-z
  38. Theisen-Toupal J, Horowitz G, Breu A. Low yield of outpatient serum folate testing: eleven years of experience. JAMA Intern Med. 2014;174(10):1696-1697. doi:10.1001/jamainternmed.2014.3593
  39. Theisen-Toupal J, Horowitz GL, Breu AC. Utility, charge, and cost of inpatient and emergency department serum folate testing. J Hosp Med. 2013;8(2):91-95. doi:10.1002/jhm.1994
  40. Robinson AR, Mladenovic J. Lack of clinical utility of folate levels in the evaluation of macrocytosis or anemia. Am J Med. 2001;110(2):88-90. doi:10.1016/s0002-9343(00)00670-7
  41. Gilmour JA, Weisman A, Orlov S, et al. Promoting resource stewardship: Reducing inappropriate free thyroid hormone testing. J Eval Clin Pract. 2017;23(3):670-675. doi:10.1111/jep.12698
  42. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract Off J Am Coll Endocrinol Am Assoc Clin Endocrinol. 2012;18(6):988-1028. doi:10.4158/EP12280.GL
  43. Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid Off J Am Thyroid Assoc. 2016;26(10):1343-1421. doi:10.1089/thy.2016.0229
  44. Endocrine Society | Choosing Wisely. https://www.choosingwisely.org/societies/endocrine-society/. Accessed January 16, 2020.
  45. Dalal S, Bhesania S, Silber S, Mehta P. Use of Electronic Clinical Decision Support and Hard Stops to Decrease Unnecessary Thyroid Function Testing. BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u223041.w8346
  46. Final Update Summary: Vitamin D Deficiency: Screening – US Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/vitamin-d-deficiency-screening. Accessed January 16, 2020.
  47. Langhorst J, Elsenbruch S, Koelzer J, Rueffer A, Michalsen A, Dobos GJ. Noninvasive Markers in the Assessment of Intestinal Inflammation in Inflammatory Bowel Diseases: Performance of Fecal Lactoferrin, Calprotectin, and PMN-Elastase, CRP, and Clinical Indices. Am J Gastroenterol. 2008;103(1):162-169. doi:10.1111/j.1572-0241.2007.01556.x
  48. Lewis JD. The utility of biomarkers in the diagnosis and therapy of inflammatory bowel disease. Gastroenterology. 2011;140(6):1817-1826.e2. doi:10.1053/j.gastro.2010.11.058
  49. Kane SV, Sandborn WJ, Rufo PA, et al. Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation. Am J Gastroenterol. 2003;98(6):1309-1314. doi:10.1111/j.1572-0241.2003.07458.x
  50. Gisbert JP, Bermejo F, Pérez-Calle J-L, et al. Fecal calprotectin and lactoferrin for the prediction of inflammatory bowel disease relapse. Inflamm Bowel Dis. 2009;15(8):1190-1198. doi:10.1002/ibd.20933
  51. Mathews B, Ratcliffe T, Sehgal R, Abraham J, Monash B. Fecal Occult Blood Testing in Hospitalized Patients with Upper Gastrointestinal Bleeding. J Hosp Med. 2017;12(7):567-569. doi:10.12788/jhm.2773
  52. Narula N, Ulic D, Al-Dabbagh R, et al. Fecal occult blood testing as a diagnostic test in symptomatic patients is not useful: a retrospective chart review. Can J Gastroenterol Hepatol. 2014;28(8):421-426. doi:10.1155/2014/189652
  53. Srygley FD, Gerardo CJ, Tran T, Fisher DA. Does this patient have a severe upper gastrointestinal bleed? JAMA. 2012;307(10):1072-1079. doi:10.1001/jama.2012.253
  54. Elwyn G, Taubert M, Davies S, Brown G, Allison M, Phillips C. Which test is best for Helicobacter pylori? A cost-effectiveness model using decision analysis. Br J Gen Pract J R Coll Gen Pract. 2007;57(538):401-403.
  55. Advisory Committee on Immunization Practices (ACIP), Fiore AE, Wasley A, Bell BP. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep Morb Mortal Wkly Rep Recomm Rep. 2006;55(RR-7):1-23.
  56. Lau DT-Y, Hewlett AT. Screening for hepatitis A and B antibodies in patients with chronic liver disease. Am J Med. 2005;118 Suppl 10A:28S-33S. doi:10.1016/j.amjmed.2005.07.014
  57. Van Damme P, Van Herck K. A review of the long-term protection after hepatitis A and B vaccination. Travel Med Infect Dis. 2007;5(2):79-84. doi:10.1016/j.tmaid.2006.04.004
  58. Tapper EB, Herzig SJ. Nondirected Testing for Inpatients With Severe Liver Injury. J Hosp Med. 2017;12(3):184-187. doi:10.12788/jhm.2705
  59. Abara WE, Qaseem A, Schillie S, McMahon BJ, Harris AM, High Value Care Task Force of the American College of Physicians and the Centers for Disease Control and Prevention. Hepatitis B Vaccination, Screening, and Linkage to Care: Best Practice Advice From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2017;167(11):794-804. doi:10.7326/M17-1106
  60. Genç O, Aksu E. [Inappropriate use of serological tests for hepatitis B virus in Evliya Celebi Education and Research Hospital of Dumlupinar University, Kütahya]. Mikrobiyol Bul. 2014;48(4):618-627. doi:10.5578/mb.8080
  61. Recommendations for Testing, Managing, and Treating Hepatitis C | HCV Guidance. https://www.hcvguidelines.org/. Accessed January 21, 2020.
  62. Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol. 2016;111(5):602-622. doi:10.1038/ajg.2016.126
  63. Spina A, Kerr KG, Cormican M, et al. Spectrum of enteropathogens detected by the FilmArray GI Panel in a multicentre study of community-acquired gastroenteritis. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2015;21(8):719-728. doi:10.1016/j.cmi.2015.04.007
  64. Laboratory Testing for Infectious Causes of Diarrhea [Algorithm]. Insights. https://news.mayocliniclabs.com/2016/01/05/laboratory-testing-for-infectious-causes-of-diarrhea-algorithm/. Published January 5, 2016. Accessed January 16, 2020.
  65. McDonald LC, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis Off Publ Infect Dis Soc Am. 2018;66(7):987-994. doi:10.1093/cid/ciy149
  66. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis Off Publ Infect Dis Soc Am. 2012;55(10):e86-102. doi:10.1093/cid/cis629
  67. Cunha CB, Cunha BA. Legionnaire’s Disease Since Philadelphia: Lessons Learned and Continued Progress. Infect Dis Clin North Am. 2017;31(1):1-5. doi:10.1016/j.idc.2016.10.001
  68. Cunha BA, Cunha CB. Legionnaire’s Disease: A Clinical Diagnostic Approach. Infect Dis Clin North Am. 2017;31(1):81-93. doi:10.1016/j.idc.2016.10.007
  69. Legionnaires Disease Diagnosis, Treatment | Legionella | CDC. https://www.cdc.gov/legionella/clinicians/diagnostic-testing.html. Published February 28, 2019. Accessed January 16, 2020.
  70. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clin Infect Dis. 2007;44(Supplement_2):S27-S72. doi:10.1086/511159
  71. Harrison M. Erythrocyte sedimentation rate and C-reactive protein. Aust Prescr. 2015;38(3):93-94. doi:10.18773/austprescr.2015.034
  72. Arora N, Gupta A, Reddy SB. Antinuclear Antibody and Subserology Testing in the Evaluation of Fibromyalgia: A Teachable Moment. JAMA Intern Med. 2017;177(9):1369-1370. doi:10.1001/jamainternmed.2017.2776
  73. Davis LA, Goldstein B, Tran V, et al. Applying Choosing Wisely: Antinuclear Antibody (ANA) and Sub-Serology Testing in a Safety Net Hospital System. Open Rheumatol J. 2015;9:82-87. doi:10.2174/1874312901409010082
  74. Fritzler MJ. Choosing wisely: Review and commentary on anti-nuclear antibody (ANA) testing. Autoimmun Rev. 2016;15(3):272-280. doi:10.1016/j.autrev.2015.12.002
  75. Wilson RL, Tadevosyan A, Ronan LK. NCMP-03. POSSIBLE OVERUSE OF ORDERABLE ANTIBODY PANELS FOR PARANEOPLASTIC ETIOLOGIES IN DIAGNOSTIC EVALUATION OF NEUROLOGIC PATIENTS. Neuro-Oncol. 2017;19(Suppl 6):vi136. doi:10.1093/neuonc/nox168.556
  76. Leypoldt F, Wandinger K-P, Bien CG, Dalmau J. Autoimmune Encephalitis. Eur Neurol Rev. 2013;8(1):31-37. doi:10.17925/ENR.2013.08.01.31
  77. Scalea JR, Levi ST, Ally W, Brayman KL. Tacrolimus for the prevention and treatment of rejection of solid organ transplants. Expert Rev Clin Immunol. 2016;12(3):333-342. doi:10.1586/1744666X.2016.1123093
  78. Strohbehn GW, Pan WW, Petrilli CM, et al. Large-Scale Variability of Inpatient Tacrolimus Therapeutic Drug Monitoring at an Academic Transplant Center: A Retrospective Study. Ther Drug Monit. 2018;40(4):394-400. doi:10.1097/FTD.0000000000000526
  79. Faisal A, Andres K, Rind JAK, et al. Reducing the number of unnecessary routine laboratory tests through education of internal medicine residents. Postgrad Med J. 2018;94(1118):716-719. doi:10.1136/postgradmedj-2018-135784
  80. Vidyarthi AR, Hamill T, Green AL, Rosenbluth G, Baron RB. Changing resident test ordering behavior: a multilevel intervention to decrease laboratory utilization at an academic medical center. Am J Med Qual Off J Am Coll Med Qual. 2015;30(1):81-87. doi:10.1177/1062860613517502
  81. Bindraban RS, van Beneden M, Kramer MHH, et al. Association of a Multifaceted Intervention With Ordering of Unnecessary Laboratory Tests Among Caregivers in Internal Medicine Departments. JAMA Netw Open. 2019;2(7):e197577. doi:10.1001/jamanetworkopen.2019.7577
  82. Choosing Wisely. /Clinicians/Guidelines-Quality/502.aspx. Published December 9, 2019. Accessed January 16, 2020.
  83. High Value Care Curriculum for Educators and Residents | ACP. https://www.acponline.org/clinical-information/high-value-care/medical-educators-resources/newly-revised-curriculum-for-educators-and-residents-version-40. Accessed January 27, 2020.
  84. Stinnett-Donnelly JM, Stevens PG, Hood VL. Developing a high value care programme from the bottom up: a programme of faculty-resident improvement projects targeting harmful or unnecessary care. BMJ Qual Saf. 2016;25(11):901-908. doi:10.1136/bmjqs-2015-004546
  85. Flanagan MR, Foster CC, Schleyer A, et al. Aligning institutional priorities: engaging house staff in a quality improvement and safety initiative to fulfill Clinical Learning Environment Review objectives and electronic medical record Meaningful Use requirements. Am J Surg. 2016;211(2):390-397. doi:10.1016/j.amjsurg.2015.09.006
  86. Gupta R, Sehgal N, Arora VM. Aligning Delivery System and Training Missions in Academic Medical Centers to Promote High-Value Care. Acad Med J Assoc Am Med Coll. 2019;94(9):1289-1292. doi:10.1097/ACM.0000000000002573
  87. Common Program Requirements. https://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements. Accessed January 27, 2020.

Abbreviations used

  • CBC: Complete blood count
  • TS: Type and screen
  • VTE: Venous thromboembolism
  • HIT: Heparin-induced thrombocytopenia
  • TSH: Thyroid stimulating hormone
  • T3: Triiodothyronine
  • FT3: Free T3
  • GIB: gastrointestinal bleed
  • FOBT: fecal occult blood test
  • BUN: Blood urea nitrogen
  • HAV: Hepatitis A virus
  • HBV: Hepatitis B virus
  • HCV: Hepatitis C virus
  • CDI: Clostridioides (Clostridium) difficile infection
  • NAAT: nucleic acid amplification test
  • GAS: Group A Streptococcus
  • ARF: Acute rheumatic fever
  • RAT: rapid antigen test
  • UAT: Urinary antigen test
  • CRP: C-reactive protein
  • ESR: Erythrocyte sedimentation rate
  • ANA: Antinuclear antibody
  • TDM: tacrolimus drug monitoring