Clinical laboratory test ordering procedures suffer from a quality gap. Clinicians don’t always follow appropriate use guidelines, directives, or algorithms, which result in duplicative tests or over- or underuse of tests. To address this systemic problem, a team of investigators conducted a meta-analysis to determine which practices would most effectively support appropriate utilization. The results appeared in the American Journal of Clinical Pathology.
The systematic review used the Centers for Disease Control and Prevention’s (CDC) Laboratory Medicine Best Practices (LMBP) initiative’s A6 cycle method to assess quality improvement in laboratory medicine. The initiative “not only has a vision of evidence-based laboratory medicine quality improvement in support of improved health care and patient outcomes but also seeks to strengthen the nation’s clinical laboratory systems,” the study’s lead author Matthew Rubinstein, MSHS, MT(ASCP), a health scientist with CDC’s Division of Laboratory Systems, told CLN Stat.
Using this method, Rubinstein and his colleagues evaluated practices that manage or support test utilization, including: computerized provider order entry (CPOE); clinical decision support systems/tools; education; feedback; test review; reflex testing; laboratory test utilization teams, and any combination of these practices. They also looked at eligible systems outcomes such as test costs, and patient-related outcomes such as the length of a patient’s hospital stay and morbidity and mortality.
Combing through more than 23,000 bibliographic records, they whittled the data down to 83 studies for the review, and eventually, 51 for the meta-analysis. “With that set of included studies, two analysis approaches were used—qualitative and quantitative—to derive a category for a practice recommendation and present data supplemental to those categorizations,” Rubinstein said.
Based on this analysis, Rubinstein and his colleagues determined that CPOE, reflex testing, and approaches combining different strategies were the most optimal practices to support appropriate clinical lab testing utilization. The strength of evidence based on CDC’s LMBP method for these three practices “attained a threshold such that users may have confidence they are effective for managing inappropriate overutilization of testing,” Rubinstein explained.
These findings are based on the current evidence base, however, which has limitations. “It’s for this reason we caution all potential users that no specific appropriate use criteria is endorsed, and that each local setting should first assess potential for harms relative to benefits in collaboration with the institution’s medical executive committee (or equivalent),” Rubinstein suggested.
The other approaches were eliminated due to insufficient evidence, with the investigators making no recommendation for or against these practices. This doesn’t necessarily rule out their effectiveness, Rubinstein said. Instead, this rating is a function of the CDC LMBP method, based on the number of studies for a practice, their effect size rating, heir quality ratings, and of the specific systematic review protocol (e.g. cutoff thresholds for effect size ratings).
“In short, that rating suggests a need for additional primary studies assessing the effect of those practices,” he said.
The study includes a number of important takeaways for labs:
- Interprofessional engagement in initiating and assessing practices in support of appropriate test utilization;
- Opportunities for improving the quality of the relevant evidence base; and
- Opportunities to advance how appropriate test utilization is benchmarked and monitored.
Apart from the practices assessed in this study, laboratories may identify other relevant practices, Rubinstein suggested. “An example might be diagnostic management teams, assuming part of their function is to support appropriate utilization of testing,” he said.