A Comparison of Ordering Pattern of Laboratory Send-Out Tests Between Naturopathic Doctors and General Practitioners in a Pediatric Population

Abstract

Abstract Objectives Naturopathy is defined as the practice of medicine for the treatment of human diseases with natural agents. It also emphasizes prevention and promotion of health through the self-healing process of the body. Even without any illness or symptoms, naturopathic doctors (NDs) often advocate for and use unique lab tests to make clinical judgments. Tests that are performed outside of the ordering institution, send-out tests, are at increased risk of ordering the wrong or unnecessary test and misinterpreting test results. Here we evaluate the laboratory send-out tests that were ordered by NDs and general practitioners (GPs) at a tertiary pediatric care center to identify opportunities for improved laboratory stewardship. Methods We performed a retrospective analysis from Seattle Children’s laboratory send-out tests, which were ordered between January 1, 2018, and December 31, 2018. We compared the tests ordered by NDs with general practitioners in our practice, by grouping the following provider specialties: adolescent medicine, family medicine, or pediatrics. All the requests were reviewed and categorized by test type: heavy metal, allergen, infectious disease, hormone and vitamin, hematology and immunology, toxicology, oncology, genetics, and others. Ordering frequency and abnormal rate from each category were analyzed. The abnormal rate was defined as percentage of abnormal results divided by total number of ordered tests. Results During the 12-month period, there were 20,312 send-out tests; 1,028 (5.1%) of them were ordered by 83 NDs for 329 patients, and 3,862 (19.0%) of them were ordered by 462 GPs for 2,139 patients. The most frequently ordered tests by NDs were heavy metal screens (506 tests, 49.2% of total), allergen panels (31.7%), and infectious disease tests (7.0%). The corresponding abnormal rates were 8.5%, 0.9%, and 8.3%, respectively, with an overall abnormal rate of 6.6%. For GPs, the most frequently ordered tests were hormone and vitamin analyses (1,346 tests, 34.9% of total), hematology and immunology tests (22.5%), and heavy metal screens (10.8%). The corresponding abnormal rates were 18.1%, 35.9%, and 18.8% and overall abnormal rate was 17.8%. Conclusion We observed different ordering patterns between GPs and NDs, with rates of abnormal findings significantly higher from the tests ordered by GPs. These data suggest some of the tests ordered by NDs have low positive predictive value or clinical significance and could be potentially mis- or overutilized. Understanding the patterns and the variety of testing from different providers can help target interventions to improve laboratory stewardship in this area.