Unnecessary Testing Research Articles

Low oxygen saturation and discordant arterial blood gas measures have diagnosed a case of hemoglobinopathy

Pulse oximeter is a simple non-invasive equipment used to determine patient’s arterial blood oxygen saturation (SpO2). However, in some people, arterial blood gas measures (SaO2) are normal and low SpO2 values are related to hemoglobin variant rather than cardiac or pulmonary illnesses. Aim. We present a case of thalassemia that manifested with low SpO2 and discordant SaO2. Conclusion. When examining a patient with an unusually low SpO2, the differential diagnosis of a suspected hemoglobin variant should be investigated. Establishing an accurate diagnosis as soon as possible may help avoid unnecessary tests.

Mitigating overuse of antinuclear antibody (ANA) testing through educational intervention: a study in internal medicine and neurology departments.

Overuse of antinuclear antibody (ANA) tests leads to increased costs, false positives, and unnecessary treatments. This study evaluated ANA overuse in internal medicine and neurology departments and assessed the impact of an educational intervention. This quality improvement educational intervention study examined ANA test overuse in five internal medicine departments and one neurology department at a university-affiliated medical center. The educational intervention included a session focusing on ANA testing appropriateness. Outcome measures comprised the ANA/new patient ratio (APR) and the percentage of positive ANA test results. Outcomes were compared between the pre- and post-intervention periods (both 6months). The intervention took place in December 2021. The APR decreased from 43% in the pre-educational intervention period to 27% in the post-intervention period in the neurology department (odds ratio [OR] 0.49, confidence interval [95% CI] 0.37-0.63, P < 0.0001) and from 2.6% to 2.2% in the internal medicine departments (OR 0.89, 95% CI 0.73-1.10, P = 0.28). The percentage of positive ANA tests increased from 43% pre-intervention to 53% in the post-intervention period (OR 1.49, 95% CI 0.90-2.46, P = 0.12) in the neurology department and from 48% to 59% (OR 1.56, 95% CI 0.99-2.44, P = 0.0543) in the internal medicine departments. A simple educational intervention reduced unnecessary ANA testing in the neurology department but not in internal medicine departments, improving patient selection and potential cost savings. The results underscore the importance of targeted education to promote evidence-based behavior among healthcare professionals. Further research with longer follow-up is needed to assess the sustainability of these improvements.

Who Keeps Changing My Results? - A Case of Heterophile Antibody Interference

Abstract Introduction/Objective Heterophile antibodies are known to cause interference in immunoassays leading to misleading results causing diagnostic confusion and unnecessary testing and/or treatment. Many clinically important analytes are tested using antibody-based assays, as such, these are prone to interference. Methods/Case Report We describe a case of a 73 year old male who was referred with history of hypocalcemia and his previous lab tests were suggestive for idiopathic hypoparathyroidism, Hashimoto’s disease and Addison’s disease raising physician concern for a possible Type 1 autoimmune endocrinopathy. One of his results (cortisol) was outside the analytical measurement range and hence the sample was diluted and tested again, but the result was much less than what was expected, prompting an investigation. Investigation for an interfering substance included serial dilution and analysis of the same sample for the same analytes by different methods (different immunoassay, mass spectrometry or both). Based on non-parallelism in serial dilution results, discordant results with other methods, and loss of interference after dilution it was determined that the most likely cause was a heterophile antibody. Results (if a Case Study enter NA) NA Conclusion Awareness of the possibility that interference by heterophile antibodies can lead to erroneous laboratory results is important to prevent unnecessary testing and inappropriate diagnosis/management.

Pre-operative CBC reflex testing prior to cardiac surgery identifies treatable causes of anemia

Abstract Blood transfusion during or after cardiac surgery has been linked to poor patient outcomes. It is therefore desirable to optimize hemoglobin status by identifying and treating anemia pre-operatively. In order to identify reversible causes of anemia efficiently in this patient cohort, we implemented a reflex order for our institution’s cardiothoracic surgery center, to be ordered for patients undergoing assessment for cardiac surgery. When ordered, complete blood count (CBC) results with a hemoglobin (Hgb) of less than 13 g/dL reflex automatically to the following laboratory tests: iron profile, ferritin, vitamin B12, and reticulocyte count. Methods The purpose of our study was to investigate the impact of this reflex order over the initial 6 months of implementation. Test results and patient notes were extracted from the electronic health record and analyzed. Results Over six months, the order was placed 99 times (median Hgb 13.4 g/dL), with 36 (36%) triggering the reflex (Hgb &amp;lt; 13 g/dL). Of these 36 patients, 19 were women and 17 were men, and the cohort had a median age of 69 years. The median Hgb was 11.9 g/dL, ranging from 7.1 to 12.9 g/dL, with a median mean corpuscular volume (MCV) of 89.6 fl. The median Hgb differed by sex: 11.6 g/dL for men, 12.2 g/dL for women. Of these 36 patients, 16 had signs of iron deficiency anemia (IDA) based on laboratory results (below reference interval for iron, transferrin saturation, or ferritin), and two patients were found with vitamin B12 below the reference interval. Chart review demonstrated that 13 of the 36 patients underwent follow-up after reflex laboratory tests resulted, defined as a new diagnosis, new treatment, and/or new consult addressing the patient’s anemia. Five of these patients were given a new diagnosis of IDA, all of which were started on iron therapy. Three patients were transfused packed red blood cells prior to surgery; one was started on vitamin B12 supplementation; two had consults placed to address anemia; and two were given a new diagnosis of unspecified anemia. Conclusion Pre-operative CBC reflex testing facilitates the efficient and timely identification of reversible causes of anemia in patients undergoing diagnostic workup prior to cardiac surgery, while avoiding unnecessary panel testing in non-anemic patients.

National recommendations of the Croatian Chamber of Medical Biochemists and Working group for Laboratory hematology of the Croatian Society of Medical Biochemistry and Laboratory Medicine: Management of samples with suspected EDTA-induced pseudothrombocytopenia.

Pseudothrombocytopenia (PTCP) is defined by the occurence of spouriously low platelet count as a consequence of in vitro platelet aggregation. It is a rare and benign artifact, not associated with any specific disorder or therapy, that becomes clinically relevant when it is not timely and reliably recognized. Thus, it may result in inappropriate clinical decisions (i.e. unnecessary further testing, misdiagnoses and potential patients' mismanagement) unavoidably compromising patient safety. The most common form of PTCP is caused by ethylenediaminetetraacetic acid (EDTA). Several approaches for the management of samples with EDTA-induced PTCP have been described in the literature. However, expert recommendations are scarce. The scope of these recommendations is to assist in achieving national harmonisation in laboratory management (i.e. detecting and reporting platelet counts) of samples with EDTA-induced PTCP. These minimal recommendations were prepared by the members of the joint working group of the Croatian Chamber of Medical Biochemists and Working group for Laboratory Hematology of the Croatian Society of Medical Biochemistry and Laboratory Medicine, and might be customized according to specific conditions (i.e. personnel and equipment) of each individual laboratory. These recommendations are primarily intended to all laboratory professionals involved in the management of samples with EDTA-induced PTCP, but also to other healthcare professionals involved in collecting samples and interpreting complete blood count results.

Analyzing supply-side moral hazard behaviors in Botswana's health care market: A qualitative study

This paper aims to analyse the behaviours and practices of health care service providers that constitute supply-side abuse of the medical health insurance schemes premised on the notion that patients visit doctors precisely to learn what amount and type of care is medically necessary. Using qualitative methods, individual in-depth interviews were carried on private health service practitioners and thematic analysis via SPSS. The study identifies systemic abuses like overcharging, billing for services not provided, and over prescription. Implication of these findings show that Fee-for-Service Payment Models incentivize providers to deliver more services, leading to potential over-utilization and increased costs in Botswana’s healthcare; due to information asymmetry providers may prioritize quantity over quality of care exploiting patients’ lack of knowledge to recommend unnecessary tests or treatments to maximize on revenue but also costs. On how to minimize supply side moral hazards, the propositions is for pursuance of cost containment strategies to ensure the smooth operation of the schemes like price listings, educate beneficiaries on cost implications and sustainability threats. These propositions can be instituted through an industry led bench-marking, on nationally through regulatory frameworks since moral hazards are an economic cost as inefficiencies brings mis-allocation of resources to enhance the sustainability of medical aid-based health care provisioning.

Pulmonary Embolism Management Audit and Machine Learning Analysis of Delayed Anticoagulation in a Swiss Teaching Hospital.

Background/Objectives: Diagnosing acute pulmonary embolism (PE) is challenging due to its wide range of symptoms and numerous differential diagnoses. Medical professionals must balance performing all essential examinations and avoiding unnecessary testing. This study aimed to retrospectively audit the diagnosis and treatment of acute PE at a Swiss public teaching hospital to determine the adherence to current guidelines and to identify the factors associated with the delayed initiation of anticoagulation in PE patients. Methods: In this retrospective observational cohort study, we included all adult patients hospitalized with PE at the Cantonal Hospital Baselland (KSBL) between November 2018 and October 2020, where the diagnosis was made within the first twelve hours of their arrival to the emergency department (ED). LASSO regression was employed to identify clinical characteristics associated with delayed anticoagulation initiation. Results: A total of 197 patients were included (mean age: 70 years, 54% female). The audit revealed that diagnostic workup was conducted according to guidelines in 57% of cases. Often, D-dimer levels were measured although not strictly necessary (70%). Pretest probability was assessed and documented using the Wells or Geneva score in only 3% of patients, and risk assessment via the Pulmonary Embolism Severity Index (PESI) score was documented in 21% of patients. The median time from ED arrival to CT scan was 120 min (IQR 89.5-210.5), and the median time to anticoagulation initiation was 193 min (IQR 145-277). Factors identified by LASSO associated with delayed anticoagulation included prolonged time from ED arrival to CT scan, the presence of distended jugular veins on examination, ED arrival in the morning, and presenting symptoms of weakness or tiredness. Complementary leg ultrasound was performed in 57% of patients, with 38% of these cases lacking prior clinical examination for deep vein thrombosis. The duration of the anticoagulation treatment was not specified in the discharge report for 17% of patients. A medical follow-up after discharge was recommended in 75% of the patients. Conclusions: In conclusion, while the management of PE at the KSBL generally adheres to high standards, there are areas for improvement, particularly in the morning performance, the use of a pretest probability assessment, D-dimer measurement, risk assessment via the PESI score, the performance of complementary leg ultrasounds, clarification of the anticoagulation duration, and follow-up management.

Reducing unnecessary outpatient group and screen testing at a regional cancer center.

Unnecessary group and screens (G&S) can lead to unnecessary antibody investigations, use of technologist time, and laboratory resources. A baseline audit at our institution identified that 25% of G&S from the cancer center were unnecessary. We aimed to reduce the ratio of monthly G&S to CBC samples processed from the cancer center by 10% (from 0.034 to 0.031) by January 2024. This represents an interrupted time series design from November 2022 to January 2024. Using Plan Do Study Act (PDSA) cycles, we aimed to increase the use of an existing reflex testing system, termed "do not test." When this option is selected, the blood bank will only process the G&S sample if specific CBC criteria are met (e.g., hemoglobin <9.0 g/dL). Educational sessions increased awareness of this feature and sought feedback from end-users on its usability. With feedback, the design was updated to include a modifiable hemoglobin threshold for G&S testing, automatic re-selection of the "do not test" feature for future G&S orders, and aesthetic changes to make the feature more visible. The percentage of samples with "do not test" selected increased from 7.2% to 63.0% (p < .0001) and the ratio of G&S to CBC specimens improved from 0.034 to 0.028, exceeding the target of 0.031. We noted an improvement in the appropriateness of G&S orders from 75% at baseline (n = 20) to 97.5% (n = 80) post intervention (p = .003). We describe an effective strategy to improve G&S utilization at our institution's cancer center using a reflex testing system.

Revisiting the Environmental Impact of Inappropriate Clinical Laboratory Testing: A Comprehensive Overview of Sustainability, Economic, and Quality of Care Outcomes.

The use of laboratory resources has seen a substantial increase in recent years, driven by automation and emerging technologies. However, inappropriate use of laboratory testing, encompassing both overuse and underuse, poses significant challenges. This review explores the complex interplay between patient safety, economic, and environmental factors-known as the "triple bottom line" or "3Ps" for people, profit, and planet-associated with inappropriate use of laboratory resources. The first part of the review outlines the impact of inappropriate laboratory testing on patient safety and economic outcomes. Then the review examines the available literature on the environmental impact of laboratory activities. Several practical solutions for mitigating the environmental impact of laboratories are discussed. Finally, this review emphasizes how decreasing unnecessary laboratory testing results in cost savings and environmental benefits, as evidenced by interventional studies, without compromising patient safety. The implementation of sustainable practices in laboratories can create a virtuous circle in which reduced testing enhances cost-efficiency, reduces the environmental footprint, and ensures patient safety, thereby benefiting the 3Ps. This review highlights the critical need for appropriate laboratory resource utilization in achieving sustainability in healthcare.

A Twin Transition in Regulatory Toxicology-moving towards Chemicals 2.0 and phasing out animal testing.

The European regulatory framework on chemicals is at a crossroads. There are calls for the framework to be more effective, by better protecting people and the environment. There is also room for it to be more efficient and cost-effective, by harmonising assessment practices across sectors and avoiding the need for unnecessary testing. At the same time, there is a political commitment to phase out animal testing in chemical safety assessments. In this commentary, we argue that these needs are not at odds with other. On the contrary, the roadmap to phase out animal testing could also be the transition pathway to a more efficient, effective and sustainable regulatory ecosystem. Central to our proposal is a framework based on biological reasoning in which biological questions can be answered by a choice of methods, with non-animal methods progressively becoming the only choice. Within this framework, a tiered approach to testing and assessment allows for greater efficiency and effectiveness, while also introducing considerations of proportionality and cost-effectiveness. Testing strategies, and their component methods, should be developed in tandem and judged in terms of their outcomes, the protection levels they inform, rather than their ability to predict the outputs of animal tests.

A-062 Determination Neonatal 17-Hydroxyprogesterone Cutoff Levels for Congenital Adrenal Hyperplasia in Korea: 3 years' experience

Abstract Background Newborn screening for congenital adrenal hyperplasia (CAH) is a crucial practice with significant global adoption. While it offers substantial benefits, it also presents challenges due to high false positive rates, which can lead to mental strain for families and unnecessary hospital visits. Our research delved into the impact of birth weight (BW), gestational age (GA), and GA combined with sampling time on 17-hydroxyprogesterone (17-OHP) concentration. Specifically, we aimed to establish appropriate 17-OHP cutoff values for preterm, low birth weight weight (LBW), and sick newborns. Methods A total of 2,429 newborns born between October 2020 and January 2024 were screened for CAH. Samples were collected from neonates on a filter paper with a heel prick method. The 17-OHP concentration was measured by AutoDELFIA Neonatal 17-hydroxyprogesterone kit (PerkinElmer, Turku, Finland). This assay is a solid phase, time-resolved fluoroimmunoassay based on the competitive reaction between europium labeled 17-OHP and sample 17-OHP for a limited amount of binding sites on 17-OHP specific polyclonal antibodies. The 99.5 percentile was applied to the cutoff of 17-OHP for CAH. Results 17-OHP concentrations in newborns with lower BW and GA were significantly higher than those in normal BW and term newborns. 17-OHP concentration showed a statistically significant negative correlation with BW (r = -0.512, p &amp;lt; 0.001) and GA (r = -0.578, p &amp;lt; 0.001). Not only the full-term subgroup, but also preterm subgroups had a same tendency of 17-OHP concentration decrease with increasing sampling time. Application of newly establishing 99.5 percentile cutoff criteria significantly reduced recall rates to 1.02%, 0.81%, and 1.45% according to each criterion of BW, GA, and GA with sampling time, respectively. Conclusions This research introduces novel 17-OHP cutoff values for preterm, low birth weight (LBW), and sick newborns in the context of congenital adrenal hyperplasia (CAH). We analyzed the distribution of these cutoff values, considering factors such as birth weight, gestational age, and the timing of sample collection. Notably, applying the newly established cutoff criteria led to a significant reduction in false positive rates. Our laboratory’s data can serve as a valuable reference for other institutions aiming to set appropriate cutoffs, thereby minimizing unnecessary follow-up tests and enhancing the efficiency of CAH screening. As we continue to accumulate additional data, further reserch in this field remains promising.

B-121 Optimizing Test Ordering: Leveraging Heuristics in Naming Conventions - A PSA Case Study

Abstract Background A common screening test for prostate cancer is the Prostate-Specific Antigen (PSA) test, which may also be referred to as total PSA or total PSA plus free PSA, among other variations. Looking at the test menus of two major reference laboratories, it's apparent that PSA can be ordered under thirteen different test names. From an end-user perspective, the question arises: which of these thirteen tests should be ordered, and why are there so many options? This plethora of choices can lead to confusion and uncertainty for clinicians and patients alike. According to various guidelines, ordering Free PSA is only warranted when PSA values exceed 4 ng/ml. In such cases, the ratio of free PSA to total PSA can aid in further clinical decision-making and patient workup. At Zuckerberg San Francisco General Hospital (ZSFGH), we offer two tests for PSA. The first is named “Prostate Specific Antigen” is total PSA done in house, while the second is labeled “Prostate Spec. Ag. Total and Free.” which is sent out to a reference lab. Upon reviewing our send-out orders, we observed a significant increase (376%) from 2022 to 2023 in the use of the send out order. Methods The ordering data for our providers was collected from February 2022 to January 2024 for both in-house and send-out orders. The data was analyzed using descriptive statistics in Microsoft Excel. Results In our population, we observed an abnormal concentration of send-outs originating from a select group of physicians. Additional we also identified a group of providers who only selected the send out test order. Analysis of in-house assay results for PSA revealed that only 15% (1292 out of 8136) exceeded the cutoff of 4 ng/ml, necessitating further testing to inform clinical decision-making. Yet our send out volume of 4157 test is in discordance with how many PSA would need further evaluation. Based on a cost analysis reducing the send out volume by 80% could result in $53,210 savings. Therefore, to reduce the send out amount and to keep the naming convention similar we decided to implement a new test name that would reflex the PSA to Free PSA if the PSA is above 4 ng/ml. We decided on the name “Prostate Specific Antigen total with reflex to Free Prostate Specific Antigen”. Conclusions Our investigation into the variability in PSA test ordering revealed a significant disparity in the number of send-out orders, particularly originating from a select group of physicians. However, the disproportionately high volume of send-out tests suggested an inefficiency in the current testing approach. To address this issue and align with clinical guidelines, we decided to process a request to our medical executive committee for approval for this reflex test in order to meet reimbursement compliance with the Office of the Inspector General. This change aims to streamline the process, reduce unnecessary send-out tests, and ultimately improve the efficiency and accuracy of prostate cancer screening at our institution.

A-111 “Activation” Of macro-ast by pyridoxal phosphate supplementation

Abstract Background Type 1 macro-AST is a high molecular weight AST (Aspartate Aminotransferase) formed between an AST monomer and immunoglobulins in plasma, which can cause elevated AST values. It is believed that reduced clearance or excretion of macro-AST can cause elevated AST results. Here we report a case of macro-AST that produced high AST values only by the AST assay that includes pyridoxal phosphate (PLP), not by the one without PLP. Case description A 54 year-old male patient diagnosed with disseminated Bartonellosis was monitored with ‘liver function” tests on a monthly basis, with AST varying between 24 to 73 U/L (Reference interval, 13-47 U/L). The patient’s AST value suddenly jumped to 378 U/L when the laboratory switched to an AST assay supplemented with PLP (named ASTPM) on Roche Cobas c702 analyzer (c702). When the same patient sample was tested using the previous AST assay which does not include PLP, a result of 14 U/L was obtained. Macro-AST was suspected, as all other “liver function” tests were within reference interval. Methods Protein-A and Protein-G were used to remove immunoglobulins from the patient sample and another sample with matching AST as a control, respectively. Three hundred microliters of washed Protein-A or Protein-G Sepharose bead slurry was mixed with 300 microliters of each sample, respectively. Each mixture was incubated at 37oC for 3 hours on a rocker. After centrifugation, the supernatant was transferred to a new tube. AST, ASTPM, and all other tests were performed on c702, and results corrected for dilution. The recovery of enzyme activity or immunoglobulin concentration after the removal of immunoglobulins was calculated, respectively. Results In the original sample, the ratio of ASTPM to AST was 28 (389 U/L vs. 14 U/L) for the patient, and 1.1 (304 U/L vs. 275 U/L) for the control. After the complete removal of immunoglobulin G (IgG), the recovery of ASTPM for the patient was 3% and for the control was 74%. The recovery of ALTPM (supplemented with PLP) was 89% for the patient and 85% for the control, showing the expected loss of enzymatic activity by Protein-A or Protein-G treatment. Conclusions The significant reduction of ASTPM activity (recovery of 3%) after removal of IgG in the patient sample proved that the AST enzyme was associated with IgG. The slight increase of ASTPM activity compared to AST (ratio of 1.1) in the control sample was an expected effect of supplementing PLP in the AST assay, however, the huge increase of ASTPM activity (ASTPM/AST ratio of 28) in the patient sample suggests that PLP “activated” the macro-AST and produced high AST result. This is a concerning effect of supplementing PLP in AST assays because it can cause spurious AST elevations in cases of macro-AST. As more laboratories begin to employ the PLP supplemented aminotransferase assays, it is important to acknowledge the interactions between PLP and macro-AST and the role of the laboratory to identify macro-AST in order to avoid unnecessary, costly, and time-consuming testing and procedures for these patients.

A-184 Evidence-based Test Utilization: Test Ordering Patterns in Functional Medicine and Community Clinics, and Implications for Laboratory Stewardship

Abstract Background Functional Medicine Physicians (FMPs) use a holistic approach to identify and address “the root cause of a disease”. These physicians routinely order laboratory tests that are not supported by clinical suspicion and practice guidelines (i.e., Centers for Disease Control and Prevention Laboratory Medicine Best Practices, and local diagnostic algorithms) and are unnecessarily duplicative, with inappropriate testing patterns. Ordering unnecessary tests does not improve diagnosis; indeed, 5% of disease-free patients falsely test positive for a given diagnostic test. Test overutilization increases the rate of false positives, leading to unnecessary medical follow-ups, compromised patient care, and financial constraints on the healthcare system. The objective of this study is to: 1) Compare test ordering patterns between FMPs and General Practitioners (GPs) to identify disparities and opportunities for laboratory stewardship improvements. 2) Analyze the potential factors impacting test utilization in areas served by FMPs, 3) investigate the proper approach to improve test utilization. Methods Using our laboratory’s information system, we conducted a retrospective study spanning from January 2022 to December 2022 to assess testing patterns by 15 FMPs in Southern Alberta, comparing them to those of randomly selected community GPs within the same geographical region. A query was executed to retrieve data on the top 50 chemistry tests ordered by functional medicine clinics and community clinics. These tests were further categorized into six groups: general chemistry, endocrinology, immunology, trace elements, toxic metals, and vitamins. Data analysis included determining the geographical locations of functional medicine clinics and assessing the socioeconomic status of their patient populations. Additionally, the percentage of abnormal test results were calculated for both functional medicine clinic and community clinics. Furthermore, the average cost of tests per patient, per physician, and per clinic was computed to evaluate the financial implications of testing practices. Results Our preliminary results showed significant variability in test ordering practices among FMPs, with potential implications for patient care and healthcare costs. Most tests ordered by FMPs were normal (94%), suggesting a need for further scrutiny regarding the necessity and appropriateness of these tests. A notable trend observed was the disproportionate preference of FMPs for expensive tests, including hormones, vitamins, and toxic metals. Our analysis reveals that the cost per reportable test from FMPs was four times higher compared to the tests ordered by GPs. Furthermore, on average, functional medicine clinics in urban areas ordered around 60% more tests annually compared to their rural counterparts. Conclusions Our preliminary findings clearly show a need to monitor the testing behavior more carefully by the functional medicine clinics. The data from this study will be shared with the physicians practicing functional medicine in Alberta. Strategies to improve the test utilization and patient care include educating the functional medicine doctors and provincial healthcare authorities about the appropriate test utilization and the impact of inappropriate use of lab on patient care. In addition, using algorithms for test ordering will be used if the pattern of inappropriate testing continues.

Deep learning model with pathological knowledge for detection of colorectal neuroendocrine tumor

Colorectal neuroendocrine tumors (NETs) differ significantly from colorectal carcinoma (CRC) in terms of treatment strategy and prognosis, necessitating a cost-effective approach for accurate discrimination. Here, we propose an approach for distinguishing between colorectal NET and CRC based on pathological images by utilizing pathological prior information to facilitate the generation of robust slide-level features. By calculating the similarity between morphological descriptions and patches, our approach selects only 2% of the diagnostically relevant patches for both training and inference, achieving an area under the receiver operating characteristic curve (AUROC) of 0.9974 on the internal dataset, and AUROCs of 0.9724 and 0.9513 on two external datasets. Our model effectively identifies NETs from CRCs, reducing unnecessary immunohistochemical tests and enhancing the precise treatment for patients with colorectal tumors. Our approach also enables researchers to investigate methods with high accuracy and low computational complexity, thereby advancing the application of artificial intelligence in clinical settings.

Costs and benefits of routine labs in hospital patients: iatrogenic anaemia and undiagnosed acute kidney injury

ImportanceGuidelines recommend avoiding unnecessary laboratory tests to minimise risks of anaemia in hospitalised patients as well as reduce costs, but there are costs to skipping routine labs including missing acute...

Minimizing unnecessary proBNP blood tests: an evaluation of a pop-up form implementation in general practice

Objective To evaluate the impact of a compulsory pop-up form on the ordering pattern of proBNP blood tests by general practitioners in the Capital Region of Denmark. Design A follow-up study comparing the average number of proBNP tests ordered before and after the implementation of an intervention. Setting and subjects From 2016 to 2021, the average number of proBNP tests increased by over 300%. In March 2022, a compulsory pop-up form was introduced in the electronic request system (WebReq), requiring general practitioners to select one of three indications for ordering proBNP, as recommended by the Danish Society of Cardiology. The study included 528 general practitioners in the Capital Region of Denmark, with data available from January 2020 to 2023, encompassing 83,576 proBNP results from 56,645 patients. Main outcome measure The average number of proBNP tests ordered per month and the median level of proBNP before and after the intervention. Results Following the intervention, the average number of proBNP tests per month decreased by 60% over a 22-month follow-up period. The highest reduction was seen among general practitioners who previously ordered the most tests (≥3 per 1000 biochemical tests). In this group, the median proBNP level increased from 12.1 pmol/L before the intervention to 13.5 pmol/L after the intervention (p < 0.0001). Conclusions This study demonstrates a significant decrease in the number of proBNP requests from general practitioners in the Capital Region of Denmark after the introduction of a pop-up form in the requisition system containing the current guidelines.

Influence of Prior Imaging Review on Recommendations for Additional Diagnostic Testing: Retrospective Analysis of Imaging Reports in a Chiropractic Radiology Practice

ObjectiveThe purpose of this study was to assess the influence of prior imaging review on recommendations for additional diagnostic testing in an academic chiropractic radiology practice. A secondary aim was to explore the influence of prior imaging review on radiographic interpretation. MethodsWe retrospectively reviewed radiology reports generated from July 18, 2022, to July 18, 2023, from the Palmer College of Chiropractic main campus (Davenport, Iowa) clinic system. Imaging interpretation included an automated search for prior images in an internal picture archival and communication system (PACS). Images from regional health system databases were available and sought by radiologists when (1) unclear radiologic findings had potential clinical implications or (2) prior imaging could clarify potential problems detected in a clinical history. Data were abstracted to a secure adaptive electronic questionnaire and analyzed descriptively. ResultsWe reviewed 1712 radiographic and 165 musculoskeletal diagnostic ultrasound reports for 1552 unique individuals (811 [52.3%] females and 741 [47.7%] males) with a mean age of 42.1 years (range, 2-93 years). Prior imaging was described in 417 (22.2%) reports; 246 (58.9%) indicated images from internal PACS, 192 (46.0%) indicated images from external PACS, and 21 noted both internal and external PACS. Prior imaging findings were credited with answering a clinical question in 98 (23.5%), and a radiographic question in 228 (54.7%) of 417 reports. The process negated the need for follow-up diagnostic testing recommendations in 119 (28.5%) instances, leading to additional imaging recommendations in 19 (4.6%). ConclusionData obtained in this study suggest that comparing current and previous imaging may help reduce unnecessary additional imaging or follow-up diagnostic testing recommendations. Prior imaging review may also facilitate diagnostic confidence and interpretation clarity.

Audiological and Vestibular Follow-Up for Children with Congenital Cytomegalovirus Infection: From Current Limitations to Future Directions.

Currently, the guidelines for audiological and vestibular follow-up in children with congenital cytomegalovirus (CMV) are not well-defined. The general recommendation is to evaluate hearing in all children with congenital CMV at the same intervals: once every 3-6 months up to 1 year of age, once every 6 months from 1 to 3 years of age, and once a year from 3 to 6 years of age. Additionally, there are no universally accepted protocols for the vestibular follow-up of children with congenital CMV, although video head impulse test (v-HIT) and cervical vestibular-evoked myogenic potentials (cVEMPs) are sometimes used. This narrative review critically evaluates existing audiological and vestibular follow-up approaches for children with congenital CMV, highlighting the need for personalized protocols. Tailoring follow-up schedules with different timing and methods based on risk factors, such as the trimester of maternal infection, CMV PCR results in amniotic fluid, and valganciclovir use, would indeed allow for more precise evaluations, timely interventions, and optimized resource allocation. This strategy would also alleviate the logistical and emotional burdens on families by ensuring that high-risk children receive more frequent and appropriate assessments and early interventions, while lower-risk children avoid unnecessary testing.

Evaluating Adherence to AAO Hydroxychloroquine Screening Guidelines

PurposeHydroxychloroquine (HCQ) is commonly prescribed for autoimmune disorders but carries a risk of retinal damage, which increases over time. The American Academy of Ophthalmology (AAO) issued updated guidelines in 2016 to optimize screening for HCQ retinopathy, recommending dosing based on real body weight and specific visual field (VF) testing patterns. This study aimed to assess adherence to the AAO guidelines for HCQ retinopathy screening in a clinical setting and to identify deviations in the implementation of these guidelines. DesignWe employed a large, single-center retrospective case series study design. MethodsWe conducted a retrospective analysis of 391 patients treated with HCQ at a single academic center from 2017 to 2019. The study focused on the appropriateness of screening tests, specifically optical coherence tomography (OCT) and VF testing, based on the duration of HCQ therapy. ResultsOur analysis showed that over-testing with OCT and VF was prevalent among patients on HCQ for five years or less, occurring in 56% and 48% of encounters, respectively. Conversely, there were missed screenings in patients on HCQ for more than five years, with 12% and 16% of encounters lacking OCT and VF testing, respectively. Notably, adherence to VF testing guidelines for Asian patients was poorly implemented, with the recommended wide pattern VF testing conducted in only two of nine cases. Additionally, there were significant instances where HCQ dosages exceeded recommended levels without subsequent adjustments, despite ophthalmologists' recommendations. ConclusionsThe study highlights a critical need for improved guideline adherence to prevent unnecessary testing costs and undetected retinopathy in long-term HCQ users. It underscores the importance of using real body weight for dosing decisions and enhancing collaboration between ophthalmologists and rheumatologists to manage the delicate balance between disease control and the risk of retinopathy. Further multi-center studies are warranted to evaluate adherence variations and develop strategies for guideline implementation.