The positive side of overdiagnosis
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1 The positive side of overdiagnosis Does an immediate comprehensive panel of laboratory tests in outpatient care improve patient outcomes? Bram Vrijsen, Maarten ten Berg, Christiana Naaktgeboren, Jolande Vis, Wouter van Solinge, Karin Kaasjager
2 Introduction Research on diagnostic error focuses on overutilization Underutilization is underappreciated Specific aspects of laboratory testing High volume Low costs per test Low burden on patients Few incidental findings More testing may lead to better outcomes and lower costs
3 POORT study (Patient Outcomes Of Rapid Testing) Improved turn-around time of laboratory services Makes laboratory testing prior to consultation possible Evaluate different strategies, focusing on patient centered outcomes Setting: internal medicine outpatient clinic
4 Three strategies Information at referral
5 Outcomes Primary outcome Time to diagnosis Secondary outcomes Appropriateness of laboratory testing Number of inappropriate tests ordered Number of appropriate tests not ordered Consequences of diagnostic error for patients Health care utilization and costs Patients preference
6 Pilot of the POORT study To evaluate logistics of lab testing prior to consultation Based on the first 100 included participants Comparison of 2 laboratory test strategies: - Individualized laboratory panel based of the information at referral (questionnaire) - Standard test panel
7 Appropriateness of tests ordered From the original blood sample, additional tests are performed after three months, so that every patient has the same set of tests performed Expert panel evaluates which tests were inappropriately ordered or not ordered
8 Standard panel prior to consultation BLOOD Haemoglobin Cell counts / differential Sodium Potassium Calcium Urea Creatinine Alkaline phosphatase γ-gt Glucose ASAT ALAT LDH Albumin CRP TSH ESR URINE Urine screening (dipstick)
9 Extended panel (after 3 months) BLOOD URINE Haemoglobin Phosphate Urine screening (dipstick) Cell counts / differential Magnesium Sodium Sodium Bicarbonate Potassium Potassium Osmolality Chloride Calcium Free-T4 Calcium Urea Thyroid antibodies Phosphate Creatinine Ferritin Magnesium Alkaline phosphatase Vitamin B12 Osmolality γ-gt Folic acid Total protein Glucose Homocysteine Albumin ASAT Methylmalonic acid ALAT Free sol. transferrin rec. LDH Intrinsic factor antibodies Albumin Parietal cell antibodies CRP Haptoglobin TSH Dir. Coombs / ZPP ESR Hemoglobin electrophoresis
10 Flow chart
11 Patient characteristics Sex Concurrent medical problems Female 64 Yes 21 Male 36 No 40 Unknown 39 Age (mean + SD) 54 ± 17 Referral reason Concurrent medical problems Fatigue 25 Cardiovascular 13 Abnormal laboratory test result 18 Pulmonary 6 Gastrointestinal complaints 16 Diabetes 4 Abnormal weight loss 10 Malignancy 4 Lymphadenopathy / tumours 7 Rheumatological 8 Other 20 Hematological 3 Excluded 4 Gastro-intestinal 2 Thyroid 2 Other 19
12 Time to diagnosis Median: 42.5 d ( )
13 Comparison of lab on referral and broad panel Number of necessary tests 10 (5-12) Laboratory panel Number of ordered tests Inappropriate tests ordered Necessary tests not ordered Individualized 18 (14-20) 10 (7-13) 2 (0-3) All values are medians with IQR Standard 22 (22-22) 14 (12-17) 1 (0-2) Medians with IQR
14 Patients consequences of inappropriately ordered tests Patients (n=94) Referral Standard panel Out of reference Anxiety 2 4 Additional visits 8 9 Additional lab orders Additional imaging 1 2 Missed diagnosis 0 0 Wrong diagnosis 0 0 Wrong therapy 0 0 Delay in diagnosis 5 6
15 Patients consequences per test (top five) Screening (urine) Total Anxiety Additional visits Additional lab orders Additional imaging Delay ESR GGT ASAT Hemoglobin
16 Patient preferences Do you prefer to have as many appointments as possible planned on one day? 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Not at all Slightly For the most part Yes, totally Is it important for you to talk to your physician before having laboratory tests performed? 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Not at all Slightly For the most part Yes, totally
17 Patient preferences Do you object to more laboratory tests being performed than are strictly necessary? 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Not at all Slightly For the most part Yes, totally Do you mind if a second blood sample is drawn on the same day, because additional tests need to be performed? 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Not at all Slightly For the most part Yes, totally
18 Conclusion and discussion The negative side-effects of overtesting appear to be limited. Patients prefer to have clustered appointments on one day. Most patients do not mind a second blood collection on the same day. Research on over- and underutilization of laboratory testing should focus on patient centered outcomes. We hypothesize that performing a protocolized laboratory panel prior to the consultation leads to a shorter time to diagnosis.
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What tests should be on the Alert List?
What tests should be on the Alert List? Dr Que Lam On behalf RCPA-AACB High Risk Results Working Party: Alan McNeil, Grahame Caldwell, Craig Campbell, Penelope Coates, Robert Flatman, Andrew Georgiou,