Usefulness of routine urine analysis in medical outpatients.

OBJECTIVE: To investigate prospectively the value of routine urine analysis in a university based, medical outpatient clinic providing primary (> 90%) and referral care (< 10%) in general internal medicine, as determined by whether it led to a new diagnosis requiring a change in medical management (new treatment; advice to patient; further follow up appointment). METHODS: A dipstick urine analysis was performed in 610 consecutive patients (mean (SD) age 41 (16) years) making their first clinic visit. A urinary sediment of the same specimen was examined in those patients with abnormal results for haemoglobin, leucocytes, or protein. A urine analysis was defined as routine when it was not considered indicated for diagnostic or management purposes by the resident in charge at the patients' initial clinic visit. The main outcome measures were the number and nature of new diagnoses leading to a change in patient management. RESULTS: In 183 patients (30%, 95% confidence interval (CI) 27% to 34%) the urine analysis was performed as an indicated test and in 427 (70%; 95% CI 64% to 73%) as a routine test. Urine analysis was abnormal in 71 of the 427 patients (17%) in whom it had been performed as a routine test. Abnormal findings led to a change in management in three patients only (0.7%; 95% CI 0.2% to 2.2%). Critical assessment makes the value of routine urine analysis debatable even in these three patients. CONCLUSIONS: In a middle aged medical outpatient group of a university based, teaching clinic providing predominantly primary care, urine analysis can be restricted to patients in whom it is clinically indicated.

Multiple biochemical blood testing as a case-finding tool in ambulatory medical patients.

PURPOSE: The usefulness and costs of multiple biochemical blood tests as a case-finding tool in ambulatory medical patients are not well known. Recommendations are lacking or based upon results of screening asymptomatic persons. We designed a study to determine prospectively the yield, potential disadvantages, and patient charges of routine biochemical testing at our medical outpatient clinic. PATIENTS AND METHODS: Twenty-three biochemical parameters were evaluated in 493 consecutive patients. Parameters not considered indicated for diagnostic or management purposes by the staff physicians at the first visit were classified as routine tests. The main outcome measures were the number and the nature of new diagnoses leading to a new management, the number of additional tests and visits, and patient charges. RESULTS: New diagnoses resulting in new management were found in 25 patients (5%). They were mainly lipid disorders. Seven additional visits and 74 further tests were caused by abnormal results of routine tests. The net charges for the detection of the new diagnoses leading to new management were $12,682. Secondary analysis revealed that the determination of only three routine tests (cholesterol, glucose, alanine aminotransferase) would have detected all clinically important diagnoses and would have reduced the charges by 30%. CONCLUSIONS: Routine biochemical testing is a useful case-finding tool with acceptable costs in middle-aged medical outpatients of a university teaching setting. However, the spectrum of newly detected disorders leading to changes in patient management is small. The results suggest that a reduced routine battery consisting of cholesterol, glucose, and alanine aminotransferase might be preferable because it will detect the clinically important diagnoses and lead to a substantial reduction of patient charges.

[Does routine ultrasonography of the abdominal organs affect the subsequent management of the patient?]. / Beeinflusst die routinemässige Sonographie abdominaler Organe die weitere Patientenbetreuung?

When abdominal ultrasound is performed it is general practice to examine not only the organs needed to answer the clinician's question but also the remaining abdominal and pelvic organs for which there is no clinical indication (= routine examinations). We investigated the effect of these routine examinations on the further management in 533 medical outpatients (222 women; 311 men; age 45 +/- 16 years). Of 7684 organs examined, 6194 (81%) were routine examinations, 469 of which revealed unexpected abnormalities. Only 19 of these were considered clinically relevant enough to warrant further work-up, and long-term follow-up was regarded as necessary in 6 patients only. However, an abnormal finding on routine examination had no eventual therapeutic implications in any patient. We conclude that in middle-aged medical outpatients it is sufficient to perform sonography on those abdominal and pelvic organs which need to be examined to answer the clinician's questions. Failure to routinely examine the remaining organs does not lead to a relevant loss of information, but may save time and money on fruitless work-up of unexpected findings.

Usefulness of complete blood counts as a case-finding tool in medical outpatients.

OBJECTIVE: To determine the usefulness of routine complete blood counts as a case-finding tool in medical outpatients. DESIGN: Prospective evaluation in a consecutive, unselected cohort. SETTING: A university-based outpatient clinic providing primary and referral care in general internal medicine. PATIENTS: A total of 595 patients (mean age [+/- SD], 40 +/- 15 years) making their initial clinic visit. INTERVENTION: A complete blood count was done in all patients. Components of the complete blood count that were not indicated for diagnostic or management purposes at the initial visit were classified as routine tests. MAIN OUTCOME MEASURES: The number and nature of new diagnoses leading to new patient management; the number of additional visits and diagnostic tests precipitated by positive results. MAIN RESULTS: Of the 2378 tests done, 1540 (65%) were routine tests. The percentages of abnormal test results for the four hematologic test components were as follows: leukocyte count, 7.6%; hemoglobin, 5.8%; mean corpuscular volume (MCV) of red blood cells, 7.9%; and platelet count, 4.5%. In only three patients (0.5%) was a new diagnosis made that led to a new management strategy (treatment of iron deficiency). Further work-up was unprofitable in 14 patients (2.4%). Two additional visits were necessary because of abnormal results on routine tests. No abnormality-associated clinical disease developed during a 15-month follow-up period in patients with unexplained abnormal results on routine hematologic tests. CONCLUSIONS: The routine complete blood count has limited usefulness as a case-finding tool and has a minimal effect on care in middle-aged medical outpatients.

[Quality of treatment in hypercholesterolemia in ambulatory patients]. / Qualität der Behandlung von Hypercholesterinämien bei ambulanten Patienten.

In 1989 serum cholesterol was determined as a routine procedure in 534 consecutive patients. The response of the physicians to elevated cholesterol levels and factors associated with a treatment decision were analyzed. A follow-up was obtained in treated patients after at least one year. 105 patients (20%) had hypercholesterolemia, 84 of whom were available for evaluation; only in 34 (40%) was treatment initiated. Patients were more likely to be treated (p less than 0.05) if they had cholesterol greater than 1 mmol/l above normal, if they were between 41 and 50 years old, and if cholesterol had been determined at the physician's special request. The decision to treat was not influenced by sex, presence of further risk factors or by manifest atherosclerosis. After one year, 11 of 26 patients were still well controlled and treated. Their mean cholesterol level was significantly lower as compared to pretreatment levels. We conclude that initial as well as long-term management of patients with hypercholesterolemia should be improved.