Rates of inappropriate laboratory test utilization in Ontario.

BACKGROUND: Medical laboratory tests ordered redundantly represent one of the targets for reducing diagnostic testing without negatively, and possibly positively, affecting patient care. We study a clearly defined category of excessive laboratory utilization for nine analytes where inappropriate diagnostic testing is defined in terms of the time interval between tests; that is, ordering a test too soon following the previous order of the same test. METHODS: Population data from the near universal public Ontario Health Insurance Plan for the years 2006-2010 are employed where the tests are fulfilled by community medical laboratories. The analytes selected for consideration are thyroid stimulating hormone, hemoglobin A1c, lipid profile, serum protein electrophoresis, immunofixation, quantitative immunoglobulins, Vitamin D, Vitamin B12, and folate. RESULTS: For the nine analytes studied, the percentage of inappropriate tests ranged from 6% to 20%. Large proportions of these inappropriate tests were completed >2weeks prior to the minimum threshold to reorder defined by practice guidelines and/or were repeated excessively within a year. Between 60% and 85% of the time, the ordering physician of an inappropriate test was the same physician who ordered the previous test. Specialists were more likely than primary care physicians to order repeat tests too soon. CONCLUSIONS: A sizeable proportion of testing for these analytes was inappropriate according to practice guidelines. It is recommended that systems for preventing unnecessary repeat testing are investigated by the funding agencies and that reducing inappropriate testing be considered as a design element for electronic medical records and related information technology systems.

Evaluation of natriuretic peptide recommendations in heart failure clinical practice guidelines.

BACKGROUND: The B-type naturietic peptides (NPs) are associated with heart failure (HF). This investigation was designed to evaluate heart failure clinical practice guideline (CPG) recommendations for the use of NPs. METHODS: A search for English language CPGs for HF published since 2011 was conducted. A search for systematic reviews (SR) and meta-analysis for NPs in HF was conducted for the years 2004-2012. Each HF CPG was evaluated by two independent reviewers. Key recommendations for NPs and the supporting references were abstracted. The key findings from each SR were abstracted. RESULTS: Seven English language HF CPGs were found, all of which made recommendations for the use of NPs in diagnosis. Four made recommendations for prognosis and three for management. The European CPG scored highly for rigor of development with the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) while the others did not. North American CPGs made stronger recommendations citing higher grades of evidence for the use of NPs in HF than the European or Australian CPGs. The CPGs mostly cited primary studies 47/66 to support the recommendations. From twelve available SRs, five were cited by CPGs. One CPG conducted a SR. CONCLUSIONS: The SR evidence to support NP use in CPGs has not been well cited in the CPGs and the recommendations are only partially supported by the SR evidence. Future CPGs should consider improving the methodology used to evaluate laboratory tests.

Successful reintroduction of statin therapy after statin-associated rhabdomyolysis.

The case report demonstrates the successful use of an alternative statin after a statin-related episode of rhabdomyolysis. Statin-associated rhabdomyolysis is a serious adverse event with a very low incidence and is considered the most severe of the muscle-related side effects of the statins. Rechallenge with statins is not a recommended practice after rhabdomyolysis. The patient experienced a myocardial infarct 1 y after the episode of rhabdomyolysis. He used alternative lipid-lowering therapy for 2 y. His low-density lipoprotein cholesterol was not meeting typical secondary prevention targets. An alternative statin was introduced and the patient has been followed for 4 years without recurrence of the rhabdomyolysis. This case suggests it may be time to reconsider the accepted practice of permanently avoiding statin therapy after rhabdomyolysis.