Reflex and reflective testing: efficiency and effectiveness of adding on laboratory tests

Srivastava, Rajeev; Bartlett, William A.; Kennedy, Ian; Hiney, Allan; Fletcher, Colin D.; Murphy, Michael J.

doi:10.1258/acb.2010.009282

Cited by 63 publications

(52 citation statements)

References 16 publications

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“…1 Proposed solutions to improve the accuracy, efficiency, and safety of ordering clinical laboratory tests and interpreting the results include clinical decision support tools, trending of test results in electronic medical records (EMRs), 2 conditionspecific algorithms to help select tests, 3 professional practice guidelines, 4 and reflex laboratory testing. 5 Many electronic resources have been developed to aid diagnostic decision making. 6 Welldesigned information technology (IT) decision support tools may improve physicians' diagnostic accuracy and efficiency and patient safety.…”

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confidence: 99%

Primary Care Physicians' Challenges in Ordering Clinical Laboratory Tests and Interpreting Results

Hickner

Thompson

Wilkinson

et al. 2014

The Journal of the American Board of Family Medicine

128

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Background:The number and complexity of clinical laboratory tests is rapidly expanding, presenting primary care physicians with challenges in accurately, efficiently, and safely ordering and interpreting diagnostic tests. The objective of this study was to identify challenges primary care physicians face related to diagnostic laboratory testing and solutions they believe are helpful and available to them.Methods: In this study, sponsored by the Centers for Disease Control and Prevention, a random sample of general internal medicine and family medicine physicians from the American Medical Association Masterfile were surveyed in 2011.Results: 1768 physicians (5.6%) responded to the survey. Physicians reported ordering diagnostic laboratory tests for an average of 31.4% of patient encounters per week. They reported uncertainty about ordering tests in 14.7% and uncertainty in interpreting results in 8.3% of these diagnostic encounters. The most common problematic challenges in ordering tests were related to the cost to patients and insurance coverage restrictions. Other challenges included different names for the same test, tests not available except as part of a test panel, and different tests included in panels with the same names. The most common problematic challenges in interpreting and using test results were not receiving the results and confusing report formats. Respondents endorsed a variety of information technology and decision support solutions to improve test selection and results interpretation, but these solutions were not widely available at the time of the survey. Physicians infrequently sought assistance or consultation from laboratory professionals but valued these consultations when they occurred.Conclusions: Primary care physicians routinely experience uncertainty and challenges in ordering and interpreting diagnostic laboratory tests. With more than 500 million primary care patient visits per year, the level of uncertainty reported in this study potentially affects 23 million patients per year and raises significant concerns about the safe and efficient use of laboratory testing resources. Improvement in information technology and clinical decision support systems and quick access to laboratory consultations may reduce physicians' uncertainty and mitigate these challenges. (J Am Board Fam Med 2014;27:268-274.)

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confidence: 99%

Primary Care Physicians' Challenges in Ordering Clinical Laboratory Tests and Interpreting Results

Hickner

Thompson

Wilkinson

et al. 2014

The Journal of the American Board of Family Medicine

128

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“…Defining appropriate follow-up testing certainly lies within the expertise of senior clinical laboratory professionals so much so that 'reflex testing' is the term used for follow-up tests that are performed automatically by the laboratory in order to avoid unnecessary clinical delays [24][25][26]. In Stockholm in 1999, HMJ Goldschmidt highlighted that in the post-analytical phase, raw data, such as the numbers in a laboratory result, are converted to information when meaning is given to that data [27].…”

Section: The Post-analytical Phasementioning

confidence: 99%

Performance criteria of the post-analytical phase

Sikaris¹

2015

Clinical Chemistry and Laboratory Medicine (CCLM)

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Quality in healthcare is ideally at an optimal benchmark, but must be at least above the minimal standards for care. While laboratory quality is ideally judged in clinical terms, laboratory medicine has also used biological variations and state-of-the-art criteria when, as is often the case, clinical outcome studies or clinical consensus are not available. The post-analytical phase involves taking quality technical results and providing the means for clinical interpretation in the report. Reference intervals are commonly used as a basis for data interpretation; however, laboratories vary in the reference intervals they use, even when analysis is similar. Reference intervals may have greater clinical value if they are both optimised to account for physiological individuality, as well as if they are harmonised through professional consensus. Clinical decision limits are generally superior to reference intervals as a basis for interpretation because they address the specific clinical concern in any patient. As well as providing quality data and interpretation, the knowledge of laboratory experts can be used to provide targeted procedural knowledge in a patient report. Most profoundly critically abnormal results should to be acted upon to minimise the risk of mortality. The three steps in quality report interpretation, (i) describing the abnormal data, (ii) interpreting the clinical information within that data and (iii) providing knowledge for clinical follow-up, highlight that the quality of all laboratory testing is reflected in its impact on clinical management and improving patient outcomes.

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“…Some test results may indicate that additional useful information about diagnosis or the significance of abnormal results can be gleaned by the addition of further tests. 5 These extra tests are often added to a request using algorithms that are usually developed 'in-house'. Best practice for this activity is not well established or defined.…”

Section: Introductionmentioning

confidence: 99%

“…Best practice for this activity is not well established or defined. For example, it is recognized that the addition of calcium and potassium when hypomagnesaemia is present, 5 the addition of magnesium when hypokalaemia is present, and the addition of potassium, magnesium and calcium when digoxin is raised, 7 are good practices. Guidelines on action limits are not evidence-based.…”

Section: Introductionmentioning

confidence: 99%

Reflex testing to define action limits for community-based requests

Barron¹,

Ng²,

Aspin³

et al. 2012

Ann Clin Biochem

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Background: Critical values are required to be phoned 24/7. Other abnormal results fall short of the thresholds used to define critical values and may only be required to be phoned during the day. Community-based requestors prefer not to be contacted unless a result is critical and contacting them requires substantial staff resource. It is common practice to add tests to requests to expedite diagnosis or clarify the significance of a particular result using algorithms. Methods: We devised algorithms for reflex addition of tests which allowed the differentiation of significantly abnormal results as either critical values or those that only require day phoning. Results: Algorithms identified 158 out of 309 tests as being critical (51%) over nine months. Reflex addition of serum bicarbonate identified 4% of serum glucose (24.9 -37.9 mmol/L) as critical. Use of estimated glomerular filtration rate by reflex addition of serum creatinine identified 68% of serum lithium (1.49 -1.99 mmol/L) as critical. Addition of serum potassium, calcium and magnesium identified 21% of serum digoxin (.2.49 nmol/L) as critical and addition of serum potassium and calcium to all samples with serum magnesium (,0.31 mmol/L) identified hypocalcaemia in all cases. The addition of serum creatinine and potassium as markers for rhabdomyolysis-induced acute renal failure did not help in the differentiation of serum creatine kinase . 4999 m/L. Conclusions: Use of reflex tests helped inform a phoning system based on the division of results into critical values and nonemergency abnormal values. This avoids disturbing requestors unnecessarily and conserves staff time at night.

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Reflex and reflective testing: efficiency and effectiveness of adding on laboratory tests

Abstract: Near-maximal efficiency of reflex testing can be achieved, depending on the reflex and diagnostic thresholds applied. Reflective and reflex testing are complementary activities, the clinical utility of which depends on the initiators used.

Cited by 63 publications

References 16 publications

Primary Care Physicians' Challenges in Ordering Clinical Laboratory Tests and Interpreting Results

Primary Care Physicians' Challenges in Ordering Clinical Laboratory Tests and Interpreting Results

Performance criteria of the post-analytical phase

Reflex testing to define action limits for community-based requests

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