Safety and efficacy of routine diagnostic test reduction interventions in patients admitted to the intensive care unit: A systematic review and meta-analysis

Abstract

Reducing unnecessary routine diagnostic testing has been identified as a strategy to curb wasteful healthcare. However, the safety and efficacy of targeted diagnostic testing strategies are uncertain. The aim of this study was to systematically review interventions designed to reduce pathology and chest radiograph testing in patients admitted to the intensive care unit (ICU). A predetermined protocol and search strategy included OVID MEDLINE, OVID EMBASE and the Cochrane Central Register of Controlled Trials from inception until 20 November 2019. Eligible publications included interventional studies of patients admitted to an ICU. There were no language restrictions. The primary outcomes were in-hospital mortality and test reduction. Key secondary outcomes included ICU mortality, length of stay, costs and adverse events. This systematic review analysed 26 studies (with more than 44,00 patients) reporting an intervention to reduce one or more diagnostic tests. No studies were at low risk of bias. In-hospital mortality, reported in seven studies, was not significantly different in the post-implementation group (829 of 9815 patients, 8.4%) compared with the pre-intervention group (1007 of 9848 patients, 10.2%), (relative risk 0.89, 95% confidence intervals 0.79 to 1.01, P = 0.06, I2 39%). Of the 18 studies reporting a difference in testing rates, all reported a decrease associated with targeted testing (range 6%–72%), with 14 (82%) studies reporting >20% reduction in one or more tests. Studies of ICU targeted test interventions are generally of low quality. The majority report substantial decreases in testing without evidence of a significant difference in hospital mortality.

Optimising a targeted test reduction intervention for patients admitted to the intensive care unit: The Targeted Intensive Care Test Ordering Cluster Trial intervention

“…Although there are a substantial number of studies reporting interventions to reduce unnecessary diagnostic testing in ICU, the quality of these studies is generally low, and none report a theorybased framework for intervention development. 3 Consequently, the safety and efficacy of targeted testing interventions remains uncertain. In contrast to existing studies, TICTOC has sought to identify and extract previously reported BCTs and use these to create a comprehensive targeted test reduction intervention with the aim of conducting a pivotal RCT.…”

“…A systematic review investigating the association between ICU targeted testing and hospital mortality was recently conducted, and the methods and findings were reported. 3 This review was used to develop the components of the TICTOC intervention by identifying, extracting, and classifying all BCTs reported in eligible studies. 6 This created a long list of possible components for the candidate intervention that was reviewed by the TICTOC management committee to identify any gaps.…”

“…The results of the systematic review, as they related to the safety and efficacy of targeted testing interventions, have been reported. 3 Overall, targeted testing interventions resulted in substantial decrease in tests ordered. Although no difference was demonstrated in mortality, the certainty of the evidence for patient-centred outcomes was low.…”

“…The trial will test the hypothesis that a targeted testing intervention is noninferior to routine ordering with respect to in-hospital mortality, and is informed by a pilot study and a recent systematic review. 3,4 Guidelines for complex healthcare interventions recommend that the intervention is developed within a theoretical framework. 5 A framework can provide a robust method of identifying the optimal behavioural components to incorporate into the intervention.…”

Everyone’s a winner if we test less: the

“…5 As many as half of all tests may not be clinically indicated, 6,7 and some are harmful due to their contribution to the development of anaemia. 8 In addition, considerable time is spent performing, processing and interpreting tests.…”