Novel test algorithm reduces unnecessary testing in patients with diarrhoea

Stephen Padilla
09 Feb 2018
Novel test algorithm reduces unnecessary testing in patients with diarrhoea

A point-of-order test restriction algorithm for hospitalized adults with diarrhoea reduces bacterial stool cultures and ova and parasites testing, which results in substantial cost and time savings, according to a recent study.

“This effect occurred in areas where the advisor was directly employed, as well as in other clinical areas that did not have access to the tool,” researchers said. “The method of test restriction … is different from those described previously, as it directly impacts the provider’s ability to order the studies rather than relying on rejection of already collected specimens that do not meet testing criteria.”

A significant decrease was observed in stool culture and ova and parasites testing rates at the adult inpatient (p=0.001 for both), paediatric (p<0.001 for both) and adult emergency department (p<0.001; p=0.009) locations. The intervention site saw an immediate decrease, while other locations exhibited a delayed but sustained decrease that suggests a collateral impact. [Am J Med 2018;131:193-199.e1]

“The use of a computerized testing advisor to guide clinicians on the appropriate testing for hospitalized patients with diarrhoea led to a significant and immediate reduction in the rate of bacterial stool culture and stool ova and parasites testing in adult inpatients,” researchers said. “This impact was sustained following implementation.”

In the outpatient setting, there was a significant increase in the rate of stool culture (p=0.02) and ova and parasites testing (p=0.001). An estimated $21,931 was saved annually.

“The financial impact of reduced stool testing, while modest at $21,931 a year, is likely underestimated, given that reduced nursing workload, decreased need for collection supplies and a reduction in other indirect costs anticipated as a result of less testing were not included in the analysis,” researchers said.

Putting this in context, an estimated $92,000 was saved annually with a computerized physician order entry-based intervention targeted at reducing redundant B-type natriuretic peptide orders, while another intervention designed to limit repetitive Clostridium difficile testing saved about $21,650 yearly, according to researchers. [BMC Med Inform Decis Mak 2013;13:43; J Clin Microbiol 2013;51:3872-3874]

The estimated cost savings included only the intervention site and might have been higher had the effects seen at the other sites been included, they said.

“Finally, the impact in the reduction of unnecessary antibiotic use and subsequent risk of C. difficile infection and contribution to the development of multidrug-resistant organisms is important to acknowledge, even if this is not able to be quantified,” they added.

Patients with diarrhoea at a tertiary academic medical centre were enrolled. The intervention was a computerized physician order entry-based test guidance algorithm that restricted the use of stool cultures and ova and parasites testing of diarrhoea in the adult inpatient location vs nonintervention sites (ie, emergency department, paediatric inpatient, and adult and paediatric outpatient locations).

Researchers measured stool culture, ova and parasites, and C. difficile testing rates from 1 July 2012 to 31 January 2016. They also calculated advisor usage, consults generated, information accuracy and cost savings.

“In an era of medicine where the reduction of unnecessary treatment and testing is recognized as an important goal, projects such as this are crucial,” researchers said. “Future efforts to expand this work to other health care systems and for the evaluation of other disease states should be considered.”

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