Medical Research: What is the background for this study? What are the main findings?
Dr. Tapper: Elevation of liver enzymes is a common problem, affecting 7.9% of Americans. It is usually related to typical conditions such as fatty liver disease or viral hepatitis. Oftentimes, clinicians test patients with elevated liver enzymes for a multitude of possible causes including very rare genetic diseases, for example, a disease called Wilson Disease. This pattern of evaluation is called non-directed testing. It is a specific form of over-testing that is common in many fields and can be expensive or generate false positives. Wilson Disease, an inborn error of copper metabolism associated with liver injury, is rare (prevalence 0.003%) and there are guidelines available to suggest who should be tested, usually with a blood test called ceruloplasmin. These guidelines suggest excluding common liver diseases before testing for Wilson Disease and testing in younger patients (< 55 years old) because it is very rare to present after age 55.
We created a ‘pop-up’ screen in our provider ordering system to present clinicians who were choosing to order ceruloplasmin with the guidelines as well as its test characteristics, while still allowing them to order the test if they wanted. We studied the 7 months before and after the implementation of this intervention. We found a 51% reduction in ceruloplasmin orders. More importantly, we found that simultaneous testing for common liver diseases like viral hepatitis declined by 54% and the number of patients over the age of 55 who were tested declined by 61%. Incidentally, all positive tests were false positives.
First, we show that adherence to guidelines can be achieved when the ordering system interrupts clinician workflow to provide concrete data and advice. Second, we feel that there is considerable benefit to be obtained from similar interventions via reduced costs and fewer false positives given how common non-directed testing is in medical practice. Other areas that could benefit include, for example, antibody tests for rheumatogic or infectious diseases and daily blood tests for stable inpatients.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Tapper: Future research should pursue two questions. First, interventions to reduce over testing should include an assessment of patient outcomes both in terms of the burden of false positives or the possibility of missed diagnoses.
Second, studies should assess whether a directed strategy of testing is cost-effective compared to the seemingly more convenient all-at-once non-directed strategy.
Tapper EB, Sengupta N, Lai M, Horowitz G. A Decision Support Tool to Reduce Overtesting for Ceruloplasmin and Improve Adherence With Clinical Guidelines. JAMA Intern Med. Published online June 01, 2015. doi:10.1001/jamainternmed.2015.2062.
Elliot B Tapper, M.D., Clinical Fellow in Medicine (EXT), Beth Israel Deaconess Medical Center, & Boston MA 02215 (2015). Pop-Up Screen On Electronic Medical Records May Reduce Some Unnecessary Testing