1.2. Saving money, improving patient outcomes
As more tests become available, including a multitude of rapid diagnostic tests (RDTs), choosing the appropriate test for a particular patient in a particular setting requires the combined knowledge and expertise of clinical microbiologists, technicians, pharmacists, data analysts and clinicians.
Without these experts’ active collaboration, a clinician could order unnecessary tests or fail to request the most appropriate one. A 2013 study estimated that 20% of tests were overused and approximately 45% of tests were underused (Zhi et al., 2013). Although the tests are less than 5% of a hospital’s total costs, inappropriate use of tests may lead to unnecessary interventions or treatments that may be harmful to the patient, and/or cause a failure to provide appropriate treatment.
Both of these factors are detrimental to the patient but may also lead to longer hospital stays, the cost of which can dwarf the cost of laboratory testing. Successful diagnostic stewardship has been shown to effectively reduce a variety of unnecessary tests, from excessive or redundant daily inpatient laboratory tests to diagnostic imaging (Dik et al., 2017).
As more tests (including RDTs) become available, it becomes more difficult for the clinician to choose the appropriate test without advice from a clinical microbiologist, and more difficult for the laboratory to know which tests to add to their list without specific input from the clinicians and the pharmacy. Information on local prescribing practices and prevalence of specific infections and resistance patterns is also required.
As well as determining which tests are appropriate, diagnostic stewardship also encompasses correctly collecting and managing samples to allow a reliable result that is reported in a timely and effective manner to the clinician, and is interpreted correctly.
Activity 2: Your experience of diagnostic stewardship
Think about the situation in your hospital or healthcare setting.
- Do you think microbiological tests are overused or underused at your facility?
- If you are not sure about this, then if you are a clinician, consider whether you have a full appreciation of all the available tests and their correct use.
- If you are a clinical microbiologist or laboratory scientist, do you have the opportunity to provide your input to the clinicians ordering the tests? Do you have a good knowledge of local patterns of antimicrobial use (AMU), which may include over-the-counter sales outside the hospital, and AMR?
- If you are at the administration or analysis level, do you think the tests available at your site(s) give you all the information you need?
- What simple changes could you make to your practice to ensure that appropriate tests are ordered and the results interpreted correctly?
Discussion
You may feel that tests are being used appropriately, but that other tests are currently unavailable at your hospital laboratory. Some of these tests could be beneficial, and this opportunity is something you could discuss with representatives from clinical, laboratory and pharmacy sectors, together with management and epidemiologists.
You could have suggested that access to the laboratory is important: transportation of specimens may be an issue in a centralised laboratory system.
If you are a clinician, you may think that you are ordering tests because you want to cover all possibilities or because you have always ordered these tests, but that you would benefit from more guidance at this stage from the laboratory.
Perhaps you suggested that a committee could be formed, comprising individuals with the relevant expertise – such as infectious disease clinicians, clinical microbiologists, administrators, pharmacists or epidemiologists– to plan and implement improvements. This is a key requirement in implementing diagnostic stewardship!
1.1 Where does diagnostic stewardship fit in?
