Nondirected testing for inpatients with severe liver injury

WHAT YOU SHOULD DO INSTEAD

In this era of increasing cost-consciousness, nondirected testing has escaped relatively unscathed. Indeed, nondirected testing is prevalent, yet has pitfalls similar to those of serologic testing (eg, vasculitis or arthritis,⁶ acute renal injury, infectious disease¹²). The alternative is deliberate, empirical, patient-centered testing that is attentive to the patient’s presentation and the harms of false positives. The idea is to select tests for each patient with acute liver injury according to presentation and the most likely corresponding diagnoses (Table, Figure).

The “one-stop shopping” in providers’ electronic order entry systems makes it too easy to over-order tests. Fortunately, these systems’ simple and effective decision supports can force pauses in the ordering process, create barriers to waste, and provide education about test characteristics and costs.^4,5,13 Our medical center’s volume of ceruloplasmin orders decreased by 80% after a change was made to its ordering system; the ordering of a ceruloplasmin test is now interrupted by a pop-up screen that displays test characteristics and an option to continue or cancel the order.^4,5 Hospitals should consider implementing clinical decision supports in this area. Successful interventions provide electronic rather than paper-based support as part of the clinical workflow, during the ordering process, and recommendations rather than assessments.¹³

• For each patient with severe acute liver injury, select tests on the basis of the presentation (Figure). Testing for rare diseases should be performed only after common diseases have been excluded.
• Avoid testing for hemochromatosis (iron indices, genetic tests), AAT deficiency (AAT levels or phenotypes), and primary biliary cholangitis (antimitochondrial antibodies) in patients with severe acute liver injury.
• Consider implementing decision supports that can curb nondirected testing in areas in which it is common.

Nondirected testing is associated with false positives and increased costs in the evaluation and management of severe acute liver injury. The alternative is deliberate, epidemiologically and clinically driven directed testing. Electronic ordering system decision supports can be useful in curtailing nondirected testing.

Disclosure

Nothing to report.

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