Several reflexively ordered tests for evaluation and management of chronic kidney disease (CKD) may be unnecessary, according to a research letter published online March 2 in JAMA Internal Medicine. Specifically, the researchers found that serum protein electrophoresis and screening for antinuclear antibody, C3, C4, hepatitis C, hepatitis B, and antineutrophil cytoplasmic antibody were commonly ordered, but test results failed to inform CKD diagnosis or management. The researchers retrospectively reviewed the electronic medical records of 1,487 patients referred for initial evaluation of CKD at nephrology clinics affiliated with Brigham and Women’s Hospital and Massachusetts General Hospital (Boston) from 2010 to 2013. Nephrology progress notes were assessed to ascertain whether a test (regardless of positive or negative results) affected diagnosis and/or management of CKD. The most frequent tests included measurement of calcium (94.8 percent), hemoglobin (84.0 percent), phosphate (83.5 percent), urine sediment (74.8 percent), and parathyroid hormone (74.1 percent) levels; urine dipstick for blood (69.9 percent) and protein (69.7 percent); serum protein electrophoresis (68.1 percent); and renal ultrasonography (67.7 percent). Tests with relatively high diagnostic yields included: hemoglobinA1c level (15.4 percent), urine total protein to creatinine ratio (14.1 percent), and urine microalbumin to creatinine ratio (13.0 percent). Those three tests also had […]
Several reflexively ordered tests for evaluation and management of chronic kidney disease (CKD) may be unnecessary, according to a research letter published online March 2 in JAMA Internal Medicine. Specifically, the researchers found that serum protein electrophoresis and screening for antinuclear antibody, C3, C4, hepatitis C, hepatitis B, and antineutrophil cytoplasmic antibody were commonly ordered, but test results failed to inform CKD diagnosis or management.
The researchers retrospectively reviewed the electronic medical records of 1,487 patients referred for initial evaluation of CKD at nephrology clinics affiliated with Brigham and Women’s Hospital and Massachusetts General Hospital (Boston) from 2010 to 2013. Nephrology progress notes were assessed to ascertain whether a test (regardless of positive or negative results) affected diagnosis and/or management of CKD.
The most frequent tests included measurement of calcium (94.8 percent), hemoglobin (84.0 percent), phosphate (83.5 percent), urine sediment (74.8 percent), and parathyroid hormone (74.1 percent) levels; urine dipstick for blood (69.9 percent) and protein (69.7 percent); serum protein electrophoresis (68.1 percent); and renal ultrasonography (67.7 percent).
Tests with relatively high diagnostic yields included: hemoglobinA1c level (15.4 percent), urine total protein to creatinine ratio (14.1 percent), and urine microalbumin to creatinine ratio (13.0 percent). Those three tests also had relatively high yields affecting patient management in 10.1 percent, 13.7 percent, and 13.3 percent, respectively. While commonly performed, serum protein electrophoresis and renal ultrasonography had much lower yields, affecting diagnosis in 1.4 percent and 5.9 percent of cases and management in 1.7 percent and 3.3 percent of the patients, respectively. Tests for antineutrophil cytoplasmic antibody and antiglomerular basement membrane antibody did not affect the diagnosis or management of any patients. Screening for antinuclear antibody (for complement proteins C3, C4) occurred in nearly one-quarter of patients, yet affected diagnosis in just over 1 percent of cases.
“Further investigation incorporating community-based patients and identifying subgroups benefiting from more extensive evaluation is needed. However, this study suggests that reflexively ordering several tests for CKD evaluation and management may be unnecessary,” write the authors led by Mallika Mendu, M.D., from Harvard Medical School in Boston. “An evidence-based, targeted approach based on pretest probabilities of disease for diagnosis and management may be more efficient and reduce costs.”
