ASCP tackles hepatitis C, stool pathogens, and more in new test guidelines

2019 09 05 16 02 0532 Hospital Lobby Busy 400

The American Society for Clinical Pathology (ASCP) has released five new recommendations for appropriate lab test ordering, including advice against repeat hepatitis C virus (HCV) testing and testing for community-acquired gastrointestinal pathogens in stool in hospitalized patients.

The society shared the guidelines ahead of its annual meeting, scheduled for September 11-13 in Phoenix. The recommendations are part of the Choosing Wisely program, an initiative of the American Board of Internal Medicine (ABIM) Foundation designed to ensure evidence-based medicine and foster dialogue about tests and treatments. The ASCP is one of 70 medical specialty associations that have published recommendations about tests and treatments as part of the initiative.

As of September, the ASCP has published a total of 30 recommendations for lab tests that it feels are commonly performed even though they offer no benefit or are harmful; the society believes the tests should be questioned by physicians and patients. The five recommendations just added are as follows:

  • Do not routinely test for community-acquired gastrointestinal stool pathogens in hospitalized patients who develop diarrhea after day 3 of hospitalization. Instead, consider a test for Clostridioides difficile.
  • Do not repeat hepatitis C virus antibody testing in patients who previously tested positive. Instead, if reinfection is suspected, order a test for hepatitis C viral load as a guide to the severity and activity of disease. HCV genotyping is often needed to guide treatment decisions.
  • Do not perform a hypercoagulable workup in patients taking direct factor Xa or direct thrombin inhibitors. Direct oral anticoagulants, such as dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis), often interfere with clot-based or chromogenic coagulation assays and may lead to inaccurate results.
  • Don't use plasma catecholamines to evaluate a patient for pheochromocytoma or paraganglioma. Recommended first-line testing is either plasma free metanephrines or urinary fractionated metanephrines. Laboratories have found that, at times, there is confusion in the workup of these patients, according to the ASCP.
  • Do not routinely order broad respiratory pathogen panels unless the result will affect patient management. As a first step, test for commonly suspected pathogens, such as respiratory syncytial virus and influenza. Rapid tests may be laboratory-based or point-of-care, depending on operational needs.

Insurance tie-in holds weight

Previously published recommendations advised against population-based screening for vitamin D deficiency and against low-risk HPV screening.

There are multiple ways of getting the word out about recommendations, including publication by the ABIM and by distributing patient information brochures for high-profile tests. Insurance companies also sometimes incorporate the criteria when making coverage policies -- that was the case with vitamin D testing, commented Dr. Lee Hilborne, chair of the ASCP Effective Test Utilization Steering Committee. Compliance improves when recommendations are incorporated into insurance company policies, he added.

"They obviously get more traction when they are tied to something like that," Hilborne said in an interview.

The ASCP also approaches payors and asks them about their areas of concern, he said.

Generally, at least one-third of tests are not appropriate: They are duplicate tests or the wrong ones. The recommendations are based on medical necessity, and underuse and overuse are problematic, he said.

The society is concerned about people getting tests they don't need, but of equal concern is people not getting tests they do need, said Hilborne, who is a professor of pathology and laboratory medicine at the David Geffen School of Medicine at the University of California, Los Angeles.

Commenting on the new batch of recommendations, Hilborne noted that it's important to ensure an appropriate diagnosis after the detection of a hepatitis C antibody now that treatments are available. More focused testing is needed to assess the extent of disease and treatment response, after an antibody that persists for life is detected, he explained.

Laboratory stewardship is a big theme of this year's ASCP meeting. Sessions on the topic include a lecture at 8 a.m. on Wednesday, September 11, about grassroots approaches to developing a stewardship program. The new Choosing Wisely recommendations will be discussed during a 2:40 p.m. session the same day, along with awards for clinicians who have helped improve the appropriateness of test utilization.

At 11:30 a.m. on Thursday, September 12, the society will host an interactive panel debate about test utilization. Thursday will also include a 3 p.m. session on the use of checklists in laboratory stewardship to improve performance and payment.

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