Cessation of Dipstick Urinalysis Reflex Testing and Physician Ordering Behavior

Froom, Paul; Barak, Mira

doi:10.1309/ajcpljfss62ybawn

Cited by 11 publications

(6 citation statements)

References 16 publications

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“…Decreasing the cutoff to > 3 WBC/HPF increased sensitivity but still resulted in an increased number of bacteremic UTI patients with negative test results. Reflex microscopic testing after a positive dipstick test result is still a common practice [ 17 ], but our results support others who have stopped reflex microscopic examination in outpatients [ 18 , 19 ] and inpatients [ 19 ] only done by physician request. On the other hand, there might be a role for microscopic examination in those with a negative dipstick in order to increase sensitivity.…”

Section: Discussionsupporting

confidence: 86%

Sensitivity of the dipstick in detecting bacteremic urinary tract infections in elderly hospitalized patients

et al. 2017

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BackgroundThe sensitivity of the dipstick in elderly patients with a suspected urinary tract infection (UTI) is unclear because of the inclusion of patients with urine contamination or asymptomatic bacteriuria in previous studies.MethodsWe selected consecutive patients aged 65 years or older hospitalized in internal medicine departments with bacteremic UTI (same organism in blood and urine cultures) minimizing misclassifications. The false positive rate was determined in consecutive patients with negative culture results. A positive dipstick was a test result with a trace leukocyte esterase and/or nitrite positivity. Bacteriuria was the growth of at least 105 colony-forming units per milliliter of urine.ResultsOf 20,555 consecutive patients, 228 had a bacteremic UTI, and 4069 a negative culture result. The sensitivity of the dipstick was 96.9% (95% CI—93.7–98.6) with a false positive rate of 42.4% (95% CI, 41.0–43.8) in those with a negative culture result.ConclusionsIn elderly hospitalized patients with a bacteremic UTI, the dipstick urinalysis is highly sensitive, much higher than reported previously in studies of UTIs in the elderly. It is unclear whether the observed high sensitivity of the dipstick was due to the exclusion of patients with asymptomatic bacteriuria or to spectrum bias. Studies of the clinical utility/disutility of using a negative dipstick to rule out a urinary tract infection are warranted.

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Section: Discussionsupporting

confidence: 86%

Sensitivity of the dipstick in detecting bacteremic urinary tract infections in elderly hospitalized patients

et al. 2017

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“…The studies that reported data included collectively 4111 physicians and 175 563 patients (2 studies did not report the number of physicians, 34,35 and 8 studies did not report the number of patients, 20,22,23,28 –30,32 –34,35 and those numbers were also not available in related papers). There were 20 studies 36 –55 in which outcomes for family physicians were not separable from those of other professional groups, and these were excluded from this review.…”

Section: Resultsmentioning

confidence: 99%

Interventions to Educate Family Physicians to Change Test Ordering

2016

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The purpose is to systematically review randomised controlled trials (RCTs) to change family physicians’ laboratory test-ordering. We searched 15 electronic databases (no language/date limitations). We identified 29 RCTs (4,111 physicians, 175,563 patients). Six studies specifically focused on reducing unnecessary tests, 23 on increasing screening tests. Using Cochrane methodology 48.5% of studies were low risk-of-bias for randomisation, 7% concealment of randomisation, 17% blinding of participants/personnel, 21% blinding outcome assessors, 27.5% attrition, 93% selective reporting. Only six studies were low risk for both randomisation and attrition. Twelve studies performed a power computation, three an intention-to-treat analysis and 13 statistically controlled clustering. Unweighted averages were computed to compare intervention/control groups for tests assessed by >5 studies. The results were that fourteen studies assessed lipids (average 10% more tests than control), 14 diabetes (average 8% > control), 5 cervical smears, 2 INR, one each thyroid, fecal occult-blood, cotinine, throat-swabs, testing after prescribing, and urine-cultures. Six studies aimed to decrease test groups (average decrease 18%), and two to increase test groups. Intervention strategies: one study used education (no change): two feedback (one 5% increase, one 27% desired decrease); eight education + feedback (average increase in desired direction >control 4.9%), ten system change (average increase 14.9%), one system change + feedback (increases 5-44%), three education + system change (average increase 6%), three education + system change + feedback (average 7.7% increase), one delayed testing. The conclusions are that only six RCTs were assessed at low risk of bias from both randomisation and attrition. Nevertheless, despite methodological shortcomings studies that found large changes (e.g. >20%) probably obtained real change.

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“…With all but one purely educational interventions having a time horizon of < 1 year there is no evidence in our review that educational strategies have long-term sustainability. In contrast there are several examples of system-based interventions which by definition require few resources to maintain, that are shown to maintain their effect for > 1 year [14,47,53]. The ratio of resource input to test reduction is not measured in the included studies but is an important consideration when deciding to implement a particular intervention.…”

Section: Sustainabilitymentioning

confidence: 99%

Influence of educational, audit and feedback, system based, and incentive and penalty interventions to reduce laboratory test utilization: a systematic review

Kobewka¹,

Ronksley

McKay

et al. 2015

Clinical Chemistry and Laboratory Medicine (CCLM)

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Laboratory and radiographic tests are often ordered unnecessarily. This excess testing has financial costs and is a burden on patients. We performed a systematic review to determine the effectiveness interventions to reduce test utilization by physicians. The MEDLINE and EMBASE databases were searched for the years 1946 through to September 2013 for English articles that had themes of test utilization and cost containment or optimization. Bibliographies of included papers were scanned to identify other potentially relevant studies. Our search resulted in 3236 articles of which 109 met the inclusion criteria of having an intervention aimed at reducing test utilization with results that could be expressed as a percent reduction in test use relative to the comparator. Each intervention was categorized into one or more non-exclusive category of education, audit and feedback, system based, or incentive or penalty. A rating of study quality was also performed. The percent reductions in test use ranged from a 99.7% reduction to a 27.7% increase in test use. Each category of intervention was effective in reducing test utilization. Heterogeneity between interventions, poor study quality, and limited time horizons makes generalizations difficult and calls into question the validity of results. Very few studies measure any patient safety or quality of care outcomes affected by reduced test use. There are numerous studies that use low investment strategies to reduce test utilization with one time changes in the ordering system. These low investment strategies are the most promising for achievable and durable reductions in inappropriate test use.

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Cessation of Dipstick Urinalysis Reflex Testing and Physician Ordering Behavior

Cited by 11 publications

References 16 publications

Sensitivity of the dipstick in detecting bacteremic urinary tract infections in elderly hospitalized patients

Sensitivity of the dipstick in detecting bacteremic urinary tract infections in elderly hospitalized patients

Interventions to Educate Family Physicians to Change Test Ordering

Influence of educational, audit and feedback, system based, and incentive and penalty interventions to reduce laboratory test utilization: a systematic review

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