Practice Parameter: Evaluation of distal symmetric polyneuropathy: Role of laboratory and genetic testing (an evidence-based review)

England, J. D.; Gronseth, G. S.; Franklin, Gary M.; Carter, GT; Kinsella, L. J.; Cohen, J.A.; Asbury, A. K.; Szigeti, Kinga; Lupski, J.R.; Latov, Norman; Ra, Lewis; Low, P. A.; Fisher, M. A.; Herrmann, DN; Howard, James F.; Lauria, Giuseppe; Miller, Rupert G.; Polydefkis, Michael; Sumner, A. J.

doi:10.1212/01.wnl.0000336370.51010.a1

Cited by 222 publications

(204 citation statements)

References 40 publications

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“…The American Academy of Neurology (AAN) recently published guidelines for the laboratory evaluation of DSP. 3 Based on a systematic review of the literature, the AAN concluded that the tests providing the highest yield are fasting blood glucose levels, serum B12, associated metabolites (methylmalonic acid and homocysteine), and serum protein electrophoresis. For those with a sensory predominant neuropathy, a glucose tolerance test could be considered.…”

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confidence: 99%

“…5 Despite the recent AAN recommendations and the publication of several clinical approaches to the evaluation of neuropathy, clinicians continue to order a wide variety of laboratory tests. [3][4][5][6][7] In this study, we evaluated the frequency of abnormal thyroid or rheumatologic results in the setting of a diagnosis of peripheral neuropathy. When the tests were abnormal, we assessed the frequency that the test changed the suspected etiology or management.…”

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confidence: 99%

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Value of thyroid and rheumatologic studies in the evaluation of peripheral neuropathy

et al. 2013

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SummaryPeripheral neuropathy is a common disorder, often prompting an extensive initial laboratory evaluation. The initial evaluation is particularly challenging to primary care physicians and neurologists because of the broad differential diagnosis. Although screening thyroid and rheumatologic tests are frequently ordered, the diagnostic yield of these tests is unclear. Data from our institution were collected on patient demographics, clinical characteristics including warning signs suggestive of a diagnosis other than distal symmetric polyneuropathy, history of thyroid or rheumatologic disease, and laboratory tests ordered. Thyroid and rheumatologic screening tests are commonly ordered in the evaluation of peripheral neuropathy. Our findings suggest a low aggregate value of these tests based on low yield and infrequent changes in the suspected etiology or management of these patients. P eripheral neuropathy encompasses a heterogeneous group of disorders, including distal symmetric polyneuropathy, multiple mononeuropathies, and demyelinating neuropathies, among many others. Peripheral neuropathy is a prevalent condition affecting approximately 2% of the general population and as many as 8% of those over the age of 55.1,2 Distal symmetric polyneuropathy (DSP) is the most frequently encountered form of peripheral neuropathy, typically presenting symmetrically in the feet with pain, *These authors contributed equally to this work.

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confidence: 99%

Value of thyroid and rheumatologic studies in the evaluation of peripheral neuropathy

et al. 2013

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“…By comparison, non-neurologists had much lower utilization of MRIs and electrodiagnostic tests, but also had lower utilization of AAN-recommended laboratory tests for neuropathy, 12 and SPEP have been shown to have a substantial yield in neuropathy presentations and abnormal results influence further relevant management including specific treatments. 8,11,12 This result highlights the fact that more testing does not equate with overutilization. Furthermore, the low utilization of AANrecommended tests by all provider types emphasizes the opportunity we have to improve the care of many patients with neuropathy.…”

Section: Test Utilizationmentioning

confidence: 87%

“…While peripheral neuropathy comprises many different subtypes that may affect what constitutes appropriate testing, the vast majority of patients have a distal symmetric polyneuropathy. 8 Recently, the AAN published a systematic review of diagnostic testing in distal symmetric polyneuropathy, and found evidence to support routine testing with serum protein electrophoresis (SPEP), B 12 , fasting glucose test, and glucose tolerance test (GTT). 8 However, the strength of the evidence is modest (Class C), and the review does not address other commonly ordered tests for this condition, including MRIs of the neuroaxis and electrodiagnostic tests.…”

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confidence: 99%

“…8 Recently, the AAN published a systematic review of diagnostic testing in distal symmetric polyneuropathy, and found evidence to support routine testing with serum protein electrophoresis (SPEP), B 12 , fasting glucose test, and glucose tolerance test (GTT). 8 However, the strength of the evidence is modest (Class C), and the review does not address other commonly ordered tests for this condition, including MRIs of the neuroaxis and electrodiagnostic tests. More work is needed to establish what should constitute a clinically effective evaluation of peripheral neuropathy, and efficiency efforts should focus on the high-impact tests that drive expenditures.…”

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Expenditures in the elderly with peripheral neuropathy

et al. 2013

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SummaryTo optimize care in the evaluation of peripheral neuropathy, we sought to define which tests drive expenditures and the role of the provider type. We investigated test utilization and expenditures by provider type in those with incident neuropathy in a nationally representative elderly, Medicare population. Multivariable logistic regression was used to determine predictors of MRI and electrodiagnostic utilization. MRIs of the neuroaxis and electrodiagnostic tests accounted for 88% of total expenditures. Mean and aggregate diagnostic expenditures were higher in those who saw a neurologist. Patients who saw a neurologist were more likely to receive an MRI and an electrodiagnostic test. MRIs and electrodiagnostic tests are the main contributors to expenditures in the evaluation of peripheral neuropathy, and should be the focus of future efficiency efforts.

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Tests and Expenditures in the Initial Evaluation of Peripheral Neuropathy

Callaghan

McCammon

Kerber³

et al. 2012

Arch Intern Med

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Background Peripheral neuropathy is a common disorder in which an extensive evaluation is often unrevealing. We sought to define diagnostic practice patterns as an early step in identifying opportunities to improve efficiency of care. Methods The 1996–2007 Health and Retirement Study (HRS) - Medicare Claims linked database was used to identify individuals with an incident diagnosis of peripheral neuropathy using ICD-9 codes and required no previous neuropathy diagnosis during the preceding 30 months. Focusing on 15 relevant tests, we examined the number and patterns of tests and specific test utilization performed 6 months before and after the incident neuropathy diagnosis. Medicare expenditures were assessed during the baseline, diagnostic, and follow-up periods. Results Of the 12,673 patients, 1,031(8.1%) received a new ICD-9 diagnosis of neuropathy and met our inclusion criteria. Of the 15 tests considered, a median of 4 (inter-quartile range (IQR)=2–5) tests were performed with over 400 patterns of testing. An MRI of the brain and/or spine was ordered in 23.2%, whereas a glucose tolerance test was rarely obtained (1%). Medicare expenditures were significantly higher in the diagnostic period compared to the baseline period (mean $14,363 versus $8,067, p<0.0001). Conclusions Patients diagnosed with peripheral neuropathy typically undergo many tests but testing patterns are highly variable. Almost one-quarter of patients receiving neuropathy diagnoses undergo high-cost, low-yield MRIs while very few receive low-cost, high-yield glucose tolerance tests. Expenditures increase substantially in the diagnostic period. More research is needed to define effective and efficient strategies for the diagnostic evaluation of peripheral neuropathy.

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Practice Parameter: Evaluation of distal symmetric polyneuropathy: Role of laboratory and genetic testing (an evidence-based review)

Abstract: Background: Distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy.

Cited by 222 publications

References 40 publications

Value of thyroid and rheumatologic studies in the evaluation of peripheral neuropathy

Value of thyroid and rheumatologic studies in the evaluation of peripheral neuropathy

Expenditures in the elderly with peripheral neuropathy

Tests and Expenditures in the Initial Evaluation of Peripheral Neuropathy

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