Overutilization and underutilization of autoantibody tests in patients with suspected autoimmune disorders
-
Rajkumar Rajendran
,
Jose H. Salazar
Abstract
Objectives
Diagnostic Management Teams (DMTs) are one strategy for reducing diagnostic errors. This study examined errors in serology test selection after a positive antinuclear antibody (ANA) test in patients with suspected systemic autoimmune rheumatic disorder (SARD).
Methods
This retrospective study included 246 patient cases reviewed by our ANA DMT from March to August 2019. The DMT evaluated the appropriateness of tests beyond ANA screening tests (overutilization, underutilization, or both) based on American College of Rheumatology recommendations and classified cases into diagnostic error or no error groups. Errors were quantified, and patient and provider characteristics associated with diagnostic errors were assessed.
Results
Among 246 cases, 60.6% had at least one diagnostic error in test selection. The number of sub-serology tests ordered was 2.4 times higher in the diagnostic error group than in the no error group. The likelihood of at least one diagnostic error was higher in males and African American/Black patients, although the differences were not statistically significant. Providers from general internal medicine, primary care, and non-rheumatology specialties were approximately two times more likely to make diagnostic errors than rheumatology specialists.
Conclusions
Diagnostic errors in test selection after a positive ANA for patients with suspected SARD were common, although there were fewer errors when ordered by rheumatology specialists. These findings support the need to develop strategies to reduce diagnostic errors in test selection for autoimmunity evaluation and suggest that implementation of a DMT can be useful for providing guidance to clinicians to reduce overutilization and underutilization of laboratory tests.
Acknowledgments
We would like to thank Dr. Mayukh Sarkar (Hematology), Kimberly Bufton (Microbiology/Serology), Dr. Hila Shaim, Dr. Alexandra Rapp, Dr. Emma Henrie, and all pathology residents rotating through the Microbiology service at UTMB for their assistance in conducting this study.
-
Research funding: None declared.
-
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
-
Competing interests: Authors state no conflict of interest.
-
Ethical approval: The UTMB Institutional Review Board (IRB) designated the study as a quality assessment/quality improvement project. Therefore, it did not require IRB approval or oversight, participant consent forms, or specific actions to prevent and minimize risks or discomforts.
References
1. National Institute of Environmental Health Sciences. Autoimmune diseases. Available from: https://www.niehs.nih.gov/health/topics/conditions/autoimmune/index.cfm [Accessed 18 Dec 2020].Search in Google Scholar
2. Walsh, JS, Rau, ML. Autoimmune diseases: a leading cause of death among young and middle-aged women in the United States. Am J Publ Health 2000;90:1463–6.10.2105/AJPH.90.9.1463Search in Google Scholar
3. Cooper, SG, Stroehla, CB. The epidemiology of autoimmune diseases. Autoimmun Rev 2003;2:119–25. https://doi.org/10.1016/s1568-9972(03)00006-5.Search in Google Scholar
4. American Autoimmune Related Diseases Association and National Coalition of Autoimmune Patient Groups. The cost burden of autoimmune disease: the latest front in the war on healthcare spending. Available from: http://www.diabetesed.net/page/_files/autoimmune-diseases.pdf [Accessed 20 Dec 2020].Search in Google Scholar
5. Singh, H, Graber, ML, Hofer, TP. Measures to improve diagnostic safety in clinical practice. J Patient Saf 2019;15:311–6. https://doi.org/10.1097/pts.0000000000000338.Search in Google Scholar
6. The National Academies of Sciences. Engineering, and Medicine. Improving diagnosis in health care. Available from: https://www.ncbi.nlm.nih.gov/books/NBK338594/#sec_000059 [Accessed 19 Dec 2020].Search in Google Scholar
7. Graber, ML, Franklin, N, Gordon, R. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493–9. https://doi.org/10.1001/archinte.165.13.1493.Search in Google Scholar PubMed
8. Laposata, EM, Laposata, M, Van Cott, ME, Buchner, SD, Kashalo, SM, Dighe, SA. Physician survey of a laboratory medicine interpretive service and evaluation of the influence of interpretations on laboratory test ordering. Arch Pathol Lab Med 2004;128:1424–7. https://doi.org/10.5858/2004-128-1424-psoalm.Search in Google Scholar
9. Sarkar, KM, Botz, MC, Laposata, M. An assessment of overutilization and underutilization of laboratory tests by expert physicians in the evaluation of patients for bleeding and thrombotic disorders in clinical context and in real time. Diagnosis 2017;4:21–6. https://doi.org/10.1515/dx-2016-0042.Search in Google Scholar PubMed
10. Plebani, M, Laposata, M, Lippi, G. Driving the route of laboratory medicine: a manifesto for the future. Intern Emerg Med 2019;14:337–40. https://doi.org/10.1007/s11739-019-02053-z.Search in Google Scholar PubMed
11. Yazdany, J, Schmajuk, G, Robbins, M, Dakin, D, Beall, A, Yelin, E, et al.. Choosing Wisely: the American College of Rheumatology’s top 5 list of things physicians and patients should question. Arthritis Care Res 2013;65:329–39. https://doi.org/10.1002/acr.21930.Search in Google Scholar PubMed PubMed Central
12. Singh, H, Meyer, AN, Thomas, EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf 2014;23:727–31. https://doi.org/10.1136/bmjqs-2013-002627.Search in Google Scholar PubMed PubMed Central
13. Covera Health. The prevalence and impact of medical misdiagnosis, in radiology and beyond. Available from: https://www.celent.com/system/media_documents/documents/791/931/163/original/457013805.pdf?1583964156 [Accessed 22 Dec 2020].Search in Google Scholar
14. Wahed, A, Rodriguez, J, Nguyen, A, Dasgupta, A, Segal, G. Overutilization of test for hemoglobinopathy evaluation: experience from a tertiary care academic medical center. Ann Clin Lab Sci 2019;49:400–2.Search in Google Scholar
15. CAP Today. The what and why of diagnostic management teams. Available from: https://www.captodayonline.com/diagnostic-management-teams/ [Accessed 21 Dec 2020].Search in Google Scholar
16. Laposata, M. How can a diagnostic management team improve patient care and save money? Long-standing and rapidly worsening problem of obtaining an accurate diagnosis quickly. Available from: https://www.aacc.org/science-and-research/scientific-shorts/2014/how-can-a-diagnostic-management-team-improve-patient-care-and-save-money [Accessed 19 Dec 2020].Search in Google Scholar
17. Suarez-Almazor, ME, Gonzalez-Lopez, L, Gamez-Nava, JI, Belseck, E, Kendall, CJ, Davis, P. Utilization and predictive value of laboratory tests in patients referred to rheumatologists by primary care physicians. J Rheumatol 1998;25:1980–5.Search in Google Scholar
18. Iturrate, E, Jubelt, L, Volpicelli, F, Hochman, K. Optimize your electronic medical record to increase value: reducing laboratory overutilization. Am J Med 2016;129:215–20. https://doi.org/10.1016/j.amjmed.2015.09.009.Search in Google Scholar PubMed
19. Hans, H, Liang, T, Zubieta, AJ, De Vera, AM. How do patients with systemic autoimmune rheumatic disease perceive the use of their medications: a systemic and thematic synthesis of qualitative research? BMC Rheumatol 2018;2:9.10.1186/s41927-018-0017-8Search in Google Scholar
20. Patarroyo, MJ, Rodriguez, A, Ortiz, MG. How does age at onset influence the outcome of autoimmune diseases? Autoimmune Dis 2012;2012:251730.10.1155/2012/251730Search in Google Scholar
21. Ballou, SP, Khan, MA, Kushner, I. Clinical features of systemic lupus erythematosus. Arthritis Rheum 1982;25:55–60. https://doi.org/10.1002/art.1780250109.Search in Google Scholar
22. Deal, CL, Meenan, RF, Goldenberg, DL. The clinical features of elderly-onset rheumatoid arthritis. A comparison with younger-onset disease of similar duration. Arthritis Rheum 1985;28:987–94. https://doi.org/10.1002/art.1780280905.Search in Google Scholar
23. Ghezzi, A. Clinical characteristics of multiple sclerosis with early onset. Neurol Sci 2004;25(4 Suppl):S336–9. https://doi.org/10.1007/s10072-004-0336-y.Search in Google Scholar
24. Venables, PJW. Sjögren’s syndrome. Best Pract Res Clin Rheumatol 2004;18:313–29. https://doi.org/10.1016/s1521-6942(04)00036-1.Search in Google Scholar
25. Fairweather, D, Rose, NR. Women and autoimmune diseases. Emerg Infect Dis 2004;10:2005–11. https://doi.org/10.3201/eid1011.040367.Search in Google Scholar PubMed PubMed Central
26. The American Society for Clinical Laboratory Sciences. Patient safety matters. Available from: https://www.ascls.org/patient-safety-in-laboratory-medicine-matters [Accessed 18 Aug 2020].Search in Google Scholar
27. Turner, JB, Laine, C. Differences between generalists and specialists: knowledge realism or primum non nocere? J Gen Intern Med 2001;16:422–4. https://doi.org/10.1046/j.1525-1497.2001.016006422.x.Search in Google Scholar PubMed PubMed Central
28. Laposata, M. Obtaining a correct diagnosis rapidly in the United States is associated with many barriers not present in other countries. Am J Clin Pathol 2018;149:458–60. https://doi.org/10.1093/ajcp/aqy010.Search in Google Scholar PubMed
29. Laposata, M, Cohen, MB. It’s our turn: implications for pathology from the institute of medicine’s report on diagnostic error. Arch Pathol Lab Med 2016;140:505–7. https://doi.org/10.5858/arpa.2015-0499-ed.Search in Google Scholar PubMed
30. Battafarano, DF, Ditmyer, M, Bolster, BM, Fitzgerald, DJ, Deal, C, Bass, RA, et al.. American college of rheumatology workforce study: supply and demand projections of adult rheumatology workforce, 2015–2030. Arthritis Care Res 2018;70:617–26.10.1002/acr.23518Search in Google Scholar PubMed
© 2021 Walter de Gruyter GmbH, Berlin/Boston
Articles in the same Issue
- Frontmatter
- Reviews
- An overview of mental health during the COVID-19 pandemic
- Potential mechanisms of action of convalescent plasma in COVID-19
- Mini Review
- Gap of knowledge in diagnosis of pyoderma gangrenosum in clinical specialties education
- Opinion Papers
- Learning clinical reasoning from the fictional detectives
- Integrating infection and sepsis management through holistic early warning systems and heuristic approaches: a concept proposal
- (F)utility of urine Bence Jones proteins for “routine” screening for plasma cell dyscrasia
- COVID-19 and the Le Chatelier’s principle
- Original Articles
- Are sniffer dogs a reliable approach for diagnosing SARS-CoV-2 infection?
- Using body temperature and variables commonly available in the EHR to predict acute infection: a proof-of-concept study showing improved pretest probability estimates for acute COVID-19 infection among discharged emergency department patients
- Identifying children at high risk for infection-related decompensation using a predictive emergency department-based electronic assessment tool
- Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology
- Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology in an integrated health system
- Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study
- Overutilization and underutilization of autoantibody tests in patients with suspected autoimmune disorders
- Postnatal ultrasound follow-up in neonates with prenatal hydronephrosis
- Clinical performance of amperometry compared with enzymatic ultra violet method for lactate quantification in cerebrospinal fluid
- Case Report – Lessons in Clinical Reasoning
- Lessons in clinical reasoning – pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error
- Case Report
- The COVID trap: pediatric diagnostic errors in a pandemic world
- Letters to the Editor
- Atrial arrhythmia and its association with COVID-19 outcome: a pooled analysis
- Serious game training in medical education: potential to mitigate cognitive biases of healthcare professionals
- Revisiting handoffs: an opportunity to prevent error
Articles in the same Issue
- Frontmatter
- Reviews
- An overview of mental health during the COVID-19 pandemic
- Potential mechanisms of action of convalescent plasma in COVID-19
- Mini Review
- Gap of knowledge in diagnosis of pyoderma gangrenosum in clinical specialties education
- Opinion Papers
- Learning clinical reasoning from the fictional detectives
- Integrating infection and sepsis management through holistic early warning systems and heuristic approaches: a concept proposal
- (F)utility of urine Bence Jones proteins for “routine” screening for plasma cell dyscrasia
- COVID-19 and the Le Chatelier’s principle
- Original Articles
- Are sniffer dogs a reliable approach for diagnosing SARS-CoV-2 infection?
- Using body temperature and variables commonly available in the EHR to predict acute infection: a proof-of-concept study showing improved pretest probability estimates for acute COVID-19 infection among discharged emergency department patients
- Identifying children at high risk for infection-related decompensation using a predictive emergency department-based electronic assessment tool
- Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology
- Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology in an integrated health system
- Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study
- Overutilization and underutilization of autoantibody tests in patients with suspected autoimmune disorders
- Postnatal ultrasound follow-up in neonates with prenatal hydronephrosis
- Clinical performance of amperometry compared with enzymatic ultra violet method for lactate quantification in cerebrospinal fluid
- Case Report – Lessons in Clinical Reasoning
- Lessons in clinical reasoning – pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error
- Case Report
- The COVID trap: pediatric diagnostic errors in a pandemic world
- Letters to the Editor
- Atrial arrhythmia and its association with COVID-19 outcome: a pooled analysis
- Serious game training in medical education: potential to mitigate cognitive biases of healthcare professionals
- Revisiting handoffs: an opportunity to prevent error
