Bolles Kathryn, Woc-Colburn Laila, Hamill Richard J, Hemmige Vagish
Department of Medicine, University of Washington, Seattle, Washington.
Division of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas.
Open Forum Infect Dis. 2019 Mar 29;6(6):ofz158. doi: 10.1093/ofid/ofz158. eCollection 2019 Jun.
Inpatient HIV care often requires specialized laboratory testing with which practitioners may not be familiar. In addition, computerized physician order entry allows for ordering tests without understanding test indications, but it can also provide a venue for education and diagnostic stewardship.
All charts of HIV-positive patients hospitalized at a tertiary care public safety net hospital in Houston, Texas, between January 1, 2014, and June 30, 2014, were reviewed for a set list of laboratory tests. Appropriateness of test ordering was assessed by 2 providers. Cost estimates for each test were obtained from Medicaid and a national nonprofit health care charge database.
A total of 274 HIV-positive patients were admitted 429 times in the 6-month study period. During the study period, 45% of the study laboratory tests ordered were not indicated. A total of 532 hepatitis serologies were ordered, only 52% of which were indicated. Overall, 71 serum qualitative cytomegalovirus (CMV) polymerase chain reactions (PCRs) and eight CMV quantitative PCRs were ordered, with most (85%) qualitative PCRs ordered for nonspecific signs of infection (eg, fever). Other tests ordered without clear indications included IgE (7), serum Epstein-Barr virus (EBV) PCR (5), parvovirus serology (7), and IgM (18). Overall, the estimated laboratory cost of inappropriate testing over the study period was between $14 000 and $92 000, depending on which cost database was used.
Many tests ordered in HIV-positive inpatients do not have indications, representing a substantial source of health care waste and cost and potentially leading to inappropriate treatment. Opportunities exist to decrease waste through education of trainees and hospitalists and through implementation of diagnostic stewardship via the electronic medical record.
住院艾滋病毒护理通常需要进行一些从业者可能并不熟悉的专门实验室检测。此外，计算机化医嘱录入系统使得在不了解检测指征的情况下也能开出检测项目，但它也能提供一个教育和诊断管理的平台。
回顾了2014年1月1日至2014年6月30日期间在德克萨斯州休斯顿一家三级医疗公共安全网医院住院的艾滋病毒阳性患者的所有病历，以获取一份实验室检测项目清单。由两名医疗服务提供者评估检测项目开具的合理性。每项检测的成本估算来自医疗补助计划和一个全国性非营利性医疗费用数据库。
在为期6个月的研究期间，共有274名艾滋病毒阳性患者入院429次。在研究期间，所开具的研究实验室检测项目中有45%并无指征。总共开出了532项肝炎血清学检测，其中仅有52%有指征。总体而言，开出了71项血清定性巨细胞病毒（CMV）聚合酶链反应（PCR）检测和8项CMV定量PCR检测，大多数（85%）定性PCR检测是针对非特异性感染体征（如发热）开出的。其他无明确指征而开出的检测项目包括IgE（7项）、血清爱泼斯坦-巴尔病毒（EBV）PCR（5项）、细小病毒血清学检测（7项）和IgM（18项）。总体而言，根据所使用的成本数据库不同，研究期间不适当检测的估计实验室成本在14,000美元至92,000美元之间。
艾滋病毒阳性住院患者所开具的许多检测并无指征，这是医疗保健浪费和成本的一个重要来源，还可能导致不适当的治疗。通过对实习医生和住院医生进行教育以及通过电子病历实施诊断管理，存在减少浪费的机会。
