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Reducing the use of coagulation test panels
Timothy K Amukele1, Geoffrey S Baird, Wayne L Chandler
1Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Insights
Coagulation panels were frequently overused and often not clinically indicated. Restricting test ordering, rather than education, effectively reduced unnecessary testing for prothrombin time (PT), partial thromboplastin time (PTT), thrombin time (TT), and fibrinogen.
Area of Science:
- Clinical Pathology
- Laboratory Medicine
- Healthcare Management
Background:
- Coagulation panels (PT, PTT, TT, fibrinogen) are crucial for bleeding evaluation but showed a significant increase in utilization.
- The rise in testing volume outpaced increases in admissions, surgeries, or transfusions, suggesting potential overuse.
Purpose of the Study:
- To assess the clinical appropriateness of coagulation panel orders.
- To identify factors contributing to inappropriate test ordering and evaluate interventions to optimize utilization.
Main Methods:
- Retrospective analysis of 28,737 coagulation panel results.
- Chart reviews to determine patient histories and clinical indications.
- Classification of results based on PT, PTT, TT, and fibrinogen levels.
- Interviews with clinicians to understand ordering practices and awareness.
Main Results:
- Only 8% of panel orders were clinically indicated.
- Normal PT/PTT occurred in 39% of panels; prolonged PT was often due to warfarin or vitamin K deficiency.
- Prolonged PTT was associated with PT or lupus inhibitors; prolonged PTT/TT indicated heparin therapy.
- Low or critical fibrinogen levels were rare but strongly associated with bleeding.
- An educational program had no impact; a change in order form to separate TT/fibrinogen reduced their testing by 90%.
Conclusions:
- A significant proportion of coagulation panel orders were not clinically justified.
- Prothrombin time (PT) testing more frequently identified vitamin K deficiency than bleeding risk.
- Order-based restrictions are more effective than educational interventions for optimizing clinical test utilization.
Abstract:
Use of a coagulation panel [prothrombin time (PT), partial thromboplastin time (PTT), thrombin time (TT) and fibrinogen], intended for evaluation of bleeding, tripled over 6 years, out of proportion to admissions, surgery, or transfusions. To determine whether the panels were ordered appropriately, we classified 28,737 sets of panel results into groups followed by chart reviews to determine typical patient histories. In 39% of panels, PT/PTT was normal. Prolonged PT occurred in 33% of results, due to liver failure (8%), warfarin (23%), and presumed vitamin K deficiency (69%). Prolonged PTT occurred in 34% of results and was primarily associated with long PT or lupus inhibitors. Prolonged PTT and TT (15% of panels) indicated heparin therapy. Fibrinogen was normal in 98% and low in 1.4%. Critical fibrinogen (below 100 mg/dl, 0.6% of panels) was associated with bleeding in 90% of patients. Only 8% of panel orders were clinically indicated based on patient history. Clinician interviews indicated many were unaware the panel included fibrinogen and TT. Interventions included an education program and an order form change. The education program had no effect on overall order volume or test selection. A later order form change made TT and fibrinogen a separate order. This reduced TT and fibrinogen testing by 90% without complaints or changes in blood transfusion statistics. We conclude that many coagulation test panel orders were not clinically indicated, that PT more often diagnosed vitamin K deficiency than bleeding risk, and that order-based restriction of testing was more effective than educational programs at introducing change in clinical test utilization.
