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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.

Blood Coagulation & Fibrinolysis : an International Journal in Haemostasis and Thrombosis
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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.

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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.