Inappropriate testing for diarrheal diseases in the hospital
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D L Siegel1, P H Edelstein, I Nachamkin
1Clinical Microbiology Laboratory, Hospital of the University of Pennsylvania, Philadelphia 19104-4283.
Abstract:
To assess the degree to which routine stool cultures, ova and parasite examinations, and Clostridium difficile toxin assays may be inappropriately ordered on hospitalized patients, we conducted a retrospective study to determine the relative yield of these tests on specimens collected from outpatients and inpatients as a function of time after admission. During a 3-year period, only 1 of 191 positive stool cultures and none of the 90 ova and parasite examinations with positive results were from the group of patients who had stool specimens submitted after 3 days of hospitalization. Analysis of laboratory work load for a 1-year period showed that specimens from this patient group contributed nearly 50% of the more than 3000 specimens received each year. In contrast, approximately 25% (range, 17% to 33%) of samples, regardless of admission status, were positive for C difficile toxin. Eliminating routine stool cultures and ova and parasite examinations on hospitalized patients would significantly reduce hospital and patient costs without altering patient care. Nationwide, such a policy might achieve a cost savings of +20 to +30 million per year.
Insights
Routine stool cultures and ova and parasite exams yield few positive results in hospitalized patients after three days. Eliminating these tests can save millions annually without impacting patient care.
Area of Science:
- Clinical Microbiology
- Healthcare Economics
- Infectious Diseases
Background:
- Routine stool cultures, ova and parasite examinations, and Clostridium difficile toxin assays are frequently ordered for hospitalized patients.
- The appropriateness and yield of these diagnostic tests, particularly when ordered late in hospitalization, require evaluation.
Purpose of the Study:
- To assess the diagnostic yield of routine stool cultures, ova and parasite examinations, and C. difficile toxin assays in hospitalized patients.
- To determine the impact of ordering time relative to admission on test results.
- To evaluate the potential cost savings from optimizing the use of these stool tests.
Main Methods:
- Retrospective study analyzing stool specimens from outpatients and inpatients over a 3-year period.
- Laboratory workload analysis over a 1-year period.
- Comparison of positive results for stool cultures, ova and parasite exams, and C. difficile toxin assays based on time of specimen collection post-admission.
Main Results:
- Only 1 of 191 positive stool cultures and none of 90 positive ova and parasite examinations were from patients with specimens submitted after 3 days of hospitalization.
- Specimens from patients hospitalized for over 3 days constituted nearly 50% of the annual laboratory workload for stool testing.
- Clostridium difficile toxin assays showed a consistent positivity rate of approximately 25% across all patient groups.
Conclusions:
- Routine stool cultures and ova and parasite examinations are of low yield for hospitalized patients when ordered more than 3 days after admission.
- Discontinuation of routine stool cultures and ova and parasite examinations for hospitalized patients could lead to significant cost savings (estimated $20-30 million annually) without compromising patient care.
- C. difficile toxin testing demonstrates a more consistent yield and may remain a valuable diagnostic tool.