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Employing a results-based algorithm to reduce laboratory utilization in ACTH stimulation testing.

Ryan J McDonough1,2,3, Patria Alba4, Kavitha Dileepan1,3

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This summary is machine-generated.

A new algorithm for the High Dose Adrenocorticotropic Hormone (ACTH) Stimulation Test significantly reduced lab utilization. This method efficiently diagnoses adrenal insufficiency by analyzing cortisol levels strategically, improving efficiency in clinical practice.

Keywords:
laboratory utilizationquality improvementstimulation testing

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Area of Science:

  • Endocrinology
  • Clinical Chemistry
  • Health Informatics

Background:

  • The High Dose Adrenocorticotropic Hormone (ACTH) Stimulation Test is the standard for diagnosing adrenal insufficiency.
  • A peak cortisol response of ≥18 μg/dL post-cosyntropin stimulation indicates normal adrenal function.
  • Current practice involves measuring cortisol at 0, 30, and 60 minutes, with diminishing utility after a normal result is achieved.

Purpose of the Study:

  • To decrease laboratory utilization by developing a results-based algorithm within the electronic medical record (EMR).
  • To optimize the diagnostic process for adrenal insufficiency while reducing unnecessary testing.

Main Methods:

  • Developed an EMR-integrated algorithm to guide cortisol level analysis.
  • Cortisol levels were initially measured at 0 and 60 minutes post-stimulation.
  • An EMR rule automatically ordered the 30-minute sample analysis only if the 60-minute cortisol level was subnormal.

Main Results:

  • Prior to the algorithm, only 8% of tests excluded adrenal insufficiency using a single stimulated cortisol level.
  • Following algorithm implementation and iterative improvements (plan-do-study-act cycles), 99% of normal tests were accurately identified using only one stimulated cortisol level.
  • Significant reduction in overall laboratory utilization was achieved.

Conclusions:

  • The laboratory-based algorithm effectively reduced unnecessary testing and aligned practice with Pediatric Endocrine Society recommendations.
  • This approach demonstrates the potential for similar algorithms to decrease laboratory utilization for other dynamic endocrine tests.
  • Optimized diagnostic protocols can lead to substantial cost savings and improved healthcare efficiency.