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Diagnostic stewardship in emergency departments using the UNTIE framework: a stepped-wedge cluster randomised study
Pramod Chandru1, Naren Gunja2,3, Simon Poon4
1Emergency Department, Westmead Hospital, Westmead, New South Wales, Australia pramod.chandru@health.nsw.gov.au.
BMJ Open
|June 16, 2026
Summary
The Unnecessary Tests in Emergency (UNTIE) study evaluated audit and feedback to reduce unnecessary pathology testing in Australian Emergency Departments (EDs). Results are pending, but the study aims to decrease the proportion of tests performed but not recommended.
Area of Science:
- Emergency Medicine
- Health Services Research
- Clinical Pathology
Background:
- Pathology testing constitutes over half of non-labour costs in Australian Emergency Departments (EDs).
- Up to one-fifth of pathology tests ordered in EDs are deemed unnecessary.
- Persistent variation in test ordering exists despite national guidelines from the Australasian College for Emergency Medicine (ACEM) and the Royal College of Pathologists of Australasia (RCPA).
Purpose of the Study:
- To evaluate the effectiveness of an audit and feedback program in reducing unnecessary pathology testing in Australian EDs.
- To assess changes in the proportion of unnecessary tests performed (UNTIE-U) and necessary tests performed (UNTIE-N).
Main Methods:
- A multicentre, stepped-wedge cluster randomised trial conducted across five metropolitan EDs in New South Wales, Australia.
- Inclusion of adult ED presentations within 29 clinical conditions covered by the 2023 ACEM-RCPA guideline.
- Development of a mapping process to align ED triage diagnoses with guideline categories for automated classification of encounters.
- Intervention involved a multifaceted audit-feedback program with local champions, education, visual prompts, and electronic dashboards generating UNTIE-U and UNTIE-N indicators.
Main Results:
- Primary outcome is the change in UNTIE-U (proportion of tests performed but not recommended) before and after intervention.
- Secondary outcome is the change in UNTIE-N (proportion of guideline-recommended tests performed).
- Data analysis will use de-identified data from all eligible ED encounters.
Conclusions:
- The UNTIE study will provide evidence on the efficacy of audit and feedback in reducing unnecessary pathology testing in the ED setting.
- Findings will inform strategies to optimize pathology test utilization and reduce healthcare costs.
- Dissemination of results through peer-reviewed publications, conference presentations, and feedback to participating EDs.
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