To test or not to test? It’s a question that often plagues healthcare professionals as they try to decide which diagnostic procedures are necessary for the treatment of their patients — and those which are not needed, or may even be harmful.
As a slice of society, seniors, and nursing home residents in particular, are some of the most heavily medicated and treated individuals around. That has made judicious use of testing and pharmacy orders more critical than ever, a pair of experts in senior care and diagnostic testing emphasized.
There is no time to waste when it comes to getting better at diagnostic stewardship, said Laurent Adler, MD, CMD, and Sing Palat, MD, CMD,
They discussed the importance of diagnostic stewardship in post-acute and long-term care settings during a recent PALTC24 Summer Encore Series webinar sponsored by AMDA, the Society for Post-Acute and Long-Term Care Medicine.
“Diagnostic stewardship is about ordering the right tests for the right patient at the right time to inform optimal patient care,” said Palat, a medical director with Optum’s senior community care and associate clinical professor at the University of Colorado Division of Geriatrics.
She said diagnostic testing is important for determining the appropriate treatment for different illnesses or ailments. But unnecessary or improper testing can have unintended consequences such as the potential for misdiagnosis of disease and unnecessary antibiotic use. That’s where diagnostic stewardship comes in.
“We know that diagnostic tests impact patient care and these are real impacts that we can feel at the bedside,” she explained. “We want to use the right testing so we can get the right diagnosis and not miss a diagnosis or delay a diagnosis.”
Misdiagnosis often results from excessive and unnecessary culturing, particularly in older patients. A positive test, even one that is likely a false positive, can prompt clinicians to take actions such as starting antibiotics inappropriately or ordering inappropriate medical procedures, according to Adler, who is a senior medical director for Optum’s ISNP Nursing Home Plan in Maryland and Virginia and president-elect of the Georgia chapter of AMDA.
A 2023 quality initiative study of hospitalized older adults in Michigan sought to determine whether diagnostic stewardship (avoiding unnecessary cultures) and antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) reduced unnecessary antibiotic use in older hospitalized patients with asymptomatic bacteriuria (ASB).
Researchers discovered antibiotic use in ASB patients declined from 29% to 17% and the percentage of patients with a positive urine culture who had ASB declined from 34% to 22%
“What they found is that reducing the number of inappropriate cultures performed and reported was more effective at reducing inappropriate treatment for asymptomatic bacteriuria than antibiotic stewardship alone,” Adler said.
Drugs-testing connection
He added that the study highlights the important relationship between diagnostic stewardship and antibiotic stewardship.
“Much of diagnostic stewardship is born from antibiotic stewardship and these two things should go hand-in-hand,” he observed. “We need to integrate diagnostic stewardship into antibiotic stewardship programs.”
Palat said there are three phases of diagnostic stewardship: the pre-analytic (ordering) phase; the analytic (processing lab tests); and post-analytic (interpretation of the results).
Palat said there is a growing need for diagnostic stewardship as more and more tests become available due to new technology and clinicians have to make decisions about appropriate testing. And clinicians need to be aware of potential risks associated with different types of testing. For example, some diagnostic tests may expose patients to radiation or contrast exposure, while even simple blood draws can potentially lead to anemia or bruising.
“Ordering a test often dictates treatment decisions,” she added. “We know that we often order a test to help us to figure out the treatment, but to believe that just ordering a test does not have an impact or can’t harm a patient is not true.”
How providers get better
Adler noted that many resources are available for post-acute and long-term care providers to improve their diagnosis stewardship.
The AMDA Choosing Wisely webpage offers a number of diagnostic testing recommendations for providers to follow to help eliminate unnecessary or potentially harmful testing. Another website, called Testing Wisely, offers a disease risk calculator, educational videos and other evidence-based resources to help providers make more accurate diagnosis and testing decisions.
Several factors are important to the success of diagnostic stewardship interventions in post-acute and long-term care facilities, according to Adler. Diagnostic stewardship interventions cannot be bypassed and should be seamlessly integrated into the workflow of the facility, clinicians should be educated about why the interventions are needed and are evidenced-based, and quality initiatives should measure patient outcomes and the success of the interventions.
“It’s important to recognize that diagnostic stewardship is a joint effort,” Adler pointed out. ”It’s not just a task for the medical director or for the PCP. All team members within the interdisciplinary team need to participate and in fact can lead this effort. The entire interdisciplinary team really needs to be aligned for diagnostic stewardship efforts to be effective.”
