Researchers focused on whether different ways of reporting clinical laboratory test results would improve care for patients at low risk for developing urinary tract infections

Simple changes in how clinical laboratory tests are reported to clinicians can contribute to improved patient safety and a reduction in the inappropriate use of antibiotics. These were the conclusions of a recent study published in the Infectious Diseases Society of America’s (IDSA) peer-reviewed medical journal, Clinical Infectious Diseases (CID).

If the findings of this study can be duplicated in other settings, it can provide pathologists and medical laboratory scientists with another approach to improve the way clinicians utilize clinical laboratory tests so as to improve patient outcomes and reduce the associated cost of care.

Could Different Ways to Report Lab Tests Help Physicians?

The subject of the study was urine culture testing and how physicians used the test results when deciding whether or not to prescribe antibiotics. Researchers decided to evaluate whether a simple change in the way laboratory tests were reported could improve clinicians’ practices when urine culture tests are ordered, particularly for hospitalized patients at low risk for developing urinary tract infections (UTIs).

This proof-of-concept pilot program, called “Reducing Antimicrobial Therapy for Asymptomatic Bacteriuria Among Noncatheterized Inpatients,” was conducted last year at Mount Sinai Hospital in Toronto, Canada.

Change in Clinical Laboratory Test Reporting Produced Two Benefits

The study ultimately determined that the changes in lab test reporting did generate two positive benefits. First, it reduced urine culture testing for patients in a low-risk category. Second, it resulted in fewer prescriptions for antibiotics for these patients.

Urine cultures for hospitalized patients are often ordered unnecessarily pointed out a news release from IDSA. Positive culture results from patients without any UTI symptoms can lead to antibiotic prescriptions that are of no benefit and may cause harm to patients, including C. difficile infection and subsequent infection with more antibiotic-resistant bacteria, the IDSA press release explained.

The key to the success was in handling patients at low risk for UTIs differently from patients at high-risk for infections. Researchers found that unnecessary antibiotic prescriptions were greatly reduced when the medical laboratory did not routinely report positive results to the ordering physician positive for inpatients at low risk for UTIs, noted the IDSA press release. Another finding was that this change in the reporting of lab test results did not affect treatment of patients who did need antibiotics, study authors wrote.

During the study, in lieu of routinely reporting positive urine culture results from noncatheterized inpatients, a message was posted to the patient’s electronic medical record. It asked caregivers to call the microbiology laboratory for results—if they strongly suspected a UTI.

Clinicians Reminded that Antibiotics Are Not Always the Answer

The message in the patient’s electric health record also reminded clinicians that “the majority of positive urine cultures from inpatients without indwelling urinary catheter represent asymptomatic bacteriuria” (ASB)—a condition where antibiotics are not usually recommended.

This message and the change in lab test reporting had a positive effect. “By no longer routinely reporting these [positive urine culture] results among low-risk inpatients, our intervention reduced the tendency to react to positive urine culture results while continuing to encourage clinicians to pursue results if they had a high suspicion of UTI. This approach appeared to be highly effective and did not require any training or education of care providers,” wrote authors of the study.

This is one more example of how relatively small changes in how clinical laboratory tests are reported and utilized can improve patient care, while at the same time contributing to a overall, lower cost of care.

Another Opportunity for Pathologists to Add Value

Most pathologists agree that there are ample opportunities to improve the utilization of medical laboratory tests. For example, a recent Dark Daily reported that Beth Israel Deaconess Medical Center researchers determined that 30% of all clinical laboratory tests are overused, and a different 30% of medical laboratory tests are underused. (See Dark Daily, “Study at Boston’s Beth Israel Deaconess Medical Center Determines that 30% of All Clinical Laboratory Tests Are Overused or Medically Unnecessary”, February 28, 2014.)

Simple changes in how urine culture test results were reported contributed to improved patient safety and a reduction in the utilization of unnecessary antibiotics. The study was led by Jerome A. Leis, M.D., MSC, of Sunnybrook Health Sciences Centre in Toronto. (Photo copyright University of Toronto.)

Simple changes in how urine culture test results were reported contributed to improved patient safety and a reduction in the utilization of unnecessary antibiotics. The study was led by Jerome A. Leis, M.D., MSC, of Sunnybrook Health Sciences Centre in Toronto. (Photo copyright University of Toronto.)

 

The lead author of the study was Jerome A. Leis, M.D., MSc, of Sunnybrook Health Sciences Centre in Toronto. “In clinical medicine, there are many examples of tests that are not routinely processed or reported when they have been shown to be of very low yield or associated with potential harms, and special requests are required in these cases, he stated. We believe this to be true of some urine cultures from medical and surgical floors where we know that the majority of positive results occur in patients without symptoms of urinary tract infection and lead to unnecessary and potentially harmful therapy with antibiotics.”

In an editorial commentary in Clinical Infectious Diseases, which accompanied the study, authors Aanand D. Naik, M.D., of the Houston Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey Veterans Affairs Medical Center; and Barbara W. Trautner, M.D., Ph.D., Department of Medicine, Baylor College of Medicine, Houston, called Leis’s simple intervention “particularly elegant.”

Recommendations about When to Present Clinical Lab Test Results

“It may be prudent to change the standard and default practices regarding ordering and reporting of urine culture results in patients with likely ASB,” wrote Naik and Trautner. “The study’s change in the default option likely forced clinicians to more deliberately reassess the pretest probability of urinary tract infection vs. ASB. If physicians do not really want the results, there is no need to present them with a positive urine culture that will blind them to the lack of urinary-associated symptoms and trigger inappropriate prescribing behavior.”

This study is one more example of how simple changes in long-established clinical laboratory test reporting protocols can contribute to measurable improvements in patient safety, as well as reduce unnecessary costs of care. The findings of this research study should inspire microbiologists and pathologists in other hospitals and health systems to engage clinicians in discussions about how similar changes in reporting urine culture test results could contribute to improved patient safety and reduce unnecessary utilization of antibiotics in their own institutions.

—By Donna Marie Pocius

Related information:

Reducing Antimicrobial Therapy for Asymptomatic Bacteriuria Among Noncatheterized Inpatients: A Proof-of-Concept Study

Simple Lab-Based Change May Help Reduce Unnecessary Antibiotic Therapy, Improve Care: Modifying how urine culture results are reported to clinicians can improve prescribing practices, pilot study suggests

Study at Boston’s Beth Israel Deaconess Medical Center Determines that 30% of All Clinical Laboratory Tests are Overused or Medically Unnecessary 

Doing the Right Thing for Asymptomatic Bacteriuria: Knowing Less Leads to Doing Less

New University of Toronto Master’s Meets Demand for Better Health Care