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Test Ordering Program

Lead your organization's laboratory stewardship to drive operational excellence, achieve diagnostic confidence, and ensure the best patient care.

Better Laboratory Stewardship

Read about utilization management techniques to help you allocate resources more effectively for better patient care.

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Many health care networks expect their laboratories to provide exemplary testing results with limited resources. If your laboratory's tight operating budget and staff shortage demand detailed attention to operational efficiency, you are not alone. The Test Ordering Program gives CAP customers essential information about commonly misapplied laboratory tests to address laboratory stewardship through test ordering patterns. The content is available to laboratories or health systems participating in CAP accreditation and proficiency testing and is organized in modules that provide information on test selection, ordering, and interpretation to effect change in an evidence-based manner.

The modules can help you:

  • Identify ways to use limited resources wisely
  • Build a laboratory stewardship program
  • Review testing patterns for efficacy and utility

The Test Ordering Program addresses laboratory testing across major scientific disciplines, with new modules added periodically. Each module provides analytical tools and expert-reviewed content to enhance your understanding of the latest recommendations, as well as informative reference sheets written specifically to share with your clinician colleagues. Although the topics vary, all aim to assist the laboratory in its quest to provide optimal patient care, with an eye toward achieving the most effective testing practices.

Lead your organization’s efforts in laboratory stewardship to drive operational excellence, achieve diagnostic confidence, and ensure the best patient care with these modules.

Chemistry

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BNP helps to evaluate dyspnea and to assess patients with congestive heart failure (CHF). Despite how common the testing is, serially measured BNP or NT-proBNP only offers limited utility.

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Several biomarkers may be used to evaluate patients with suspected neuroendocrine tumors. Patient and testing conditions can affect testing, however, and optimal laboratory testing can help avoid interpretative error and accurate diagnosis for patients with carcinoid syndrome and these tumors.

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Cardiac troponin (cTn) is often cited in guidelines as the preferred marker for acute myocardial injury (AMI). The evaluation methodology in this module may be applied to other markers of AMI such as creatine kinase MB (CK-MB), too.

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Although red blood cell folate testing is often ordered to determine nutritional folate deficiency, serum folate testing should be a first line test for detecting folate deficiency.

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Acute pancreatitis, an inflammation of the pancreas, is one of the most frequent gastrointestinal causes of hospital admissions. Lipase is preferred over amylase as a diagnostic biochemical marker when diagnosing acute pancreatitis, as explained in this module.

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Limitations of laboratory testing assays and preanalytical variables affecting testing for pheochromocytomas and paragangliomas may hinder accurate interpretation. Selecting the right assay and implementing strategies to reduce erroneous interpretation will lead to better patient outcomes.

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Total PSA testing is used to test for likelihood of prostate cancer, and until recently prostate biopsy was recommended if the total PSA exceeded 4.0 ng/mL. That could lead to unnecessary biopsies and unwarranted concerns about cancer. Free PSA testing when total PSA is within a specific range is a more reliable method.

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A rapid diagnostic protocol for standard urine dipstick testing can help triage specimens for more specific myoglobin testing.

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Microbiology

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C. difficile is a common cause of hospital-acquired infections, and several tests for exist for it. Clinical and laboratory technical issues may determine which testing methods to use. In some instances, appropriate pre-analytic testing criteria should be satisfied in addition to timely reporting for effective patient care.

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Because so many scenarios exist that can require testing for UTI or ASB, determining which test for which patient is critical to afford appropriate treatment and avoid unnecessary antibiotic therapies.

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Immunology

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HCV testing methods include serologic, viral load, and genotyping. When clinicians should order each type of testing, as well as when to combine testing methods or the limited circumstances when serologic and genotyping testing should be repeated?

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There are multiple testing options for diagnosing HBV and immune status, but there are multiple factors to select appropriate serologic and antigenic testing. The laboratory can take steps to help select the best testing method to reduce incomplete testing and diagnostic error.

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MGs are associated with several disorders, and effective monitoring and treatment for each disorder depends on accurately identifying subclassification. Determining the best initial screening tests can lead to identifying the subclassification properly through establishing a baseline of the appropriate biomarkers.

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Hematology-Coagulation

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An individual’s genetic makeup does not change within his/her lifetime, so repeating a constitutional genetic test usually is unnecessary. Applying interventions may avoid retesting, but there are a few rare situations where it may be warranted.

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Often mistakenly ordered for patients at risk for thromboembolism, coronary heart disease, and recurrent pregnancy loss, MTHFR may have utility for other clinical indications.

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Under certain conditions, PC and PS testing is susceptible conditions leading to mistaken diagnoses. To avoid these situations and assure clinical utility, a protocol to delay testing may help.

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Molecular Pathology

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A common hereditary disorder that can lead to severe complications from iron toxicity. Diagnosis of the most common form comes from genotyping the HFE gene. Selection of appropriate criteria for HFE genetic testing and accurate interpretation of test results to inform treatment are important to optimize use of this test.

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A subset of colorectal cancer (CRC) tumors test positive for the BRAF V600E mutation, whose presence is associated with methylation of MLH1, which correlates with microsatellite instability (MSI). BRAF V600E alone is not useful for excluding Lynch Syndrome. The recommended method is an algorithmic approach to evaluate CRC through immunohistochemistry (IHC) or polymerase chain reaction (PCR) testing.

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Attestation Forms

The Test Ordering Program was approved by ABPath (American Board of Pathology) for pathologists to fulfill IHHC/IMP requirements. Pathologist participants may self-report use of the Test Ordering program for a quality performance improvement project using the downloadable form.

Laboratory scientists may self-report use of the Test Ordering program towards fulfilling education and credential maintenance program requirements for agencies such as the American Society for Clinical Pathology using the downloadable form.

CAP Resources on Test Utilization

Laboratory Stewardship Recommended Readings and References

For more information on laboratory stewardship practices and research, the following published materials may also be helpful.

  • Laposata, Mike. Overcoming barriers as a diagnostic management team. LabMind. Podcast.
  • Warren JS. Laboratory test utilization program: structure and impact in a large academic medical center. American Journal of Clinical Pathology. 2013;139(3):289-297. https://doi.org/10.1309/AJCP4G6UAUXCFTQF
  • Brian R. Jackson, BR, Krasowski, MD, Sims PJ., Laboratory diagnostic oversight committees and the profession of laboratory medicine.American Journal of Clinical Pathology. 2013:139(3):273 – 274, https://doi.org/10.1309/AJCPYK7EKWDCBTJC
  • Zhi M, Ding EL, Theisen-Toupal J, Whelan J, Arnaout R. The landscape of inappropriate laboratory testing: a 15-year meta-analysis. PLoS One. 2013;8(11):e78962. Published 2013 Nov 15. Accessed December 20, 2023. https://pubmed.ncbi.nlm.nih.gov/24260139/
  • CLSI. Developing and Managing a Medical Laboratory (Test) Utilization Management Program. 1st ed. CLSI Report. CLSI report GP49. Clinical and Laboratory Standards Institute; 2017. Accessed December 20, 2023. https://clsi.org/standards/products/general-laboratory/documents/gp49/
  • Procop GW, Yerian LM, Wyllie R, Harrison AM, Kottke-Marchant K. Duplicate laboratory test reduction using a clinical decision support tool. Am J Clin Pathol. 2014;141(5):718-723. doi:10.1309/AJCPOWHOIZBZ3FRW
  • Procop GW, Keating C, Stagno P, et al. Reducing duplicate testing: a comparison of two clinical decision support tools. Am J Clin Pathol. 2015;143(5):623-626. doi:10.1309/AJCPJOJ3HKEBD3TU
  • Nikolic D, Richter SS, Asamoto K, Wyllie R, Tuttle R, Procop GW. Implementation of a clinical decision support tool for stool cultures and parasitological studies in hospitalized patients. J Clin Microbiol. 2017;55(12):3350-3354. doi:10.1128/JCM.01052-17
  • Phelan MP, Reineks EZ, Schold JD, Hustey FM, Chamberlin J, Procop GW. Preanalytic factors associated with hemolysis in emergency department blood samples. Arch Pathol Lab Med. 2018;142(2):229-235. doi:10.5858/arpa.2016-0400-OA
  • Riley JD, Stanley G, Wyllie R, Kottke-Marchant K, Procop GW. The impact of an electronic expensive test notification. Am J Clin Pathol. 2018;149(6):530-535. doi:10.1093/ajcp/aqy021
  • Riley JD, Stanley G, Wyllie R, et al. An electronic strategy for eliminating unnecessary duplicate genetic testing. Am J Clin Pathol. 2020;153(3):328-332. doi:10.1093/ajcp/aqz163
  • Mandelia Y, Procop GW, Richter SS, Worley S, Liu W, Esper F. Optimal timing of repeat multiplex molecular testing for respiratory viruses. J Clin Microbiol. 2020 Jan 28;58(2):e01203-19. doi: 10.1128/JCM.01203-19. PMID: 31748321; PMCID: PMC6989085.
  • Procop GW, Weathers AL, Reddy AJ. Operational aspects of a clinical decision support program. Clin Lab Med. 2019;39(2):215-229. doi: 10.1016/j.cll.2019.01.002. PMID: 31036276.
  • Zhou Y, Procop GW, Riley JD. A novel approach to improving utilization of laboratory testing. Arch Pathol Lab Med. 2018;142(2):243-247. doi: 10.5858/arpa.2017-0031-OA. Epub 2017 Oct 5. PMID: 28981372.
  • Phelan MP, Nakashima MO, Good DM, Hustey FM, Procop GW. Impact of interventions to change CBC and differential ordering patterns in the emergency department. Am J Clin Pathol. 2019;151(2):194-197. doi: 10.1093/ajcp/aqy128. PMID: 30247523.
  • Wilson, M. L., Procop, G. W., & Barth Reller, L. Test utilization and clinical relevance. In: eds Garcia LS, Bachner P, Baselski, VS, et al.Clinical Laboratory Management. American Society for Microbiology Press; 2013: 876- 889.https://doi.org/10.1128/9781555817282.ch49.

Please direct questions, comments, or success stories to testordering@cap.org or call 800-323-4040.