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Test Ordering Program

Lead your organization into more effective laboratory test ordering

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Pathologists are uniquely suited to engage their clinician colleagues and hospital administrators to identify the right test, at the right time, to provide a patient an accurate diagnosis. Whether resulting in squandered laboratory resources, inconclusive data, or even misdiagnosis for the specific patient case, the US health care system faces the critical challenge of optimal use of laboratory testing. Many pathologists regard this as the most pressing issue in the practice of pathology today.

Test Ordering Program for CAP Members

Recognizing this critical issue, the CAP offers the Test Ordering Program. This complimentary members-only resource, compiled by Fellows of the CAP, provides pathologists with essential information about commonly misapplied laboratory tests, often with study data, to address laboratory stewardship through test ordering programs. Content is organized in modules that provide information on test selection, ordering, and interpretation to effect change in an evidence-based manner. The modules help:

  • Understand and quantify the problem
  • Find system-wide solutions to operational and policy challenges
  • Address the issue with clinician colleagues and hospital administrators
  • Include questions to reinforce content mastery
  • Offer tools for impact analysis and economic value

The Test Ordering Program modules cover a broad array of tests used by primary care practitioners and specialists. When viewing the modules, viewers may identify analytes that a health care team can target for improvement. Questions are provided for each module to reinforce the lessons learned. The impact analysis portion of the module is designed to guide users through straightforward calculations that can help pathologists demonstrate the economic value of their interventions. Finally, each module has a handout component that complements the full module, which pathologists may share with their clinician colleagues.

Pathologists who use the Test Ordering Program modules may self-claim Continuing Certification (CC) for Improvement in Medical Practice (Part IV) Credit from the American Board of Pathology. Simply complete the self-reporting form and follow its instructions, then add this activity to your CAP education transcript. Click here to download the self-report form.

Hepatitis B Virus (HBV) Infection

Selecting among the multiple serologic and antigenic tests for Hepatitis B infections can be confusing for the non-specialist. A clear strategy that optimizes test ordering based on specific clinical indications will help select optimal testing choices.

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Heparin-Induced Thrombocytopenia Testing

Limiting HIT testing to those patients with a greater likelihood improves the predictive value of immunoassay testing. Developing a pre-test predictive scoring system can ensure optimal utilization of laboratory and pharmacy resources.

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Lipase in the Diagnosis of Acute Pancreatitis

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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Syphilis Serology for Screening and Monitoring Disease

With multiple serological assays available, diagnosing and monitoring syphilis infections can be complex. Ordering the incorrect assay can lead to confusion and misinterpretation of testing results. Using an optimized testing algorithm aids healthcare providers to interpret results accurately and provide effective patient care.

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Testing for Pheochromocytoma/Paraganglioma

Histologically identical, testing for pheochromocytomas and paragangliomas often lead to inaccurate interpretations. Implementing proper strategies can address preanalyitcal variables and assay limitations and ensure selection of proper testing.

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Testing for Carcinoid Syndrome

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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Laboratory Workup for Urinary Tract Infections

With several methods for the workup of urinary tract infections (UTIs) available, it can be confusing to choose the appropriate test(s) for the patients. Proper testing can identify appropriate treatment promptly while reducing unnecessary treatment with antimicrobials and the emergence of resistant strains.
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Clostridioides (Clostridium) difficile Testing

C. difficile is one of the most common causes of hospital-acquired infections. Whether the patient has an infection, and thus needs treatment, or is simply an asymptomatic carrier is not always easily defined by laboratory tests results. Implementing processes that ensure testing only appropriate patients and interpreting results in a clinical context is important.

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Biomarkers in Colorectal Cancer: BRAF Testing as a Follow Up to Microsatellite Instability in the Exclusion of Lynch Syndrome

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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B-Type Natriuretic Peptide (BNP) or N-Terminal-ProBNP (NT-proBNP)

BNP is frequently used in the evaluation of dyspnea and to assess risk and prognosis of patients with congestive heart failure (CHF). While useful for differentiating pulmonary causes from cardiac causes of dyspnea, repeat inpatient BNP testing may not be valuable.

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Cardiac Marker Testing Practices

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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Appropriate Testing for Hepatitis C Virus (HCV) Infection

Are positive serologic HCV assays being repeated? Is the same patient having HCV genotyping tests repeated without evidence of a new infection?

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Red Blood Cell Folate Testing

Testing serum folate levels is the preferred method for detecting nutritional folate deficiency. Serum folate levels may be preferred over RBC folate testing to assess patient status. This module addresses issues to achieve reliable, conclusive results.

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Celiac Disease Testing

Increased public awareness of Celiac disease has driven higher testing rates and increased incidence of diagnosis, yet many health care providers agree that many cases remain undiagnosed. Optimal testing, however, remains controversial, especially because of the large number of assays available. An algorithmic approach may support the most reliable diagnoses for Celiac disease.

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Free Prostate Specific Antigen (PSA) Testing

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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Repetitive Constitutional Genetic Testing

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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Urine Myoglobin

Urine myoglobin testing is primarily indicated for diagnosis and risk assessment of kidney injury in patients with rhabdomyolysis. However, this test is best ordered for clinical use and interpretation after the urine dipstick hemoglobin test result is known.

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Vitamin D

There are multiple assays available to test for Vitamin D deficiency, and these are not always easily distinguishable. To test appropriately, there are often specific high-risk factors to consider when the testing would be appropriate, and which test is most applicable for the patient.

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5, 10-Methylenetetrahydrofolate Reductase (MTHFR)

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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Tick-Borne Infections

There are multiple factors that can complicate testing for suspected tick-borne infections. Appropriate testing practices can be difficult to determine, and there may be limitations for that testing. A strategic approach to reduce complexity for ordering appropriate tests can facilitate appropriate treatment.
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Thyroid Disorder

Thyroid stimulating hormone (TSH) is a common indicator for assessing thyroid function in most patients, but as a single indicator, it may not provide enough information. Implementing a testing algorithm to classify thyroid disorders may be more effective.

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Want to learn more about this topic? The CAP has several other resources, including scholarly articles and case studies, that can help you develop your knowledge in this important area of laboratory resources management.

Case Studies

Do you have a case study or example you’d like to share with your colleagues? Email us at testordering@cap.org to tell your story.



Other Resources

Smart Test Ordering

Read how the Test Ordering Program can help you demonstrate the pathologist’s value in improving patient care.

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