Overuse of INR and PT Testing in Medical Inpatients

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Presentation transcript:

Overuse of INR and PT Testing in Medical Inpatients Kevin Pham, PGY2

Guidelines JAMA. 1989;262(17):2429.

Preoperative Testing Liver function testing (including INR/PT) only if there are suspicions for liver disease based on prior abnormal LFTs, history, and exam. Nature Clinical Practice Gastroenterology & Hepatology. 2007 ;(4) :266-276

Methods Cross sectional analysis Sample size n=20 Randomly review current medical inpatient charts until sample size is attained. Only one INR/PT per patient closest to admission date was included in sample. Inclusion criteria: medical inpatients, INR testing during current admission Exclusion criteria: surgical, MICU, SICU, heme/onc, OB/GYN inpatients, and those without INR/PT testing.

Results Total charts review: 28 INR/PT testing present: 20 INR/PT testing absent: 8 Indicated: 10 Not Indicated: 10

Results 10/20 INR/PT tested (50%) were not indicated 1/10 INR/PT tested (10%) of the “not indicated” group was abnormal (based on UCI Medical Center laboratory reference ranges). Abnormal INR/PT did not have clinical significant and did not change management.

Results Indications for inappropriate INR/PT testing were unknown since they were not documented. Inappropriate INR/PT ordered by ED: 4/10 (40%) Inappropriate INR/PT ordered by medical residents: 6/10 (60%)

Results Indications of appropriate INR/PT testing 1/10 for Coumadin bridging for LV thrombus 3/10 for malnutrition and invasive procedure 3/10 for cirrhosis and invasive procedure 3/10 for active bleeding

Cost Cost per INR/PT testing: $8.45 Charge per test: $59.86 Patient volume 2013 (Tower): 3,343 Test volume 2013 for tower patients: 8,343 Assuming 50% of INR/PT testing are inappropriate as demonstrated by these data, potential cost annually due to inappropriate INR/PT is $35,249. Inappropriate charge to patient is $249,705.

Conclusion The incidence and cost of inappropriate INR/PT testing is high. Increased awareness of guidelines for INR/PT testing may reduce the incidence and cost.

References Erban, S.B., et al. Routine use of the Prothrombin and Partial Thromboplastin Times. JAMA. 1989;262(17) :2429. Hanje, A.J and Patel, T. Preoperative evaluation of patients with liver disease. Nature Clinical Practice Gastroenterology & Hepatology. 2007 ;(4) :266-276