title: Analysis of Thrombophilia Test Ordering Practices at an Academic Center: A Proposal for Appropriate Testing to Reduce Harm and Cost.
abstract: Ideally, thrombophilia testing should be tailored to the type of thrombotic event without the influence of anticoagulation therapy or acute phase effects which can give false positive results that may result in long term anticoagulation. However, thrombophilia testing is often performed routinely in unselected patients. We analyzed all consecutive thrombophilia testing orders during the months of October and November 2009 at an academic teaching institution. Information was extracted from electronic medical records for the following: indication, timing, comprehensiveness of tests, anticoagulation therapy at the time of testing, and confirmatory repeat testing, if any. Based on the findings of this analysis, we established local guidelines in May 2013 for appropriate thrombophilia testing, primarily to prevent testing during the acute thrombotic event or while the patient is on anticoagulation. We then evaluated ordering practices 22 months after guideline implementation. One hundred seventy-three patients were included in the study. Only 34% (58/173) had appropriate indications (unprovoked venous or arterial thrombosis or pregnancy losses). 51% (61/119) with an index clinical event were tested within one week of the event. Although 46% (79/173) were found to have abnormal results, only 46% of these had the abnormal tests repeated for confirmation with 54% potentially carrying a wrong diagnosis with long term anticoagulation. Twenty-two months after guideline implementation, there was an 84% reduction in ordered tests. Thus, this study revealed that a significant proportion of thrombophilia testing was inappropriately performed. We implemented local guidelines for thrombophilia testing for clinicians, resulting in a reduction in healthcare costs and improved patient care.
authors.affiliation: Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America.
authors.forename: Yu-Min
authors.initials: YM
authors.lastname: Shen
authors.affiliation: Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America.
authors.forename: Judy
authors.initials: J
authors.lastname: Tsai
authors.affiliation: Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America.
authors.forename: Evelyn
authors.initials: E
authors.lastname: Taiwo
authors.affiliation: Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America.
authors.forename: Chakri
authors.identifier: 0000-0001-6269-9222
authors.initials: C
authors.lastname: Gavva
authors.affiliation: Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America.
authors.forename: Sean G
authors.initials: SG
authors.lastname: Yates
authors.affiliation: Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America.
authors.forename: Vivek
authors.initials: V
authors.lastname: Patel
authors.affiliation: Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America.
authors.forename: Eugene
authors.initials: E
authors.lastname: Frenkel
authors.affiliation: Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America.
authors.forename: Ravi
authors.initials: R
authors.lastname: Sarode
mesh_terms: D000046:Academic Medical Centers / Q000592:standards / Q000706:statistics & numerical data; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001780:Blood Coagulation Tests / Q000009:adverse effects / Q000191:economics / Q000379:methods / Q000592:standards; D015897:Comorbidity; D005260:Female; D005500:Follow-Up Studies; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D019851:Thrombophilia / Q000175:diagnosis* / Q000453:epidemiology* / Q000209:etiology; D055815:Young Adult