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The SHEA Podcast | SHEA & ASM on The Ramifications of Testing – Why Dx Stewardship is Critical · The SHEA Podcast

• 0:06
  SPEAKER_02: Hi, everybody.
• 0:06
  SPEAKER_02: Welcome to Shay's podcast, this time in collaboration with the American Society for Microbiology.
• 0:11
  SPEAKER_02: I am Dr.
• 0:12
  SPEAKER_02: Francesca Lee, an associate professor in the departments of pathology and internal medicine at UT Southwestern Medical Center, and a member of the Division of Infectious Diseases and Geographic Medicine.
• 0:21
  SPEAKER_02: I formerly served as director of the Antimicrobial Stewardship Program for UT Southwestern Medical Center and currently serve as the technical director for our hospital's microbiology laboratory.
• 0:30
  SPEAKER_02: I'm very pleased to serve as today's moderator as we discuss the ramifications of testing, or more simply, why diagnostic stewardship is critical.
• 0:38
  SPEAKER_02: It's great to have representatives from both SHA and ASM speaking on this podcast, as diagnostic stewardship is a joint healthcare effort and should be approached collaboratively.
• 0:46
  SPEAKER_02: Before we get started, I'd like to introduce you to today's speakers.
• 0:50
  SPEAKER_02: Representing ASM, we have Dr.
• 0:52
  SPEAKER_02: Laura Filkins, the Director of Microbiology at Children's Health in Dallas, Texas.
• 0:56
  SPEAKER_02: After receiving a doctoral degree at Dartmouth College, Hanover, New Hampshire, in 2015, she completed fellowship training in medical and public health microbiology through the University of Utah and ARUP laboratories in Salt Lake City, Utah in 2018.
• 1:09
  SPEAKER_02: Her research and academic interests focus on the integration of emerging technologies into the clinical setting for pathogen detection and how to guide optimal utilization of these new diagnostic tests.
• 1:19
  SPEAKER_02: Dr.
• 1:19
  SPEAKER_02: Philkins is also the chair for the American Society of Microbiology Clinical and Public Health Subcommittee on Laboratory Practices.
• 1:25
  SPEAKER_02: Dr.
• 1:25
  SPEAKER_02: Philkins, welcome.
• 1:27
  SPEAKER_01: Thank you so much for that introduction and for the invitation to join you guys today.
• 1:31
  SPEAKER_02: Excellent.
• 1:32
  SPEAKER_02: Representing SHAY, we have Dr.
• 1:34
  SPEAKER_02: Dan Morgan, a physician, epidemiologist, and tenured professor of epidemiology and medicine.
• 1:39
  SPEAKER_02: He directs the Center for Innovation and Diagnosis.
• 1:41
  SPEAKER_02: He was a founding member and director of the Society for Healthcare Epidemiology of America Research Network and was on the SHAE Board of Directors and SHA chair for ID Week 2022.
• 1:51
  SPEAKER_02: At the VA Maryland Healthcare System, he directs epidemiology and his research explores probability in medicine, medical overuse, diagnostic stewardship, infection prevention, and AI.
• 2:01
  SPEAKER_02: Dr.
• 2:01
  SPEAKER_02: Morgan, it's great to have you here.
• 2:03
  SPEAKER_00: Oh, thank you.
• 2:04
  SPEAKER_00: Look forward to talking to you, Frankie and Laura.
• 2:07
  SPEAKER_02: So I am excited to hear both of your opinions on this very important topic today.
• 2:11
  SPEAKER_02: And let's go ahead and get started.
• 2:12
  SPEAKER_02: First, let's start with what does diagnostic stewardship mean to you in your role?
• 2:18
  SPEAKER_02: And Dr.
• 2:18
  SPEAKER_02: Phillikins, why don't you start us off?
• 2:20
  SPEAKER_01: Sure.
• 2:21
  SPEAKER_01: So as a clinical microbiology director, I potentially view diagnostic stewardship maybe a little bit differently than many providers do.
• 2:30
  SPEAKER_01: You'll often hear the definition for diagnostic stewardship as being quoted as aiming or something along the lines of aiming to deliver the right test to the right patient at the right time.
• 2:42
  SPEAKER_01: And that is a huge component of diagnostic stewardship.
• 2:46
  SPEAKER_01: However, these three actions really focus on just one part of the testing process, the ordering and hopefully even going into the collection phase.
• 2:55
  SPEAKER_01: And so in the laboratory, we refer to these steps as the pre-analytic testing steps.
• 3:00
  SPEAKER_01: And I will say that the majority of our testing projects or our stewardship projects focus on these pre-analytic steps.
• 3:08
  SPEAKER_01: However, for the laboratory, diagnostic stewardship really applies to the entire testing process.
• 3:15
  SPEAKER_01: So the analytic stage, thinking about cultures, how are we working up our cultures?
• 3:19
  SPEAKER_01: Are we doing this in an optimal manner?
• 3:22
  SPEAKER_01: Or when selecting a test to bring into the laboratory or maybe even developing a test, are we choosing the appropriate pathogens to target?
• 3:29
  SPEAKER_01: Does it make sense for the indication that the test is usually used for?
• 3:33
  SPEAKER_01: So those would be analytic phase considerations in diagnostic stewardship.
• 3:37
  SPEAKER_01: And then the post-analytic phase, which is also can be thought of as the reporting phase.
• 3:42
  SPEAKER_01: Here we think about how are we communicating our results?
• 3:46
  SPEAKER_01: Are we supporting the optimal result interpretation and downstream management?
• 3:50
  SPEAKER_01: So for example, antimicrobial susceptibility testing.
• 3:54
  SPEAKER_01: Are we releasing all of the drugs up front all at once, or are we selecting just individual drug bug combinations that make the most sense for our institution based on the formulary and working closely with the stakeholders and then potentially cascading to additional drugs as needed?
• 4:11
  SPEAKER_01: So those are just kind of a few examples of how diagnostic stewardship really does cross over the entire testing process.
• 4:19
  SPEAKER_01: And I think what's really important on the laboratory side is to remember that we can't and we definitely shouldn't attempt to do this alone.
• 4:26
  SPEAKER_01: So in my role as a director, that means when thinking about diagnostic stewardship, it's important that I help to coordinate these partnerships and seek out recommendations from stakeholders.
• 4:37
  SPEAKER_01: We work extremely closely with infectious disease, antimicrobial stewardship, infection prevention and control.
• 4:44
  SPEAKER_01: But then also depending on the project, it's important to collaborate with specialty groups where they're using the test the most.
• 4:51
  SPEAKER_01: So this could be the emergency department, it could be inpatient groups or even clinic groups.
• 4:57
  SPEAKER_02: Sounds good.
• 4:58
  SPEAKER_02: Oh, sorry, Dr.
• 4:59
  SPEAKER_02: Morgan, I was going to just ask you if you wanted to add anything else.
• 5:02
  SPEAKER_02: So go for it.
• 5:03
  SPEAKER_00: No, no, I mean it's it's really interesting.
• 5:05
  SPEAKER_00: I feel like this you know conversation between uh you know people who are laboratory experts and sort of the more clinical side of diagnostic stewardship is great.
• 5:14
  SPEAKER_00: And I just would would emphasize I I love the broad perspective of like talking about like ordering what happens in the lab with there being, you know, obviously a very broad view.
• 5:23
  SPEAKER_00: And and I think the the broader the better, with a lot of that really being needing to be driven by the laboratory professionals given they're the ones who know what's available and what's not and what can realistically be done.
• 5:34
  SPEAKER_00: But then the reporting, you know, trying to really get the best actions out of the test.
• 5:39
  SPEAKER_00: So I think it's great.
• 5:40
  SPEAKER_00: And I think that the term diagnostic stewardship has really sort of become like an umbrella term, kind of like for a lot of things that were out there in different ways.
• 5:48
  SPEAKER_00: You know, laboratory stewardship, as I think some people had called it in the past, or you know, just clinical microbiology, like in the 70s or 80s or something, but uh trying to use tests most effectively to get good patient outcomes and really focusing on the clinical side and how we implement tests so that they can be used most effectively.
• 6:08
  SPEAKER_02: Dr.
• 6:08
  SPEAKER_02: Morgan, let's keep going with that topic.
• 6:10
  SPEAKER_02: And you address the impact on patient care.
• 6:12
  SPEAKER_02: So, how does the overuse or misuse of diagnostic tests impact patient care?
• 6:17
  SPEAKER_02: And what are the potential ramifications in the healthcare setting?
• 6:20
  SPEAKER_00: Well, I mean, I I think I always find this interesting to think about just how this is a just a new situation we find ourselves in.
• 6:27
  SPEAKER_00: I mean, testing has really exploded since the 1970s.
• 6:30
  SPEAKER_00: Seems like, you know, before then there were really very few tests, often they were done by clinicians themselves, even.
• 6:36
  SPEAKER_00: And uh, you know, now we have over 14 billion tests a year in the United States alone.
• 6:40
  SPEAKER_00: And I think the science just hasn't really caught up to it.
• 6:43
  SPEAKER_00: Like how we interpret tests, what are the terms we use, how do we evaluate if a test is good or not?
• 6:49
  SPEAKER_00: And I think that we know that a lot of tests, most tests are not good enough for indiscriminate use, and we need kind of thoughtful application of those.
• 6:56
  SPEAKER_00: And that's really the problem that I think diagnostic stewardship addresses is it can't really improve the expert clinician who's being thoughtful about test ordering, but it can really improve the thoughtless use of testing, where like everyone you know comes to the emergency room, gets a urine culture, or these uh order sets where like it's encouraging lots of tests that may not be appropriate in that patient, and they're done thoughtlessly.
• 7:19
  SPEAKER_00: I mean, I think that diagnostic stewardship is great for being able to identify rules or practices to limit the most inappropriate use of tests, like when they're not needed, or you know, potentially when they are needed.
• 7:32
  SPEAKER_00: Um, and you know, diagnostic stewardship has really been focused mostly on ID, I would say infectious disease type problems, you know, with clinical microbiology and not as frequently expanded to like the broad laboratory services or even radiology.
• 7:47
  SPEAKER_00: But I think in ID, the the real benefit of trying to uh have more uh precise use of testing is to have fewer wrong diagnoses, less unnecessary antibiotics, and more precise diagnoses to explain the problems that patients have.
• 8:03
  SPEAKER_01: I fully agree with that.
• 8:04
  SPEAKER_01: And I think to follow up too, with when thinking about some of the potential ramifications for the healthcare system.
• 8:11
  SPEAKER_01: So, yes, definitely the patient that that test is being ordered and then interpreted for.
• 8:16
  SPEAKER_01: But then even taking that more broadly, I'm sure we've all experienced that we feel very squeezed for resources.
• 8:23
  SPEAKER_01: In the laboratory, we're seeing trends where many laboratories are being consolidated or centralized, we don't have enough lab techs.
• 8:31
  SPEAKER_01: If you think about the ED and how busy they are, every phase of the test, again, we have to not only is it getting ordered, but someone has to collect that test.
• 8:39
  SPEAKER_01: So was that test really the ideal test is to spend that resource and time and effort on collecting and putting the patient through that collection?
• 8:47
  SPEAKER_01: And then when it gets to the laboratory, we have to work up that test, right?
• 8:50
  SPEAKER_01: And so really thinking about resources not just from the pure cost of a test, but how you're then creating additional competition for those limited resources.
• 9:01
  SPEAKER_01: And the more tests that are potentially not needed but still ordered on the laboratory side, we we don't know which one is the appropriate test versus the less appropriate test.
• 9:12
  SPEAKER_01: We're not going to use that in our prioritization of how we work up those tests, right?
• 9:16
  SPEAKER_01: And so it kind of creates a competition between the more essential tests and the less essential tests, and that can affect your turnaround times and the demand on the laboratory and the healthcare system as a whole.
• 9:29
  SPEAKER_00: Great point.
• 9:30
  SPEAKER_01: Dr.
• 9:30
  SPEAKER_02: Fulkins, along with resource limitations, what are some other common challenges or misconceptions that surround diagnostic testing and how could these contribute to the need for better stewardship?
• 9:40
  SPEAKER_01: So, in my experience, I think the greatest misconception is that diagnostic stewardship is seen as saying no to testing and policing its use and being restrictive.
• 9:51
  SPEAKER_01: And to be fair, that's actually a lot of the things that we've already just talked about because this is this is a component of diagnostic stewardship.
• 9:58
  SPEAKER_01: But I think where that can be maybe problematic or a disadvantage to stewardship is that it gives kind of a negative feeling towards it.
• 10:06
  SPEAKER_01: People don't like to be told no, right?
• 10:09
  SPEAKER_01: But really, I view diagnostic stewardship the ultimate goal is to be able to say yes and promote the correct testing and try to change that approach or kind of how we view what we're doing here.
• 10:22
  SPEAKER_01: So, I mean, through stewardship, we we do a lot of both.
• 10:24
  SPEAKER_01: We do a lot of saying yes, we do a lot of saying no.
• 10:27
  SPEAKER_01: I think clinical consultation is a great opportunity for diagnostic stewardship because within a conversation, you can do both of those things.
• 10:35
  SPEAKER_01: You can offer a test and then recommend why to avoid a test.
• 10:38
  SPEAKER_01: So, for example, let's say it's summertime and a provider is concerned about West Nile virus and the patient's presented with two days of symptoms.
• 10:48
  SPEAKER_01: And so you can have that conversation about, well, with two days of symptoms, PCR testing, whether it's from the blood or the CNS or CS, sorry, CSF, depending on how the patient's presenting, that would be a more appropriate specimen type than, for example, serology, which we wouldn't expect the antibodies to have developed by then with just two days of symptoms.
• 11:09
  SPEAKER_01: So kind of taking each opportunity to provide a recommendation and then also an explanation of why to maybe avoid another test.
• 11:16
  SPEAKER_00: I think, I mean, those are really great points about the you know police aspect too.
• 11:20
  SPEAKER_00: I mean, I think that's something that antimicrobial stewardship has struggled with at times too, just the idea of if you are you know limiting or guiding um practice, it has the potential for that.
• 11:30
  SPEAKER_00: But I mean, I do think the way you implement things and you know, especially just the individuals who are involved can do a lot to shape that.
• 11:37
  SPEAKER_00: I mean, it reminds me of a story that I heard from Kevin Massikars, who's a pediatric ID doctor who does a lot in the lab in Denver, that uh they were designing a diagnostic stewardship approach for um multiplex CSF testing, knowing that it was often overused in the ER in patients who didn't have any white blood cells in their CSF and they would find these sort of false positive, you know, viral tests that they weren't sure what to do with.
• 12:02
  SPEAKER_00: And it turned out when they spoke to the clinicians, a lot of the ER doctors said, well, we don't really want it if there's no white blood cells.
• 12:08
  SPEAKER_00: We have to order it together.
• 12:09
  SPEAKER_00: We can't go back and reorder it or else it's like a difficult workflow.
• 12:13
  SPEAKER_00: So when they worked with the ER doctors and they created like a conditional called CSF test that would only happen if pyr, only if white blood cells are present in uh CSF, the clinicians actually were happy with it too.
• 12:25
  SPEAKER_00: So I think it does emphasize that if you work with people, you know, most doctors want the best test to be chosen and they often are happy to have some help with it if the science supports it.
• 12:35
  SPEAKER_00: So it takes more effort, but if there's a you know extra communication, I think it it can be seen as a positive by all.
• 12:41
  SPEAKER_01: Yeah, and I think that's another theme that we're probably gonna see come up a lot during this discussion today, which is the potential wonderful role of our information systems and really leveraging EMRs and order sets and reflex testing and those types of tools that can help guide testing, you know, make it easier for providers to follow an entire algorithm that an institution determines.
• 13:08
  SPEAKER_01: I mean, these are just this is a huge, huge, huge aspect to diagnostic stewardship now.
• 13:14
  SPEAKER_02: This is a great discussion.
• 13:15
  SPEAKER_02: Dr.
• 13:16
  SPEAKER_02: Morgan, in what ways can excessive testing lead to unnecessary health care costs and how can diagnostic stewardship help address this issue?
• 13:24
  SPEAKER_00: Great.
• 13:24
  SPEAKER_00: Well, I mean, I think, you know, we're talking about um healthcare costs.
• 13:28
  SPEAKER_00: I think the small way is sort of the immediate test costs that, you know, are often most apparent in the lab because it's that is their part of the budget.
• 13:35
  SPEAKER_00: But um, I mean, I think the bigger type of cost that is way more important to me is the unnecessary health care that flows from it.
• 13:43
  SPEAKER_00: Um, sometimes if you have tests that aren't needed, then you can only have potential harms and no benefits, you know, from this for the patient.
• 13:50
  SPEAKER_00: And um, you know, potentially longer length of stay or follow-up tests and this kind of cascade of events that can occur.
• 13:56
  SPEAKER_00: So, I mean, I think that the costs are important, but uh often they're a good leverage point around trying to provide just the best care.
• 14:04
  SPEAKER_00: And I think the most efficient care is is sometimes cheaper.
• 14:07
  SPEAKER_00: And uh and trying to keep that focus on the unnecessary suffering or confusion around healthcare is the most important part to me about diagnostic stewardship.
• 14:17
  SPEAKER_02: Dr.
• 14:17
  SPEAKER_02: Filkins, how does diagnostic stewardship play a role in improving patient outcomes and preventing potential harm that's associated with unnecessary testing?
• 14:27
  SPEAKER_01: Oh, that's a great topic.
• 14:28
  SPEAKER_01: We can talk about that for an hour alone.
• 14:30
  SPEAKER_01: So I'm gonna use just one example here because there's really endless ways that optimizing testing can benefit management and improve care.
• 14:39
  SPEAKER_01: So, one of the things that comes to mind is our work on C.
• 14:42
  SPEAKER_01: diffacyl testing.
• 14:43
  SPEAKER_01: Now, C diff testing is a very commonly stewarded test and for good reasons.
• 14:49
  SPEAKER_01: We know that detection of colonization with C diff in the absence of the appropriate clinical risks and appropriate presentation can lead to unnecessary antibiotic treatment, and then of course, other undesirable consequences, both for the patient and for the healthcare system.
• 15:05
  SPEAKER_01: So at our institution, the project that we were working on, as a little bit of background, we we perform both a targeted C.
• 15:13
  SPEAKER_01: diffacyl toxin gene PCR, and in our laboratory, we also offer a broad gastrointestinal PCR panel.
• 15:21
  SPEAKER_01: So, unfortunately, the broad GI panel also included C.
• 15:26
  SPEAKER_01: diffacil as a target.
• 15:27
  SPEAKER_01: And this led to more C.
• 15:29
  SPEAKER_01: diff testing than was clinically indicated because providers would order the panel out of a desire to test the other targets, but they couldn't avoid testing CDF when they made that order.
• 15:42
  SPEAKER_01: So, about two years ago, the manufacturer applied a wonderful modification to their test.
• 15:48
  SPEAKER_01: We'd been asking for it for years, and it allowed for us to choose to essentially block the C diffacile target on the GI panel.
• 15:57
  SPEAKER_01: So when this became available, we worked really closely with ID, infection prevention, stewardship, and also the primary users of the GI panel, which at our institution is the GI service, and our HEMONG and transplant teams.
• 16:11
  SPEAKER_01: And we made two changes actually when this became available.
• 16:14
  SPEAKER_01: So we made the analytic testing change of removing C diff from the panel.
• 16:20
  SPEAKER_01: And then we also took the same opportunity to modify our pre-analytic ordering stage process at our institution for both the GI panel and the C diff standalone test.
• 16:32
  SPEAKER_01: And within those orders, we included required questions and also indications to ensure that it was the test was matching the population that we intended it for.
• 16:43
  SPEAKER_01: And so the combination of these two changes, we did it at the same time, so we really can't tell which one had a bigger effect, but the combination of the two led to us halfing, so 50% of the number of patients that had a positive C diff result after we made the changes compared to before when it was available on the panel.
• 17:04
  SPEAKER_01: Also importantly, we always, when we make a change like this, we want to make sure that we're not doing harm.
• 17:08
  SPEAKER_01: And so we also haven't seen any signals that we're now missing diagnoses of C diff.
• 17:13
  SPEAKER_01: So I mean, this is a huge potential impact of stewardship, both for the patients and for the healthcare system.
• 17:22
  SPEAKER_00: No, that's a great example.
• 17:23
  SPEAKER_00: I find, you know, C diff is one that I feel like it's it's been very interesting in my lifetime where I've gone from like uh toxin testing is a bad test to PCR is a great test to PCR is a bad test to toxin testing uh is is part of the algorithm in many places again.
• 17:38
  SPEAKER_00: I mean, I I think that, you know, and one point that I guess over time has stood out for me is that I do think diagnostic stewardship is um is a great practice and it's one of the more evidence-based ways to improve diagnosis and diagnostic test use.
• 17:53
  SPEAKER_00: But I think also like it probably will, you know, make it easier to do the right thing and it will limit the worst use by you know not testing patients who clearly don't need the test and helping to provide interpretation for you know the best actions from a test.
• 18:07
  SPEAKER_00: But you know, all of this of course it needs to go along with clinicians, you know, learning also how to most appropriately use tests.
• 18:14
  SPEAKER_00: Because I don't think we're gonna, you know, it's you can't sort of work out all situations that well without needing to rely on clinicians to use tests as well as possible, also.
• 18:24
  SPEAKER_00: So I think if there's an element of education, sometimes we can build that into the way that we guide ordering of tests or kind of give information about people when it is appropriate or not, and uh try to get clinicians on board for being better at testing too.
• 18:38
  SPEAKER_02: Yeah, these are all really good topics on my end.
• 18:40
  SPEAKER_02: I'll say that I think a lot of the challenges that we face are that multiplex testing is really beneficial in many situations, but overly broad in many of those exact same situations, right?
• 18:51
  SPEAKER_02: They're the only way to get some of the assay results quickly, but then you are testing for a whole bunch of stuff that you don't necessarily want to test for.
• 18:58
  SPEAKER_02: And it's very difficult to help clinicians streamline that because the assays don't even allow them to, right?
• 19:04
  SPEAKER_02: So that that is really difficult.
• 19:06
  SPEAKER_02: Um, not to mention the IT challenges involved in trying to build all of these orders correctly to guide people.
• 19:12
  SPEAKER_02: So, Dr.
• 19:14
  SPEAKER_02: Morgan, are there any specific medical conditions or scenarios uh along the lines of the C diff one that Dr.
• 19:20
  SPEAKER_02: Fulkins just gave us where diagnostic stewardship is particularly crucial and why?
• 19:24
  SPEAKER_00: Great question.
• 19:25
  SPEAKER_00: And I think Dr.
• 19:25
  SPEAKER_00: Fulkins already gave us a you know a good discussion of C diff testing, which I think is where a lot of places started, especially with you know C diff HAI reporting being very based around a positive test result.
• 19:36
  SPEAKER_00: I mean, I think in ID there are obvious problems like urine cultures, blood cultures, and to a lesser degree sputum cultures that lead to unnecessary antibiotics and wrong diagnosis, you know, and closing thoughts on what the right diagnosis may be.
• 19:49
  SPEAKER_00: But I think that we should, you know, always be thinking about applying it to the most dangerous test.
• 19:53
  SPEAKER_00: And uh, I think we often don't think about tests this way, sort of tests are tests, and then they give us information and people can act on those.
• 20:00
  SPEAKER_00: But you know, I think often the decision to test is ultimately the decision to treat if you have a positive result.
• 20:06
  SPEAKER_00: So I think being aware of that when you order things.
• 20:09
  SPEAKER_00: And I mean, to my mind, even some of the most dangerous tests are those with the most major life changes or things like PSA or testing or mammograms or things where you're sort of committing to chemo or surgery if you decide to go down this pathway.
• 20:23
  SPEAKER_00: So I think just thinking about testing that way that it's it's not how easy it is to do the immediate test, but like what's the cascade and what will happen one way or the other.
• 20:33
  SPEAKER_00: And um, you know, and a lot of this is sort of on clinicians to be thinking down the road from what the test is, but to think about how dangerous they are.
• 20:42
  SPEAKER_00: And some of these are an infectious disease.
• 20:44
  SPEAKER_00: I think they're some of the easier ones though, like when we talk about like cancer screening or things that, you know, often have very big impacts on people.
• 20:51
  SPEAKER_01: I I like this concept of thinking about it in terms of danger to the patient.
• 20:55
  SPEAKER_01: And I think that makes a lot of sense.
• 20:58
  SPEAKER_01: In addition to how they may be treated, another thing that can be kind of very harmful to the patient is any direct costs that they might incur.
• 21:07
  SPEAKER_01: And so this is an area within infectious disease that's getting a lot of attention, is some of these highly expensive tests, whether it's a broad molecular multiplex panel, or today we actually see a lot of discussion and increased availability of next generation sequencing tests.
• 21:26
  SPEAKER_01: And some of these tests can carry a cost of at least$1,000, if not upwards towards$10,000 by the time you know some factor of multiplication happens between the lab and the patient's bill.
• 21:39
  SPEAKER_01: And in cases where there's either no insurance coverage or a reimbursement or very limited reimbursement, this, you know, it's a kind of a mystery of what exactly is going to happen if you order that test.
• 21:51
  SPEAKER_01: And will that bill ultimately go directly to the patient?
• 21:55
  SPEAKER_01: Will it just get absorbed by the healthcare system?
• 21:57
  SPEAKER_01: It really depends on the situation and the institution.
• 22:00
  SPEAKER_01: The potential that that could go directly to a patient is something that I always discuss.
• 22:04
  SPEAKER_01: We we generally we send very limited next generation sequencing tests, but especially if it's an outpatient where it's considered that's something that we try to ensure beforehand is what will happen through insurance if this test is sent.
• 22:17
  SPEAKER_00: That's a great point.
• 22:18
  SPEAKER_00: I mean, I think the financial harm to patients can be a huge one from healthcare.
• 22:23
  SPEAKER_00: And, you know, obviously, I think uh probably none of us could think of a situation we'd be in where it would be worth$10,000 to have next-gen sequencing on ourselves.
• 22:33
  SPEAKER_02: So, Dr.
• 22:33
  SPEAKER_02: Fulkins, continuing with that topic, in the current healthcare landscape, how can healthcare professionals balance the demand for diagnostic testing with the goal of responsible and judicious use of those tests?
• 22:44
  SPEAKER_01: Yeah, one issue that I think can kind of disrupt this balance is which is a good thing, but it can also be a bad thing, patient self-advocacy.
• 22:52
  SPEAKER_01: And so patient self-advocacy, especially when it's maybe a little bit misguided or misinformed.
• 22:57
  SPEAKER_01: For example, our ED providers sometimes experience that a patient, or honestly, in our pediatric setting, often as a parent, demands a broad respiratory panel, but maybe the patient's, you know, quite stable, they're unlikely to be admitted, they have no underlying issues.
• 23:12
  SPEAKER_01: And so I think these types of situations are really great opportunities for the providers to help with that education and be stewards themselves and kind of explain to the patients, you know, what the test will or won't do and what they would actually get out of it, which in many cases is going to be no management change compared to a narrower panel, as well as the cost, the potential cost to the patient.
• 23:36
  SPEAKER_01: I think that that education is really helpful.
• 23:38
  SPEAKER_01: A second challenge, which again it actually originates from a wonderful thing, but it was mentioned earlier that we have so many tests now, and technology is increasing, and the menu of tests is growing.
• 23:50
  SPEAKER_01: And so providers' familiarity with each test may be variable and they may not be as experienced with the performance and indication of each test.
• 23:59
  SPEAKER_01: So I think this is going to be a process of lifelong learning and trying to keep up with technology and figuring out how to best use these tests.
• 24:08
  SPEAKER_01: But some of the things that institutions can do is potentially identifying areas where there's more frequent use and potentially more frequent misuse, and then develop guidelines or algorithms at the institution level about how they want to use those tests.
• 24:22
  SPEAKER_01: So those types of tools can be really helpful.
• 24:25
  SPEAKER_01: We talked about EMR tools and decision support tools.
• 24:28
  SPEAKER_01: I think there's a lot of ways that we can improve that education on both whether it's a poster on the wall or an immediate education through the order sets that we use or how we build our tools.
• 24:43
  SPEAKER_00: Yeah, I think one point that's worth making, which you know is kind of obvious, I think, from just who's on the call here.
• 24:48
  SPEAKER_00: Um, obviously you guys spend your days like working on getting lab tests done for people.
• 24:53
  SPEAKER_00: And uh, and I order plenty of lab tests, is that diagnostic testing is very helpful too.
• 24:57
  SPEAKER_00: And it's you know, it is a great advance in medicine and have practice in places without it.
• 25:02
  SPEAKER_00: And uh it feels much more uncertain what you're doing.
• 25:06
  SPEAKER_00: But uh I think we're just all talking about like the needing to do it scientifically and be focused, and that you know, these tests aren't good enough to uh to be used indiscriminately.
• 25:16
  SPEAKER_00: So just uh emphasizing for people that I mean, I think we all believe that they are very helpful, but uh just the trying to guide them towards being used most appropriately so they you know we can get all the benefits without the harms of using them the wrong way.
• 25:29
  unknown: Dr.
• 25:30
  SPEAKER_02: Fulkins, you alluded to the technological advancements that are coming with diagnostic testing, and those same advancements and innovations are gonna shape the future of diagnostic stewardship.
• 25:40
  SPEAKER_02: So, how can we leverage those to improve patient care?
• 25:43
  SPEAKER_02: Dr.
• 25:43
  SPEAKER_02: Morgan, what are your thoughts about this?
• 25:46
  SPEAKER_00: I mean, I think better tests always sound great, right?
• 25:48
  SPEAKER_00: I mean, it's an emphasis we've had with funding decisions and Carbex and CDC and others.
• 25:53
  SPEAKER_00: And so I'm always trying to be open towards better tests.
• 25:57
  SPEAKER_00: I I do think often new tests are maybe a trade-off though, and not, you know, clearly better.
• 26:02
  SPEAKER_00: Like often new tests are more sensitive, but maybe not as specific.
• 26:06
  SPEAKER_00: So we have problems with uh we can pick up lots of things, but we're not sure if they're causing a disease or not.
• 26:12
  SPEAKER_00: You know, in this issue, we have an ID with picking up little bits of you know genetic material, say, and not being sure if it's what's making the patient sick or not.
• 26:20
  SPEAKER_00: And um, you know, needing to really try to have good science behind, you know, what does that mean and how can we best use it?
• 26:27
  SPEAKER_00: I think diagnostic stewardship is an innovation to curb some of these problems with tests that works pretty well with some of the new tests.
• 26:34
  SPEAKER_00: But uh, I mean, ideally, I would say evaluation of new tests would consider these issues.
• 26:40
  SPEAKER_00: And I think that maybe a lot of tests can be useful if you use them correctly, but not with indiscriminate use.
• 26:45
  SPEAKER_00: And I think this has been a bit of the issue with like say vicarious test that, you know, it's an interesting test, it's probably useful in certain circumstances, but if you just release it into the wild and doctors use it however they feel and some use it all the time and others never.
• 26:58
  SPEAKER_00: It doesn't tend to provide much value, but if we really think about how we can deploy it in the right places and then ideally do like a randomized trial or something, then we could get much better information to really guide how we can use it scientifically and not, you know, just sort of using it in a way that makes sense to each person and varies, you know, from clinician to clinician.
• 27:17
  SPEAKER_01: Learning more about indications for use, I think, is is a major component of this.
• 27:22
  SPEAKER_01: I agree.
• 27:23
  SPEAKER_01: When we think about tests that are FDA approved, all FDA-approved tests have to come with an indication for use.
• 27:29
  SPEAKER_01: And yet it's often broad, and that makes sense from a manufacturer standpoint, and honestly, even from a clinical standpoint, because we don't want to be pigeonholed into only being able to use a new technology for a very specific time.
• 27:42
  SPEAKER_01: But at the same time, that can lead to maybe too broad of use or not really understanding the appropriate individual clinical situations for which a test is truly indicated.
• 27:56
  SPEAKER_01: And I think the way to solve that is just post-market research and utilization studies.
• 28:02
  SPEAKER_02: I had a resident once ask me, can't we just use a PCR for everything?
• 28:08
  SPEAKER_02: Which led to quite a discussion.
• 28:10
  SPEAKER_02: All right.
• 28:10
  SPEAKER_02: Are there any existing policies or guidelines in place to promote diagnostic stewardship?
• 28:15
  SPEAKER_02: And how can healthcare organizations ensure adherence to these principles?
• 28:19
  unknown: Dr.
• 28:20
  SPEAKER_02: Philkins, any thoughts?
• 28:21
  SPEAKER_02: Lots of thoughts.
• 28:22
  SPEAKER_01: Um, there are a variety of requirements and resources that can really help guide laboratories and also clinicians in using tests in the best way.
• 28:33
  SPEAKER_01: So these can range from CLIA regulations, which is the federal law that mandates how laboratories operate and how we ensure quality practices.
• 28:44
  SPEAKER_01: There are also best practice activities from accrediting agencies.
• 28:49
  SPEAKER_01: So this could be at the level of the laboratory or at the healthcare system.
• 28:52
  SPEAKER_01: The CAP is one example that often is a common accrediting body for laboratories, but also joint commission, which can accredit laboratories and entire hospitals, and there are others.
• 29:02
  SPEAKER_01: And then we have, of course, society guidelines and local institutional guidelines.
• 29:07
  SPEAKER_01: So from the regulatory perspective, laboratories must ensure that they are consistently having appropriate specimen collection and that the collected specimen types or conditions are appropriate for the test.
• 29:21
  SPEAKER_01: These quality aspects are really the core of the laboratory.
• 29:23
  SPEAKER_01: So it's things that we do every day, and yet they are parts of diagnostic stewardship.
• 29:27
  SPEAKER_01: And then for utilization, I'd actually like to highlight a couple of different resources that might be helpful to our listeners.
• 29:33
  SPEAKER_01: So earlier this month, in I think it was March 5th, if I'm remembering correctly, IDSA and ASM jointly published a guideline.
• 29:42
  SPEAKER_01: It's an updated guideline to the utilization of microbiology laboratory for the diagnosis of infectious diseases.
• 29:50
  SPEAKER_01: And that was published in Clinical Infectious Diseases.
• 29:53
  SPEAKER_01: And so this guideline is really nice because it covers laboratory testing approaches to many different categories.
• 30:00
  SPEAKER_01: It kind of takes each broad infection category as a chapter.
• 30:03
  SPEAKER_01: And within each section, it details many different tests that could be used for that for that category of diagnosis.
• 30:12
  SPEAKER_01: But what's really nice is that it also will prioritize and put the preferred tests to least preferred tests in an order.
• 30:19
  SPEAKER_01: So it's just a really great resource for laboratories and also providers to refer to.
• 30:24
  SPEAKER_01: And then a couple more things that we're working on.
• 30:27
  SPEAKER_01: So through our Clinical and Public Health Microbiology Subcommittee on Lab Practices and ASM, we have two additional guidelines that we're actively preparing and we hope to be published later this year.
• 30:39
  SPEAKER_01: So the first talks about the foundation and importance of microbiology labs to be leaders in diagnostic stewardship.
• 30:47
  SPEAKER_01: And it also highlights examples of CLIA regulations, billing requirements, and accreditation checklist items that emphasize this need for laboratories to not only participate but also drive stewardship.
• 30:58
  SPEAKER_01: And then the second document will outline approaches that laboratories can use in collaboration with stakeholders to identify tests to prioritize for stewardship, talks about different methods of stewarding, and then also approaches to monitoring the impact and effectiveness of stewarding.
• 31:17
  SPEAKER_00: Great.
• 31:18
  SPEAKER_00: I mean, those are super interesting to hear about.
• 31:19
  SPEAKER_00: And I hadn't, I didn't realize there was an updated version of the IDSA ASM guidance on testing, which uh always seems like uh an exhaustingly big task to complete.
• 31:30
  SPEAKER_00: So I'll be looking at that.
• 31:31
  SPEAKER_00: Um, the only things I would add is uh there's the Shea Task Force on Diagnostic Stewardship that released uh four guidance papers.
• 31:38
  SPEAKER_00: Um I'd refer people to those.
• 31:40
  SPEAKER_00: Those are um available open access.
• 31:42
  SPEAKER_00: And I would point out that the CDC is working on guidance around diagnostic excellence.
• 31:48
  SPEAKER_00: It's kind of a big task, but trying to combine sort of different worlds from the sort of diagnostic stewardship side to like the overdiagnosis group to the uh diagnostic excellence and medicine type group.
• 31:59
  SPEAKER_00: So uh I would say keep your eyes open for that too, and hopefully that will be appearing in the next six months or so.
• 32:06
  SPEAKER_02: Thanks to both of you for providing those resources.
• 32:08
  SPEAKER_02: Earlier, Dr.
• 32:09
  SPEAKER_02: Flickins alluded to a scenario in which patients or in the case of pediatrics, a patient's parent may actually request testing that isn't always indicated.
• 32:18
  SPEAKER_02: But is there a flip side to that?
• 32:20
  SPEAKER_02: Is there a way in which patient education and engagement could actually contribute to a more informed and responsible approach to diagnostic testing?
• 32:27
  SPEAKER_02: And if so, how can we enhance awareness in this regard?
• 32:32
  SPEAKER_00: Yeah, I mean, I think uh, you know, talking about how we engage patients in these decisions is is critical.
• 32:38
  SPEAKER_00: I mean, one obvious reason too is that a lot of these tests are starting to become more like available over-the-counter from pharmacies.
• 32:44
  SPEAKER_00: So uh there may not be a clinician involved in the process, even.
• 32:46
  SPEAKER_00: But I mean, I think a lot of diagnostic stewardship we think of as being kind of behind the scenes, like patients aren't aware of maybe doctors aren't even saying like if the lab test is comes back, like you know, likely contaminant, no, no uh organisms are reported, say.
• 33:00
  SPEAKER_00: And I I think a lot of this involves education.
• 33:02
  SPEAKER_00: I mean, there's this real kind of zeitgeist in in the US and elsewhere that tests are great, right?
• 33:08
  SPEAKER_00: And information is always good.
• 33:09
  SPEAKER_00: And, you know, go get tested, make certain you don't have it.
• 33:12
  SPEAKER_00: And you know, we saw this during COVID, right?
• 33:14
  SPEAKER_00: Where like somebody got famous saying like rapid tests will end the pandemic in two weeks, which, you know, I think most of us have some skepticism around.
• 33:21
  SPEAKER_00: But uh, I mean, I think this this involves a lot of education around the technology and understanding the pros and cons of testing.
• 33:29
  SPEAKER_00: And and you know, I think most of the time patients don't clearly want exactly one test, but they really want it to be taken care of well.
• 33:35
  SPEAKER_00: And technology seems like an easy way to give that to them.
• 33:38
  SPEAKER_00: Like, okay, sure, we can test you for that, and you know, and then the doctor's done.
• 33:41
  SPEAKER_00: Whereas it takes a lot more time to explain to them like why you don't want this test now, but when you would, and making them feel comfortable that they're being taken care of.
• 33:50
  SPEAKER_00: I know the CDC guidance that I talked about on diagnostic excellence, there's a real emphasis to try to engage patients or patient representatives in this process.
• 34:00
  SPEAKER_00: And and I think that that could help with it, but it will take a lot of work to uh, you know, to work on the education and just understanding, um, you know, and hopefully there can be help from the media and others around this too.
• 34:12
  SPEAKER_01: Yeah, patient education is a challenging one.
• 34:15
  SPEAKER_01: And I I would add to that one of the things that we've moved towards, especially in the past couple of years with some of the laws, more recent laws, is to increase how much patients can see their chart results, their test results.
• 34:29
  SPEAKER_01: And so now thinking about, we think so much about how we communicate our test results with providers.
• 34:36
  SPEAKER_01: But I don't know that we're accustomed to thinking about how we're communicating, at least on the laboratory side, probably patient-facing providers are a little bit more used to thinking about this.
• 34:45
  SPEAKER_01: But on the laboratory side, we haven't been as challenged in the past to think about how a patient is going to interpret that result.
• 34:53
  SPEAKER_01: And hopefully they will do that with the help of a provider, but we also know that it might cross to their my target or whatever else at midnight, and probably a provider's not sitting there calling them up right at the time that it crosses.
• 35:05
  SPEAKER_01: And so, really thinking about how do we not necessarily that we have to explain every result in every report to a patient, but how do we make sure that it's not coming across as something that might be misconstrued or highly alarming, or in what cases is it really essential that there's a slight delay in when those results cross so that the provider can be the first one to see it.
• 35:27
  SPEAKER_01: And just being a little bit more cognizant of that experience on the patient's end.
• 35:32
  SPEAKER_01: We even think about this from test naming now because one of the things that we've tried to move towards is on tests that are highly can be confusing.
• 35:41
  SPEAKER_01: So if you have a couple of different tests with similar names, but they're used for different indications, we've moved a little bit towards trying to add some indications into the test name.
• 35:50
  SPEAKER_01: But we also know that there are going to be times in a subspecialty where maybe they're appropriately using that test, but not for the most common indication.
• 35:57
  SPEAKER_01: And so just thinking about how the patient then is going to experience that when they're they see a test come across that says, you know, for cancer screening or something like that, and it's like not at all being used for that at that moment, um, and and what that might do to the patient's experience.
• 36:11
  SPEAKER_00: I mean, this is a super interesting point.
• 36:14
  SPEAKER_00: That I mean, I think I thought about them a little bit, but not exactly in regard to this.
• 36:18
  SPEAKER_00: And you know, I mean, that a lot of times patients will get their results before they see a doctor to interpret them.
• 36:22
  SPEAKER_00: And I mean, I've heard one answer is chat GPT.
• 36:26
  SPEAKER_00: That's how that's how you can interpret your, you know, your test results.
• 36:29
  SPEAKER_00: Uh, I know someone who did that with an MRI scan to try to figure out what it meant.
• 36:33
  SPEAKER_00: So uh I think that's that's essential, and we should be thinking more about that.
• 36:37
  SPEAKER_00: And you know, probably we need some actual clinical studies or something to see what works and doesn't now that we're you know in this age of kind of extra transparency and maybe information overload for patients.
• 36:48
  SPEAKER_02: Yeah, there's nothing like uh seeing a patient on rounds and they've gotten their updated test result before you even knew that something had crossed over.
• 36:56
  SPEAKER_02: Right?
• 36:57
  SPEAKER_02: That's great.
• 36:58
  SPEAKER_02: Can you guys share some examples or case studies where effective diagnostic stewardship has led to positive outcomes for patients and the healthcare systems?
• 37:06
  SPEAKER_01: Sure, I can start.
• 37:07
  SPEAKER_01: Um, we've had several projects over the past five years that I've been at this institution.
• 37:12
  SPEAKER_01: One of the biggest projects that we worked on when I first got here was with metagenomic testing.
• 37:18
  SPEAKER_01: And so this again, this was five years ago.
• 37:22
  SPEAKER_01: Um, I think we're actually a lot a lot more familiar and comfortable with metagenomic testing, and yet still today there are a lot of questions that remain unclear about when to use each methodology and which patient is the best.
• 37:34
  SPEAKER_01: So, what we did five years ago was for plasma metagenomic cell-free DNA testing, we we actually developed a committee approach to evaluating any requests.
• 37:46
  SPEAKER_01: So it was it was a restricted test, it still is a restricted test, and only infectious disease providers at our institution can request the test.
• 37:55
  SPEAKER_01: But to really start to look at how this testing would be best used for our patients and our population, we thought that it would be helpful to have more discussions around each consideration.
• 38:08
  SPEAKER_01: So we did develop a committee, it was half laboratorians, clinical pathologists, and half infectious disease providers.
• 38:15
  SPEAKER_01: And we would together review charts and think about the potential positives, how it would change management if you know if we got a certain result, and also how to minimize or try to avoid potential negative outcomes because of, as it was alluded to before, some maybe non-specific detection of little fragments of DNA that we aren't sure how to interpret.
• 38:38
  SPEAKER_01: And so we did that for a few years, and it was it was a really positive experience.
• 38:44
  SPEAKER_01: So we wound up with it was rather limited in how much we tested, but over three years, I think we tested uh nine patients and we evaluated and considered testing 12 patients.
• 38:54
  SPEAKER_01: And we also really looked at the three patients that we didn't test retrospectively to it's always hard because it's adjudication based, but to assess, you know, was there a really negative potential consequence of not testing those patients that we had agreed didn't merit testing?
• 39:10
  SPEAKER_01: And all patients recovered from their syndromes without the testing.
• 39:13
  SPEAKER_01: So again, we don't really know what the impact would have been if we had provided that test, but we felt comfortable with the test that we ultimately deferred.
• 39:22
  SPEAKER_01: And so on the flip side, the nine patients that we did test, in five cases, they led to a management change.
• 39:29
  SPEAKER_01: The results led to a management change, which is much higher than you'll see in the literature.
• 39:32
  SPEAKER_01: Um, so I think that was a good experience, not only because we were able to potentially reduce how much testing was occurring that might not be clinically indicated, so saving the healthcare system some money.
• 39:43
  SPEAKER_01: We really were able to improve our yield, or maybe I shouldn't say improved because we didn't compare it to anything, but we we had a high yield of that testing.
• 39:52
  SPEAKER_01: But I think actually maybe the greatest outcome from that was that we were all thinking about the patients together.
• 39:59
  SPEAKER_01: And so for our own institution, we really started to learn how we wanted to use that test.
• 40:04
  SPEAKER_01: And so we were able to then transition out of a committee-based approach into a more institutional guideline, kind of pre-approved indications.
• 40:11
  SPEAKER_01: Here's where we think it's most useful for our patients approach after that.
• 40:15
  SPEAKER_00: I mean, that's great.
• 40:16
  SPEAKER_00: I mean, I do think that probably the cost of some of those tests allows for like a drive some more thoughtful approach, like the this tumor board type approach, which uh, I mean, I think obviously is one of the best ways to approach testing, to take it seriously and you know, think about it a lot.
• 40:30
  SPEAKER_00: The examples that I would highlight are are kind of like sort of more the more dumbed down examples that are pretty common.
• 40:35
  SPEAKER_00: But like at my hospital, we started um playing with how we do urine cultures, and we started out with just making it conditional and that it's only done if pyuria is present.
• 40:44
  SPEAKER_00: And uh, you know, sometimes people call this reflex testing.
• 40:46
  SPEAKER_00: I avoid that because people get confused about which what kind of reflex it is.
• 40:50
  SPEAKER_00: But it's become the standard for urine cultures now, and we're changing the name just to call it urine culturing, not reflex or um conditional culturing.
• 40:58
  SPEAKER_00: And clinicians have gone to where they don't even think about it.
• 41:00
  SPEAKER_00: They just get a result that says it wasn't performed, and they're like, okay, sure, there's no uh no white blood cells there, so it wouldn't happen.
• 41:06
  SPEAKER_00: But uh, you know, we we dramatically decreased the number of unnecessary cultures that were being done.
• 41:11
  SPEAKER_00: I think it's about a 30% decline in in the number of cultures the lab had to process, but also we we had an improved diagnosis of UTI, and so we weren't treating patients as often who are like nursing home patients with confusion or some of these non-specific uses.
• 41:27
  SPEAKER_00: And we've seen similar things with C diff testing where this a toxin is the last step, and antimicrobial stewardship is interprets that and gives recommendations to the team about whether to treat or not.
• 41:37
  SPEAKER_00: So I mean, I think those are two examples that in my hospital I feel like have improved the way we care for patients and uh have made me happy about the time invested in this process.
• 41:46
  SPEAKER_01: I can't agree with the urine culture example more.
• 41:49
  SPEAKER_01: I actually have a meeting in 11 minutes about our UA reflex test build, which is not quite as clear-cut on the pediatric side, but I think it still pertains and is really important.
• 41:59
  SPEAKER_01: So I thought I I wanted to bring it back to a concept that I introduced earlier, which was saying yes to testing.
• 42:05
  SPEAKER_01: And I think we we often do focus our diagnostic stewardship on areas where we see overuse of tests, but there are also examples where we've had underuse or delays in testing, which are equally, if not even more, important.
• 42:20
  SPEAKER_01: So, an example of a project that we worked on a couple of years ago was to improve diagnostic testing of syphilis at our institution.
• 42:28
  SPEAKER_01: So historically, we had had individually orderable tests for each component of the syphilis diagnostic algorithm, and we use the traditional algorithm at our institution.
• 42:37
  SPEAKER_01: So that means we start with RPR if positive, you follow up with a trepanemal antibody test, which we use TPPA.
• 42:44
  SPEAKER_01: And so we found actually that working with the ED that it it was difficult for them to have to either remember to add on the second step if the RPR was positive, or in some cases having a patient come back and they were having some issues with follow-up.
• 43:00
  SPEAKER_01: So, some one of the stewardship projects that we worked on was how to streamline that.
• 43:04
  SPEAKER_01: And again, it's not it's not like a novel idea, others have done this, but it's really it can really impact the patient's experience and timeliness of results.
• 43:12
  SPEAKER_01: So we developed a reflex.
• 43:15
  SPEAKER_01: I I appreciate that you don't like the term reflex.
• 43:17
  SPEAKER_01: I'd actually never even thought of that.
• 43:18
  SPEAKER_01: So it was just accustomed to using that term.
• 43:21
  SPEAKER_01: But yes, we developed an order where the RPR would be first, it would then automatically be interpreted, and if positive, then it would be recognized that that was meriting follow-up.
• 43:31
  SPEAKER_01: And so the TPPA would automatically be ordered and performed if that original reflex test was ordered.
• 43:38
  SPEAKER_01: And then at the same time, we also found that there was a lot of confusion about all of these different testing modalities.
• 43:43
  SPEAKER_01: So thinking about that education piece, we also went up renaming all of our syphilis tests and we added indications to them.
• 43:50
  SPEAKER_01: So, for example, we have a separate order for congenital testing, which at a pediatric hospital is very important.
• 43:56
  SPEAKER_01: We have a separate order for our routine diagnostic algorithm, separate order for neuro syphilis, and a few other orders as well.
• 44:04
  SPEAKER_01: And so the goal of that was really to actually help ensure that patients did get that next test.
• 44:09
  SPEAKER_01: And we expected that to lead to increased testing, not decreased testing.
• 44:14
  SPEAKER_02: I like those examples.
• 44:15
  SPEAKER_02: I'll just throw in mind, I'm just gonna keep going with your syphilis example actually on our side, when our institution switched to the reverse algorithm, which I'm sure many people are familiar with, which instead of starting with an RPR, which is still the standard, I think, in pediatrics, right?
• 44:27
  SPEAKER_02: But in adults, now we start in many cases with the um syphilis antibody, the trepanemal antibody directly.
• 44:33
  SPEAKER_02: And so it was leading to a lot of confusion, people weren't sure how to order it.
• 44:37
  SPEAKER_02: So we actually built two orders, one that is called syphilis diagnosis for somebody who'd never been diagnosed, and it starts with the treponemal antibody.
• 44:45
  SPEAKER_02: And if that is positive, then it reflexes to an RPR.
• 44:49
  SPEAKER_02: And then if it's discordant, then it reflexes to a TPPA as the sort of tiebreaker in that sense.
• 44:55
  SPEAKER_02: And then we have a separate order that is syphilis monitoring for a patient who is known to be positive, and then that's just just the RPR.
• 45:02
  SPEAKER_02: And so we found that that I think really reduced a lot of confusion and led to a lot less repeating of unnecessary testing in somebody because it was able to guide them.
• 45:12
  SPEAKER_02: And then it goes back to what you were saying earlier about what do you even call the test, you know, and how do you get people to order the right thing.
• 45:17
  SPEAKER_02: So well, I want to thank you both very much, Dr.
• 45:21
  SPEAKER_02: Phillips and Dr.
• 45:22
  SPEAKER_02: Morgan, for sharing your perspectives and experiences on the importance of diagnostic stewardship.
• 45:27
  SPEAKER_02: I I think this was a great discussion, and I'm certain that the audience out there is gonna have a lot of points that they can take back to their institutions and their own practices.
• 45:37
  SPEAKER_02: So thank you both so much for joining today.
• 45:40
  SPEAKER_02: Thank you so much for the opportunity to participate.
• 45:43
  SPEAKER_00: Yeah, great talking with both of you.
• 45:45
  SPEAKER_02: All right, and for everybody out there, that concludes this episode of the Shea podcast.
• 45:49
  SPEAKER_02: Thank you so much for tuning in, and we'll see you again soon.