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Overuse of INR and PT Testing in Medical Inpatients

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.

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Overuse of INR and PT Testing in Medical Inpatients

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

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

  3. 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

  4. 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.

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

  6. 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.

  7. 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%)

  8. 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

  9. 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.

  10. 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.

  11. 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

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