1/ #SHEASpring2023 @samdominguez309 talking to us about the nuts and bolts of building a diagnostic stewardship program!
@COpedsID
2/ Things are complex and we are getting a lot of sensitive tests coming to market. Interpreting results can be challenging
3/ The goal of diagnostic stewardship isn’t just about stopping testing! It’s ensuring that tests are being used in a thoughtful way. Dr. Dominguez has been working in this space for years, but calls for more outcomes and economics research in this space
4/ Right test:
📌 is the test appropriate for the clinical setting?
📌 performance (sensitivity, specificity, ppv, npv)
📌 testing volumes
📌 additional test or replacement?
📌 we should do more theoretical clinical impact simulations!
📌 cost vs. value
5/ right patient:
Will the patient be affected by this result? If not, may not be the right test!
6/ How do we making change and impact?
Consider hierarchy of effectiveness
7/ Example: implementing the meningitis/encephalitis panel in a pediatric setting
8/ Right time:
Will the test result be available in time to impact care?
📌 consider setting, lab workflow
Right interpretation:
Will the clinician understand the result?
9/ The Banerjee study is a great example of this — most impact of rapid diagnostic test seen when combined with active stewardship
10/ there are potential harms of dx stewardship and we should acknowledge them.
📌 risk of missed diagnosis
📌 clinician perceived loss of autonomy
Possible solutions for this:
11/ Teamwork and stakeholder engagement is key!
12/ Ending with a big THANKS to a wonderful team!
13/ Next up, Dr Handel talking to us about new diagnostics pitfalls and promise
14/ what about novel/less common diagnostic tests?
mNGS is a great example. One test to rule them all?
📌 while the 2014 study in NEJM sparked a lot of excitement, things aren’t always so clear or accurate in this space.
14/ Use of these tests is variable with lots of (sometimes passionate) feelings about how/why/when to use them.
So what to do?!
Hint: it’s complex
15/ Right test:
📌 what question is being asked?
📌 are there alternatives to answering that question?
📌 do data for using mNGS in the given scenario exist?
Example of where this seemed to work well:
16/ Right person:
Should we use something like this in immunosuppressed vs immunocompetent patients?
17/ interpretation can be really challenging!
Will this test prompt the right action?
18/ The recommendations for this type of testing include:
📌 oversight is needed! ID and/or lab personnel should approve testing
📌 carefully consider the question you’re trying to answer (review the literature)
📌 pause to consider utility
📌 considering drawing and holding
19/ Finally, ways we can fill the gaps are listed. Im a huge fan of a collaborative for sharing diagnostic stewardship strategies!
@AndrewHandel
20/ Now updates from @CWoodsHillMD on future of brightSTAR collaborative
21/ what’s next?!
📌 assessing the sustainability of BrightStar 1, seeing what really happened to CLABSI
📌some D&I work (LIBRA)
📌 BrightStar respiratory (yay!!)
22/
36% reduction in CLABSI. The reasoning for this is unclear, but the team is going to dig deeper into this to work to understand it. More to come!
23/ Application of implementation science coupled with behavioral science to understand why clinicians choose to order tests.
📌 picu clinicians like to act
📌 picu clinicians like to provide usual/customary care
📌 outcome bias
23/ Loss aversion may drive how we approach diagnostic testing in the PICU
24/ LIBRA will be a hybrid pilot trial that will explore implementation strategies to implement optimal use of blood cultures safely
24/ BrightStar respiratory
@asicksamuels is a leader on this one! Can’t wait to see if/how this program safely reduces unnecessary respiratory testing!
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