1/ #SHEASpring2023 @samdominguez309 talking to us about the nuts and bolts of building a diagnostic stewardship program!
@COpedsID
@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
📌 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!
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
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?
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:
📌 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.
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
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:
📌 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?
Should we use something like this in immunosuppressed vs immunocompetent patients?
17/ interpretation can be really challenging!
Will this test prompt the right action?
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
📌 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
@AndrewHandel
21/ what’s next?!
📌 assessing the sustainability of BrightStar 1, seeing what really happened to CLABSI
📌some D&I work (LIBRA)
📌 BrightStar respiratory (yay!!)
📌 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!
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
📌 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!
@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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