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https://doi.org/10.11613/BM.2021.010703

Using clinical guidelines to assess the potential value of laboratory medicine in clinical decision-making

Allan J. Hicks ; School of Medical Science, Griffith University, Southport, Australia
Zoe L. Carwardine ; Clinical Biochemistry, Sidra Medicine, Doha, Qatar
Mike J. Hallworth ; Clinical Biochemistry, Royal Shrewsbury Hospital, Shrewsbury, UK
Eric S. Kilpatrick ; Department of Clinical Biochemistry, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK

Puni tekst: engleski, pdf (124 KB) str. 74-84 preuzimanja: 26* citiraj
APA 6th Edition
Hicks, A.J., Carwardine, Z.L., Hallworth, M.J. i Kilpatrick, E.S. (2021). Using clinical guidelines to assess the potential value of laboratory medicine in clinical decision-making. Biochemia Medica, 31 (1), 74-84. https://doi.org/10.11613/BM.2021.010703
MLA 8th Edition
Hicks, Allan J., et al. "Using clinical guidelines to assess the potential value of laboratory medicine in clinical decision-making." Biochemia Medica, vol. 31, br. 1, 2021, str. 74-84. https://doi.org/10.11613/BM.2021.010703. Citirano 14.04.2021.
Chicago 17th Edition
Hicks, Allan J., Zoe L. Carwardine, Mike J. Hallworth i Eric S. Kilpatrick. "Using clinical guidelines to assess the potential value of laboratory medicine in clinical decision-making." Biochemia Medica 31, br. 1 (2021): 74-84. https://doi.org/10.11613/BM.2021.010703
Harvard
Hicks, A.J., et al. (2021). 'Using clinical guidelines to assess the potential value of laboratory medicine in clinical decision-making', Biochemia Medica, 31(1), str. 74-84. https://doi.org/10.11613/BM.2021.010703
Vancouver
Hicks AJ, Carwardine ZL, Hallworth MJ, Kilpatrick ES. Using clinical guidelines to assess the potential value of laboratory medicine in clinical decision-making. Biochemia Medica [Internet]. 2021 [pristupljeno 14.04.2021.];31(1):74-84. https://doi.org/10.11613/BM.2021.010703
IEEE
A.J. Hicks, Z.L. Carwardine, M.J. Hallworth i E.S. Kilpatrick, "Using clinical guidelines to assess the potential value of laboratory medicine in clinical decision-making", Biochemia Medica, vol.31, br. 1, str. 74-84, 2021. [Online]. https://doi.org/10.11613/BM.2021.010703

Rad u XML formatu

Sažetak
Introduction: It is often quoted that 70% of clinical decisions are based on laboratory results, but the evidence to substantiate this claim is lacking.
Since clinical guidelines aim to document best-practice decision making for specific disease conditions, inclusion of any laboratory test means that
the best available evidence is recommending clinicians use it. Cardiovascular disease (CVD) is the world’s most common cause of mortality, so this
study reviewed all CVD guidelines published by five national/international authorities to determine what proportion of them recommended laboratory
testing.
Materials and methods: Five leading CVD guidelines were examined, namely the European Society of Cardiology (ESC), the UK National Institute
for Health and Clinical Excellence (NICE), the American College of Cardiology (ACC), the Australian Heart Foundation (AHF) and the Cardiac Society of
Australia and New Zealand (CSANZ).
Results: A total of 101 guidelines were reviewed. Of the 33 individual ESC guidelines relating to CVD, 24/33 made a direct reference to the use of
clinical laboratory tests in either diagnosis or follow-up treatment. The same applied to 15/20 of NICE guidelines, 24/32 from the ACC and 15/16 from
the AHF/CSANZ. Renal function and blood count testing were the most recommended (39 and 26 times), with lipid, troponin and natriuretic peptide
measurement advocated 25, 19 and 19 times respectively.
Conclusions: This study has shown that laboratory testing is advocated by between 73% and 94% of individual CVD guideline recommendations
from five national/international authorities. This provides an index to assess the potential value of laboratory medicine to healthcare.

Ključne riječi
cardiovascular diseases; guideline; clinical laboratory testing

Hrčak ID: 252078

URI
https://hrcak.srce.hr/252078

▼ Article Information



Introduction

The contribution of laboratory medicine to patient diagnosis, management and follow-up has proven difficult to quantify with systematic evidence of improved patient outcomes scarce (1). The phrase that ‘laboratory medicine influences 70% of clinical decisions’, or similar, has been published many times but the evidence to substantiate this claim is lacking. An editorial in the Annals of Clinical Biochemistry stated that the 70% figure was first published in 1996 and was based on anecdotal evidence and unpublished studies (2). The editorial lists various examples of the use of this phrase, albeit with slight modifications, for example; Lord Carter’s report on the UK Pathology service, the First Report of the UK House of Commons Select Committee on Health, and in the UK Department of Health report “Modernizing Pathology Services” (2).

A related and also oft-quoted statistic is that 70% of the electronic patient record is composed of laboratory data, but the main limitation of this observation is that the presence of laboratory results in a patient record does not necessarily equate to it being used in any clinical decision-making process (3). Over-requesting of testing is a common feature of many healthcare systems and panels of tests may include many analytes which are unrelated to the patient’s clinical condition. A 2016 study of laboratory use by oncologists and cardiologists found that 75% of all their patients underwent laboratory testing, and that this testing led to a substantial clinical decision in 66% of the patients (4).

Over time the 70% claim has apparently gained legitimacy simply due to the number of times that it had been repeated. Partly to examine this claim more closely, the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) established a Task Force on the Impact of Laboratory Medicine on Clinical Management and Outcomes in 2012. Its purpose was twofold: first, to evaluate the available evidence supporting the impact of laboratory medicine in healthcare; and secondly to develop a study design methodology for new retrospective and prospective studies capable of generating evidence to determine the contribution made by laboratory medicine to healthcare.

The IFCC Task Force published a summary of its findings in 2015 which included as one of its suggestions that the contents of authoritative clinical guidelines could provide an objective means of assessing the role of laboratory medicine in the management of specific health conditions (1). Clinical guidelines are documents which aim to guide decisions regarding diagnosis, management and treatment in specific areas of health care. By using the best evidence available the assumption is that each individual guideline recommendation is how clinicians should be making their clinical decisions.

In respect to which health condition should have its guidelines examined, according to the World Health Organization (WHO) cardiovascular disease (CVD) is the world’s most prevalent cause of mortality encompassing a large number of diseases including those of coronary heart disease, heart failure, rhythm and valvular abnormalities as well as cerebrovascular diseases (5). The report estimated that 17.9 million people worldwide die from CVDs which equates to 31% of all deaths and, of these, 85% were due to myocardial infarction or stroke (5). The British Heart Foundation report that CVD accounts for almost 170,000 deaths in the UK costing the National Health Service there £6.8 billion in 2012/2013 (6). In Europe, CVD is responsible for 3.9 million (45%) of all deaths annually (7). The American Heart Association has reported that coronary heart disease is the leading cause of death among Americans, accounting for 840,678 (30%) deaths in 2016 (8). According to the Australian Institute of Health and Welfare Alliance, CVD directly contributed to 45,400 deaths in 2015 which accounts for 29% of all deaths that year in Australia (9).

Accordingly, this study has chosen to examine some national and international cardiovascular clinical guidelines in detail from the countries just mentioned in order to determine what proportion of them recommended laboratory testing.

Materials and methods

We conducted a review of all the individual cardiovascular guidelines available on the websites of the UK National Institute for Health and Care Excellence (NICE), the European Society of Cardiology (ESC), the American College of Cardiology (ACC), and Cardiac Society of Australia and New Zealand (CSANZ) and Australian Heart Foundation (AHF) in their online versions which were current on the 23rd April 2020 (10-14). All the guidelines from the cardiology societies were examined while the NICE guidelines were limited only to those categorised by them as referring to ‘cardiovascular conditions’. The AHF and the CSANZ guidelines were combined because a number of their guidelines were shared and, where they were identical, only one was included in the analysis statistics. These specific national/international guidelines were chosen because of their geographical spread and because they have previously been found to be rigorous with, for example, NICE and ESC guidance having the highest Appraisal of Guidelines for Research and Evaluation (AGREE) II scores for cardiovascular risk assessment in a systematic review (15).

Each individual guideline was read through in its entirety to determine if it was documented that laboratory involvement (defined as a test usually associated with one of the Laboratory Medicine disciplines, Histology or Genetics) was required for either an initial diagnosis or the ongoing management of care of the cardiovascular condition referred to in the document. Data was collected separately for tests which were used for initial diagnosis compared to those required for follow-up, and all forms of testing were included, not just analyses traditionally associated with CVD.

The proportion of guidelines containing laboratory medicine recommendations were determined for each national/international authority (AHF and CSANZ regarded as one) and for them combined. These proportions were calculated by simply dividing the number of individual guidelines indicating testing (if used for diagnosis and/or follow-up this was counted as one) by the total number of guidelines, whether for each national/international authority or for all authorities combined.

For solely the purpose of determining which types of tests were mentioned most frequently by the guidelines, some related tests were categorised together. Thus, renal function related testing included ‘renal function tests’, ‘creatinine’ and ‘eGFR’ in the text; natriuretic peptides included ‘natriuretic peptides’, ‘BNP’ and ‘NT-proBNP’; ‘calcium’, if mentioned separately from other electrolytes, was included in an "electrolytes group" and FBC and CBC were regarded as synonyms. Genetic and histology tests were not subcategorised any further.

As this is a review of existing guidelines, no Institutional Review Board approval was required.

Results

Table 1 shows the 101 guidelines related to CVD available from NICE, ESC, ACC and the AHF/CSANZ and summarises the number and/or percentage indicating pathology testing for either initial diagnosis, follow up pathology testing or a combination of both. Taken together, in vitro diagnostic testing was required for diagnosing 64% of the conditions alluded to in the cardiovascular guidelines, with a similar proportion (62%) advocating testing for the continued management of such patients. As tests were sometimes recommended for both the diagnosis and follow-up of same condition, it means some form of testing was, on average, required by 77% of individual guidelines.

Table 1 Summary of requirement for in vitro diagnostic testing as part of individual cardiovascular guideline recommendations from 5 sources
Organisation
(Country/Region)
Testing required for initial diagnosis*Testing required for further managementGuidelines requiring any testingTotal number of CVD guidelines
NICE (UK)10131520
ESC (Europe)20172433
ACC (USA)20242432
AHF/CSANZ (Australasia)1591516
Total, N (%)65 (64)63 (62)78 (77)101 (100)
*All refer to the number of guidelines requiring testing. NICE - UK National Institute for Health and Clinical Excellence. ESC - European Society of Cardiology. ACC - American College of Cardiology. AHF - Australian Heart Foundation. CSANZ - Cardiac Society of Australia and New Zealand. CVD - cardiovascular disease.

Tables 2-5{ label needed for table-wrap[@id='t3'] }{ label needed for table-wrap[@id='t4'] }{ label needed for table-wrap[@id='t5'] } respectively show details of the individual NICE, ESC, ACC and the AHF/CSANZ guidelines including the year published and the tests mentioned within the body of the document. The test names used in these tables are as described in the respective guidelines.

Table 2 National Institute for Health and Clinical Excellence (NICE) Guidelines
GuidelineYear publishedTesting required for initial diagnosisTesting required for further managementIndicated test(s)
Hypertension in pregnancy: diagnosis and management2019YesYesRFT, LFT, FBC, urinalysis
Chronic heart failure in adults: management2018YesYesNT-proBNP, RFT, LFT, FBC, lipids, HbA1c, TFT, urinalysis
Stable angina: management2016YesYescTn, FBC
Hypertension in adults: diagnosis and management2019NoYesRFT, eGFR, Lipids, HbA1c, creatinine, urinalysis
Hyperglycaemia in acute coronary syndromes: management2016NoYesGlucose, HbA1c
Venous thromboembolic diseases: diagnosis, management and thrombophilia testing2020YesYesD-dimer, PT, APTT, FBC, RFT, LFT
Peripheral arterial disease: diagnosis and management2018NoNo/
Stroke rehabilitation in adults2013NoNo/
Myocardial infarction with ST-segment elevation: acute management2013NoNo/
Varicose veins: diagnosis and management2013NoNo/
Atrial fibrillation2014NoYesLFT, INR, digoxin concentrations
Cardiovascular Disease: risk assessment and reduction, including lipid modification2016YesYeseGFR, lipids, albumin, HbA1c, LFT, RFT, CK
Acute Heart Failure: diagnosis and management2014YesYesBNP, RFT, NT-proBNP
Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures2016NoNo/
Stroke and transient ischaemic attack in over 16s: diagnosis and initial management2019NoYesINR, glucose, HbA1c,
Familial hypercholesterolemia: identification and management2019YesYesLipids
Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism2019NoNoeGFR
Unstable angina and Non-ST-elevation myocardial infarction: early management2013NoYescTn, creatinine, glucose, FBC
Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis2016YesNocTn
Myocardial Infarction: cardiac rehabilitation and prevention of further MI2013NoYesRFT
RFT - renal function tests. LFT - liver function tests. FBC - full blood count. NT-proBNP - N-terminal pro-B-type natriuretic peptide. HbA1c - haemoglobin A1c. TFT - thyroid function tests. cTn - cardiac troponins. eGFR – estimated glomerular filtration rate. PT - prothrombin time. APTT - activated partial thromboplastin time. INR - international normalized ratio. CK - creatine kinase. BNP – B-type natriuretic peptide.
{ label needed for table-wrap[@id='t3'] }
Table 3 European Society of Cardiology (ESC) guidelines
GuidelinesYear publishedTesting required for initial diagnosisTesting required for further managementIndicated test(s)
Infective Endocarditis (Guidelines on Prevention, Diagnosis and Treatment of)2015YesYesCRP, ESR, IS, BC, creatinine, bilirubin, CBC
Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death2015NoYesElectrolytes,
Pericardial Diseases (Guidelines on the Diagnosis and Management of)2015YesYesCRP, CBC, ESR, CK, cTn, RFT, LFT
Acute Coronary Syndromes in patients presenting without persistent ST-segment elevation2015YesYescTn, lipids
Pulmonary Hypertension (Guidelines on Diagnosis and Treatment of)2015YesYesRFT, CBC, iron studies, LFT
Hypertrophic Cardiomyopathy2014YesNoBNP, cTn, CK, TFT, RFT, CBC,
Aortic Diseases2014YesNoBNP, cTn
ESC/EACTS Guidelines in Myocardial Revascularisation (Guidelines for)2018NoNo/
Acute Pulmonary Embolism (Diagnosis and Management of)2019YesNoD-dimer
ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management2014YesNocTn
Diabetes, Pre-Diabetes and Cardiovascular Diseases developed with the EASD2019YesYesGlucose, lipids, HbA1c
Stable Coronary Artery Disease (Management of)2019YesYesGlucose, LFT, TFT, CBC, lipids, HbA1c, CK, creatinine
Cardiac Pacing and Cardiac Resynchronization Therapy2013NoNo
Arterial Hypertension (Management of)2018YesYesGlucose, LFT, RFT, eGFR, lipids, creatinine
Valvular Heart Disease (Management of)2017YesYesBNP
Atrial Fibrillation (Management of) 2010 and Focused Update (2012)2016NoNo/
Acute Myocardial Infarction in patients presenting with ST-segment elevation (Management of)2017YesNocTn
Acute and Chronic Heart Failure2016YesYesBNP
CVD Prevention in clinical practice (European Guidelines on)2016NoNo/
Dyslipidaemias (Management of)2019YesYesLipids, CRP
Cardiovascular Diseases during Pregnancy (Management of)2018YesYesCBC, RFT, LFT, BNP, cTn, D-dimer, urine protein
Peripheral Artery Diseases (Diagnosis and Treatment of)2017YesYesGlucose, lipids, creatinine, urine protein, CBC, RFT, HbA1c,
Grown-Up Congenital Heart Disease (Management of)2010NoYesCBC, ferritin, creatinine, uric acid, BNP, folic acid, vitamin B12
Device Therapy in Heart Failure (Focused Update)2010NoNo/
Syncope (Guidelines on Diagnosis and Management of)2018NoNo/
The Role of Endomyocardial Biopsy in the Management of Cardiovascular Disease2007YesNoHistological examination
B-Adrenergic Receptor Blockers (Expert Consensus Document on)2004NoNo/
Angiotensin Converting Enzyme Inhibitors in Cardiovascular Disease (Expert Consensus Document on)2004NoYesRFT, creatinine
Antiplatelet Agents (Expert Consensus Document on the Use of)2004NoNo/
Supraventricular Arrhythmias (ACC/AHA/ESC Guidelines for the Management of Patients with)2003NoYesTFT
Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project2003YesNoLipids
Neonatal Electrocardiogram (Guidelines for the interpretation of the)2002NoNo/
Chest Pain (Management of)2002YesYescTn, CK
CRP - C-reactive protein. ESR - erythrocyte sedimentation rate. IS - infectious serology. BC - blood culture. CBC – complete blood count. CK - creatine kinase. cTn - cardiac troponins. RFT - renal function tests. LFT - liver function tests. BNP – B-type natriuretic peptide. TFT - thyroid function tests. HbA1c - haemoglobin A1c. eGFR – estimated glomerular filtration rate.
{ label needed for table-wrap[@id='t4'] }
Table 4 American College of Cardiology (ACC) Guidelines
GuidelineYear publishedTesting required for initial diagnosisTesting required for further managementIndicated test(s)
Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation2019NoYesCRP, CBC, TFT, RFT, LFT, electrolytes, INR, coagulation monitoring
Guideline on the Management of Blood Cholesterol2018YesYesLipids
Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay2018NoNo/
Guideline for the Management of Adults With Congenital Heart Disease2018NoYesAPTT, INR, BNP
Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death2017YesYesBNP, cTn, electrolytes, lipids, calcium
Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults2017YesYesFasting glucose, CBC, lipids, creatinine, eGFR, Ca2+, electrolytes, TFT, urinalysis
Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure2017YesYesBNP, cTn, eGFR, iron
Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease2017YesYesBNP, cTn, electrolytes, RFT, iron
Guideline for the Evaluation and Management of Patients With Syncope2017YesYesCBC, electrolytes, BNP, cTn, glucose
Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease2016NoYesFasting glucose, RFT, HbA1c
Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease2016NoNo/
Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction2015NoNo/
Surgery for Aortic Dilatation in Patients With Bicuspid Aortic Valves2015NoNo/
Guideline for the Management of Adult Patients With Supraventricular Tachycardia2015NoNo/
Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes2014YesYescTn, BNP, lipids, RFT fasting glucose, HbA1c, creatinine, eGFR,
Strategies to Enhance Application of Clinical Practice Guidelines in Patients With Cardiovascular Disease and Comorbid Conditions2014NoNo/
Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery2014NoYesNatriuretic peptides
Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease2012YesYesLipids, HbA1c, creatinine
Guideline for the Management of Patients with Atrial Fibrillation2014YesYesCRP, CBC, TFT, RFT, LFT, electrolytes, INR, coagulation monitoring
Guideline for the Management of Patients with Valvular Heart Disease2014NoYeseGFR, BNP, INR, LFT, BC, IS, histology, RF
Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)2013NoYesFasting glucose, RFT, HbA1c
Guideline on the Assessment of Cardiovascular Risk2013YesYesCRP, creatinine, eGFR
Guideline for the Management of Heart Failure2013YesYesFasting glucose, CBC, lipids, creatinine, eGFR, Ca2+, electrolytes, TFT, urinalysis
ST-Elevation Myocardial Infarction2012YesYesLipids, glucose, HbA1c, cTn, RFT, coagulation monitoring
Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy2011YesYescTn, genetic testing
Guideline for Coronary Artery Bypass Graft Surgery2011NoNo/
Guideline for Percutaneous Coronary Intervention2011YesYesGlucose, HbA1c, RFT, cTn, BNP, iron, lipids
Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease2011YesYeslipids, RFT, electrolytes,
Cardiovascular Disease Prevention in Women2011YesYesLipids, glucose, HbA1c, hormone concentrations
Extracranial Carotid and Vertebral Artery Disease2011YesYesCBC, Ca2+, lipids, glucose, HbA1c
Thoracic Aortic Disease2010YesYesGenetic testing, IS, BC, D-dimer, CRP, CBC, coagulation monitoring,
blood type and screen, urinalysis
Device-Based Therapy of Cardiac Rhythm Abnormalities2008NoNo/
CRP - C-reactive protein. CBC – complete blood count. TFT - thyroid function tests. RFT - renal function tests. LFT - liver function tests. INR - international normalized ratio. APTT - activated partial thromboplastin time. BNP – B-type natriuretic peptide. cTn - cardiac troponins. eGFR – estimated glomerular filtration rate. Ca2+ - ionized calcium. HbA1c - haemoglobin A1c. BC - blood culture. IS - infectious serology. RF - rheumatoid factor. IS - infectious serology.
{ label needed for table-wrap[@id='t5'] }
Table 5 Australian Heart Foundation (AHF) and the Cardiac Society of Australia and New Zealand (CSANZ) Guidelines
GuidelineSourceYear PublishedTesting required for initial diagnosisTesting required for further managementIndicated test(s)
Australian Clinical Guidelines for the Diagnosis and Management of Atrial FibrillationAHF/CSANZ2018YesYesCBC, RFT, TFT, HbA1c, INR, electrolytes, lipids
Guidelines for the Prevention, Detection, and Management of Heart Failure in AustraliaAHF/CSANZ2018YesYesBNP, genetic testing, RFT, creatinine, glucose, CBC
Coronary Artery Calcium ScoringCSANZ2017YesNoeGFR, glucose, HbA1c, lipids,
Clinical Guideline for the diagnosis and management of hypertension in adultsAHF2016YesYesUrinalysis, RFT, glucose, eGFR, creatinine, lipids, CBC
Guidelines for the Diagnosis and Management of Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)CSANZ2016NoYesGenetic testing
Clinical guidelines for the management of Acute coronary syndromeAHF/CSANZ2016YesYescTn, lipids, glucose, HbA1c, eGFR, APTT, CBC
Diagnosis and Management of Familial Dilated CardiomyopathyCSANZ2016YesNoCK, genetic testing
Diagnosis and Management of Familial HypercholesterolaemiaCSANZ2016YesYesLipids, genetic testing
Update on the Diagnosis and Management of Familial Long QT SyndromeCSANZ2016YesNoGenetic testing
Diagnosis and Management of Hypertrophic CardiomyopathyCSANZ2016YesNoHistological examination, genetic testing
Update on the diagnosis and management of inherited aortopathies, including Marfan syndromeCSANZ2016YesNogenetic testing
The routine cardiac assessment of newborns with Down
syndrome
CSANZ2016NoNo/
Position Statement on the Diagnosis and Management of Brugada SyndromeCSANZ2015YesNoGenetic testing
Guidelines for the management of Absolute cardiovascular disease riskAHF/CSANZ2012YesYesUrinalysis, RFT, glucose, eGFR, creatinine, lipids, CBC
Guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart diseaseAHF/CSANZ2012YesYesCBC, CRP, BC, IS, ESR
Guidelines for the diagnosis and management of Arrhythmogenic Right Ventricular CardiomyopathyCSANZ2019YesNoGenetic testing
CBC – complete blood count. RFT - renal function tests. TFT - thyroid function tests. HbA1c - haemoglobin A1c. INR - international normalized ratio. BNP – B-type natriuretic peptide. eGFR – estimated glomerular filtration rate. cTn - cardiac troponins. APTT - activated partial thromboplastin time. CK - creatine kinase. CRP - C-reactive protein. BC - blood culture. IS - infectious serology. ESR - erythrocyte sedimentation rate.

Twenty seven different test categories were explicitly mentioned 276 times within the 78 guidelines requiring testing (Tables 2-5{ label needed for table-wrap[@id='t3'] }{ label needed for table-wrap[@id='t4'] }{ label needed for table-wrap[@id='t5'] }). The commonest were renal function related biochemistry (mentioned 39 times), complete (or ‘full’) blood counts (26 times), lipids (25 times) and blood/plasma glucose (20 times). More specific to cardiovascular disease were the troponins (19 times) and natriuretic peptides (19 times).

Discussion

Guidelines are designed to inform optimum decision-making by clinicians, and therefore provide a measure of the value of laboratory medicine. This study has shown that between 73% and 94% of individual UK (NICE), European (ESC), United States (ACC) and Australasian (AHF/CSANZ) guidelines related to CVD state that laboratory testing of some sort is recommended. The topics of these individual guidelines tend to be related to specific clinical conditions, so it means that, taken together, 77% of clinical recommendation pathways involving each of these cardiovascular diseases require laboratory assistance at some point in their diagnosis or management.

There are both limitations and strengths to using guidelines as a measure of laboratory medicine’s contribution to healthcare. One potential limitation is that clinical guidelines are not necessarily followed by all physicians or other healthcare staff. A clinician’s own pathway for patients may therefore involve more or less testing than is being recommended. However, the main advantage of our method is that at least the guidelines define an evidence-based recommendation for best practice in each specific clinical scenario. The guidelines also tend to be specific in the test or tests that are recommended, which is advantageous in two ways. First, it helps ensure that the contribution of laboratory medicine to healthcare is not exaggerated by over-requesting - as could be the case if health records were solely being examined - and, secondly, that a clinical decision relevant to the health condition is intended to be taken on the basis of the result.

It should be noted that the guidelines examined in this study were produced in relatively affluent countries with developed healthcare systems and so the use of laboratory medicine testing advocated in other, less wealthy, countries may well differ. Nonetheless, this does not preclude the same methodology as used here being applied to any alternative CVD guidelines from other countries.

Beyond CVD, there is also the possibility that the same objective approach to guidelines could be applied to determine the contribution of laboratory medicine in other, less prevalent, disease groups. Combining the findings from these different disease groups could potentially provide a more accurate overall assessment of the significance of laboratory medicine to healthcare in general.

In summary, this study has found a requirement for the use of laboratory testing in 73% to 94% of cardiovascular guidelines produced by five different organisations. It does not provide a direct link to improved patient outcomes but does provide an index to assess the potential value of laboratory medicine to healthcare which can complement other metrics.

Acknowledgements

I, Allan Hicks, would like to thank A/Prof Indu Singh, Dr Avinash Kundur and Dr Adrian Charles as my doctorate supervisors.

Notes

[1] Conflicts of interest Potential conflict of interest

None declared.

References

1 

Hallworth MJ, Epner PL, Ebert C, Fantz CR, Higgins TN, Kilpatrick ES, et al. IFCC Task Force on the Impact of Laboratory Medicine on Clinical Management and Outcomes. Current evidence and future perspectives on the effective practice of patient-centered laboratory medicine. Clin Chem. 2015;61:589–9. DOI: http://dx.doi.org/10.1373/clinchem.2014.232629 PubMed: http://www.ncbi.nlm.nih.gov/pubmed/25646214

2 

Hallworth MJ. The “70% claim”: what is the evidence base? Ann Clin Biochem. 2011;48:487–8. DOI: http://dx.doi.org/10.1258/acb.2011.011177 PubMed: http://www.ncbi.nlm.nih.gov/pubmed/22045648

3 

Becich MJ. Information management: moving from test results to clinical information. Clin Leadersh Manag Rev. 2000;14:296–300. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/11210218

4 

Rohr UP, Binder C, Dieterle T, Giusti F, Messina CGM, Toerien E, et al. The value of in vitro diagnostic testing in medical practice: a status report. PLoS One. 2016;11:e0149856. DOI: http://dx.doi.org/10.1371/journal.pone.0149856 PubMed: http://www.ncbi.nlm.nih.gov/pubmed/26942417

5 

World Health Organization. Cardiovascular diseases (CVDs) factsheet. Available at: https://www.who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds). Accessed April 26th 2020.

6 

Bhatnagar P, Wickramasinghe K, Williams J, Rayner M, Townsend N. The epidemiology of cardiovascular disease in the UK 2014. Heart. 2015;101:1182–9. DOI: http://dx.doi.org/10.1136/heartjnl-2015-307516 PubMed: http://www.ncbi.nlm.nih.gov/pubmed/26041770

7 

Wilkins E, Wilson L, Wickramasinghe K, Bhatnagar P, Leal J, Luengo-Fernandez R, et al. European Cardiovascular Disease Statistics 2017. Brussels: European Heart Network, 2017.

8 

Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics - 2019 update: a report from the American Heart Association. Circulation. 2019;139:e56–528. DOI: http://dx.doi.org/10.1161/CIR.0000000000000659 PubMed: http://www.ncbi.nlm.nih.gov/pubmed/30700139

9 

Australian Institute of Health and Welfare. Cardiovascular Disease snapshot. Available at: https://www.aihw.gov.au/reports/heart-stroke-vascular-disease/cardiovascular-health-compendium/contents/how-many-australians-have-cardiovascular-disease. Accessed April 23rd 2020.

10 

National Institute for Health and Care Excellence Guidance and advice list. Available at: https://www.nice.org.uk/guidance/published?type=apg,csg,cg,mpg,ph,sg,sc,dg,hst,ipg,mtg,qs,ta. Accessed April 23rd 2020.

11 

European Society of Cardiology Clinical guidelines. Available at: https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines. Accessed April 23rd 2020.

12 

American College of Cardiology guidelines. Available at: https://www.acc.org/guidelines#doctype=Guidelines. Accessed April 23rd 2020.

13 

Cardiac Society of Australia and New Zealand resources. Available at: https://www.csanz.edu.au/resources/. Accessed April 23rd 2020.

14 

The Australian Heart Foundation clinical information. Available at: https://www.heartfoundation.org.au/for-professionals/clinical-information/. Accessed April 23rd 2020.

15 

Khanji MY, Bicalho VVS, van Waardhuizen CN, Ferket BS, Petersen SE, Hunink MGM. Cardiovascular risk assessment. A systematic review of guidelines. Ann Intern Med. 2016;165:713–22. DOI: http://dx.doi.org/10.7326/M16-1110 PubMed: http://www.ncbi.nlm.nih.gov/pubmed/27618509


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