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Twenty Five Choosing Wisely Recommendations from ASCP

As part of the Choosing Wisely Campaign, the American Society for Clinical Pathology has published 25 laboratory tests that physicians and patients should question. The first set of five recommendations was released in February 2014 and the last set in October 2018. Below is the complete list of ASCPs’ recommendations.

  1. Don’t perform population based screening for 25-OH Vitamin D deficiency.
  2. Don’t perform low risk HPV testing.
  3. Avoid routine preoperative testing for low risk surgeries without a clinical indication.
  4. Only order Methylated Septin 9 to screen for colon cancer on patients for whome conventional diagnostics are not possible.
  5. Don’t use bleeding time test to guide patient care.
  6. Don’t order erythrocyte sedimentation rate (ESR) to look for inflammation in patients with undiagnosed conditions. Order C-reactive protein (CRP) to detect acute phase inflammation.
  7. Don’t test vitamin K levels unless the patient has an abnormal international normalized ratio (INR) and does not respond to vitamin K therapy.
  8. Don’t prescribe testosterone therapy unless there is laboratory evidence of testosterone deficiency.
  9. Don’t test for myoglobin or CK-MB in the diagnosis of acute myocardial infarction. Instead, use troponin I or T.
  10. Don’t order multiple tests in the initial evaluation of a patient with suspected non-neoplastic thyroid disease. Order thyroid-stimulating hormone (TSH), and if abnormal, follow up with additional evaluation or treatment depending on the findings.
  11. Do not routinely perform sentinel lymph node biopsy or other diagnostic tests for the evaluation of early, think melanoma because these tests do not improve survival.
  12. Do not routinely order expanded lipid panels (particle sizing, nuclear magnetic resonance) as screening tests for cardiovascular disease.
  13. Do not test for amylase in cases of suspected acute pancreatitis. Instead, test for lipase.
  14. Do not request serology for H. pylori. Use the stool antigen or breath tests instead.
  15. Do not perform fluorescence in situ hybridization (FISH) for myelodysplastic syndrome (MDS)-related abnormalities on bone marrow samples obtained for cytopenias when an adequate conventional karyotype is obtained.
  16. Do not order a frozen section on a pathology specimen if the result will not affect immediate (i.e., intraoperative or perioperative) patient management.
  17. Do not repeat hemoglobin electrophoresis (or equivalent) in patients who have a prior result and who do not require therapeutic intervention or monitoring of hemoglobin variant levels.
  18. Do not test for Protein C, Protein S, or Antithrombin levels during an active clotting event to diagnose a hereditary deficiency because these tests are not analytically accurate during an active clotting event.
  19. Do not order red blood cell folate levels at all. In adults, consider folate supplementation instead of serum folate testing in patients with macrocytic anemia.
  20. Do not use sputum cytology to evaluate patients with peripheral lung lesions.
  21. Don’t request a serum creatinine only to test adult patients with diabetes and/or hypertension for CKD; instead use the Kidney Profile (serum Creatinine with eGFR and urinary albumin-creatinine ratio).
  1. Don’t transfuse plasma to correct a laboratory value; treat the clinical status of the patient.
  2. Don’t order IgM antibody serologic studies to assess for acute infection with infectious agents no longer endemic in the US, and in general avoid using IgM antibody serologies to test for acute infection in the absence of sufficient pre-test probability.
  3. Do not perform peripheral blood flow cytometry to screen for hematological malignancy in the settings of mature neutrophilia, basophilia, erythrocytosis, thrombocytosis, isolated anemia, or isolated thrombocytopenia.
  4. Don’t perform Procalcitonin Testing without an established, evidence-based protocol.

I suspect that most progressive clinical laboratories have already adopted most of twenty recommendations. I consider these recommendations to be low hanging fruit. Now, I would like to see ASCP and CAP tackle the more difficult test utilization issues of maximum allowable frequency, limits on standing orders and orders for expensive esoteric tests.

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