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February 16, 1990, Vol 263, No. 7 >
ARTICLE | February 16, 1990

Inappropriate Testing for Diarrheal Diseases in the Hospital FREE

Don L. Siegel, PhD, MD; Paul H. Edelstein, MD; Irving Nachamkin, DrPH
[+] Author Affiliations

Reprint requests to the Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Founders Bldg, Room 6-55, 3400 Spruce St, Philadelphia, PA 19104-4283 (Dr Siegel).


JAMA. 1990;263(7):979-982. doi:10.1001/jama.1990.03440070067034
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References

To assess the degree to which routine stool cultures, ova and parasite examinations, and Clostridium difficile toxin assays may be inappropriately ordered on hospitalized patients, we conducted a retrospective study to determine the relative yield of these tests on specimens collected from outpatients and inpatients as a function of time after admission. During a 3-year period, only 1 of 191 positive stool cultures and none of the 90 ova and parasite examinations with positive results were from the group of patients who had stool specimens submitted after 3 days of hospitalization. Analysis of laboratory work load for a 1-year period showed that specimens from this patient group contributed nearly 50% of the more than 3000 specimens received each year. In contrast, approximately 25% (range, 17% to 33%) of samples, regardless of admission status, were positive for C difficile toxin. Eliminating routine stool cultures and ova and parasite examinations on hospitalized patients would significantly reduce hospital and patient costs without altering patient care. Nationwide, such a policy might achieve a cost savings of $20 to $30 million per year.

(JAMA. 1990;263:979-982)

REFERENCES

1 +
Hughes JM, Guerrant RL. CRC Handbook of Hospital Acquired Infections . Boca Raton, Fla: CRC Press Inc; 1981;:539-562.
2 +
Gilligan PH.  Diarrheal disease in the hospitalized patient . Infect Control. 1981;;7:607-609.
3 +
Schroeder SA, Aserkoff B, Brachman PS.  Epidemic salmonellosis in hospitals and institutions . N Engl J Med. 1968;;279:674-678.
4 +
Kaplan JP, Fineberg HV, Benfari-Ferraro MJ, Rosenberg ML.  Value of stool cultures . Lancet. 1980;;2:413-416.
5 +
GilliganPH, McCarthy LR, Genta VM.  Relative frequency of Clostridium difficile in patients with diarrheal disease . J Clin Microbiol. 1981;;14:26-31.
6 +
Yannelli B, Gurevich I, Schoch PE, Cunha BA.  Yield of stool cultures, O&P tests, and Clostridium difficile determination in nosocomial diarrheas . Am J Infect Control. 1988;;16:246-249.
7 +
Blaser MJ, Berkowitz ID, LaForce FM, Cravens J, Reller LB, Wang WL.  Campylobacter enteritis: clinical and epidemiologic features . Ann Intern Med. 1979;;91:179-185.
8 +
Melvin DM, Brooke MM. Laboratory Procedures for the Diagnosis of Intestinal Parasites . Atlanta, Ga: Centers for Disease Control; 1980;;45-55. Dept of Health and Human Services publication (CDC) 80-8282.
9 +
Watson B, Blitzer M, Rubin H, Nachamkin I.  Direct wet mounts versus concentration for routine parasitological examination: are both necessary? Am J Clin Pathol. 1988;;89:389-391.
10 +
Nachamkin I, Lotz-Nolan L, Skalina D.  Evaluation of a commercial cytotoxicity assay for detection of Clostridium difficile toxin . J Clin Microbiol. 1986;;23:954-955.
11 +
Conn RB.  Clinical laboratories: profit center, production industry, or patient-care resource? N Engl J Med. 1978;;298:422-427.
12 +
Carels EJ. The Physician and Cost Control . Boston, Mass: Oelgeschlager Gunn & Hain Publishers Inc; 1980;.
13 +
Eisenberg JM, Williams SV.  Cost containment and changing physicians' practice behavior: can the fox learn to guard the chicken coop? JAMA. 1981;;246:2195-2201.
14 +
Williams SV, Eisenberg JM.  A controlled trial to decrease the unnecessary use of diagnostic tests . J Gen Intern Med. 1986;;1:8-13.
15 +
Spiegel JS, Shapiro MF, Berman B, Greenfield S.  Changing physician test ordering in a university hospital: an intervention of physician participation, explicit criteria, and feedback . Arch Intern Med. 1989;;149:549-553.
16 +
Mandell GL, Douglas RG, Bennett JE, eds. Principles and Practice of Infectious Diseases. 2nd ed. New York, NY: John Wiley & Sons Inc; 1985;:642.
17 +
Dixon RH, Laszlo J.  Utilization of clinical chemistry services by medical house staff: an analysis . Arch Intern Med. 1974;;134:1064-1067.
18 +
Bacti-Lab Monitor, Volume 1988-1 . Plymouth Meeting, Pa: IMS America; 1988;.
19 +
Soave R, Danner RL, Honig CL, et al.  Cryptosporidiosis in homosexual men . Ann Intern Med. 1984;;100:504-511.
20 +
Janoff EN, Smith PD.  Perspectives on gastrointestinal infections in AIDS . Gastroenterol Clin North Am. 1988;;17:451-463.
21 +
Blaser MJ, Wells JG, Feldman RA, Pollard RA, Allen JR.  Campylobacter enteritis in the United States: a multicenter study . Ann Intern Med. 1983;;98:360-365.

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1 +
Hughes JM, Guerrant RL. CRC Handbook of Hospital Acquired Infections . Boca Raton, Fla: CRC Press Inc; 1981;:539-562.
2 +
Gilligan PH.  Diarrheal disease in the hospitalized patient . Infect Control. 1981;;7:607-609.
3 +
Schroeder SA, Aserkoff B, Brachman PS.  Epidemic salmonellosis in hospitals and institutions . N Engl J Med. 1968;;279:674-678.
4 +
Kaplan JP, Fineberg HV, Benfari-Ferraro MJ, Rosenberg ML.  Value of stool cultures . Lancet. 1980;;2:413-416.
5 +
GilliganPH, McCarthy LR, Genta VM.  Relative frequency of Clostridium difficile in patients with diarrheal disease . J Clin Microbiol. 1981;;14:26-31.
6 +
Yannelli B, Gurevich I, Schoch PE, Cunha BA.  Yield of stool cultures, O&P tests, and Clostridium difficile determination in nosocomial diarrheas . Am J Infect Control. 1988;;16:246-249.
7 +
Blaser MJ, Berkowitz ID, LaForce FM, Cravens J, Reller LB, Wang WL.  Campylobacter enteritis: clinical and epidemiologic features . Ann Intern Med. 1979;;91:179-185.
8 +
Melvin DM, Brooke MM. Laboratory Procedures for the Diagnosis of Intestinal Parasites . Atlanta, Ga: Centers for Disease Control; 1980;;45-55. Dept of Health and Human Services publication (CDC) 80-8282.
9 +
Watson B, Blitzer M, Rubin H, Nachamkin I.  Direct wet mounts versus concentration for routine parasitological examination: are both necessary? Am J Clin Pathol. 1988;;89:389-391.
10 +
Nachamkin I, Lotz-Nolan L, Skalina D.  Evaluation of a commercial cytotoxicity assay for detection of Clostridium difficile toxin . J Clin Microbiol. 1986;;23:954-955.
11 +
Conn RB.  Clinical laboratories: profit center, production industry, or patient-care resource? N Engl J Med. 1978;;298:422-427.
12 +
Carels EJ. The Physician and Cost Control . Boston, Mass: Oelgeschlager Gunn & Hain Publishers Inc; 1980;.
13 +
Eisenberg JM, Williams SV.  Cost containment and changing physicians' practice behavior: can the fox learn to guard the chicken coop? JAMA. 1981;;246:2195-2201.
14 +
Williams SV, Eisenberg JM.  A controlled trial to decrease the unnecessary use of diagnostic tests . J Gen Intern Med. 1986;;1:8-13.
15 +
Spiegel JS, Shapiro MF, Berman B, Greenfield S.  Changing physician test ordering in a university hospital: an intervention of physician participation, explicit criteria, and feedback . Arch Intern Med. 1989;;149:549-553.
16 +
Mandell GL, Douglas RG, Bennett JE, eds. Principles and Practice of Infectious Diseases. 2nd ed. New York, NY: John Wiley & Sons Inc; 1985;:642.
17 +
Dixon RH, Laszlo J.  Utilization of clinical chemistry services by medical house staff: an analysis . Arch Intern Med. 1974;;134:1064-1067.
18 +
Bacti-Lab Monitor, Volume 1988-1 . Plymouth Meeting, Pa: IMS America; 1988;.
19 +
Soave R, Danner RL, Honig CL, et al.  Cryptosporidiosis in homosexual men . Ann Intern Med. 1984;;100:504-511.
20 +
Janoff EN, Smith PD.  Perspectives on gastrointestinal infections in AIDS . Gastroenterol Clin North Am. 1988;;17:451-463.
21 +
Blaser MJ, Wells JG, Feldman RA, Pollard RA, Allen JR.  Campylobacter enteritis in the United States: a multicenter study . Ann Intern Med. 1983;;98:360-365.

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