Public Release: 

Are doctors using unnecessary tests to diagnose chronic kidney disease?

New research indicates that many low-yield tests are obtained frequently

Brigham and Women's Hospital

Boston, MA--Chronic Kidney Disease (CKD) affects 13 percent of adults in the U.S. and is associated with significant morbidity, mortality and costs. Researchers at Brigham and Women's Hospital (BWH) in Boston have found that many of the tests frequently conducted to screen for CKD have little clinical benefit on diagnosis and therapeutic management. These findings are published in a research letter in JAMA Internal Medicine on March 2, 2015.

"To our knowledge, there has been no comprehensive assessment of the tests used to assess if someone has CKD," explained Mallika Mendu, MD, MBA, a physician in the Division of Renal Medicine at BWH and lead author of this study. "In our study, we tallied the number and frequency of laboratory and imaging tests that were obtained in the initial evaluation of CKD, and then determined whether or not these tests were useful and affected diagnosis and management of the disease."

The researchers conducted a retrospective cohort study of 1487 patients referred for initial evaluation of CKD from 2010 to 2013. They then reviewed nephrology progress notes to ascertain the presumed cause of CKD and whether a specific test was documented that specifically contributed to, confirmed, or established the underlying diagnosis and or any management decision related to CKD. Frequently obtained tests included measurement of calcium, hemoglobin, phosphate, urine sediment, parathyroid hormone levels, and many others.

The researchers found that tests such as serum protein electrophoresis and screening for antinuclear antibody, C3, C4, hepatitis C, hepatitis B and antineutrophil cytoplasmic antibody were obtained frequently, up to 68 percent of the time, despite infrequently affecting disease diagnosis or management. Urine protein quantification and hemoglobin A1c had the highest rates of impact on diagnosis and/or management among all of the tests obtained.

"This study suggests that reflexively ordering several tests for CKD evaluation and management may be unnecessary," explained Mendu. "An evidence-based, targeted approach based on pretest probabilities of disease for diagnosis and management may be more efficient and reduce cost."

The researchers say that next steps will be to make clinical recommendations on what specific tests to avoid and which ones are needed in CKD evaluation.

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This research was supported by a National Institutes of Health Grant F32 DK103339-01.

Brigham and Women's Hospital (BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. BWH has more than 3.5 million annual patient visits, is the largest birthing center in Massachusetts and employs nearly 15,000 people. The Brigham's medical preeminence dates back to 1832, and today that rich history in clinical care is coupled with its national leadership in patient care, quality improvement and patient safety initiatives, and its dedication to research, innovation, community engagement and educating and training the next generation of health care professionals. Through investigation and discovery conducted at its Brigham Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, more than 1,000 physician-investigators and renowned biomedical scientists and faculty supported by nearly $650 million in funding. For the last 25 years, BWH ranked second in research funding from the National Institutes of Health (NIH) among independent hospitals. BWH continually pushes the boundaries of medicine, including building on its legacy in transplantation by performing a partial face transplant in 2009 and the nation's first full face transplant in 2011. BWH is also home to major landmark epidemiologic population studies, including the Nurses' and Physicians' Health Studies and the Women's Health Initiative as well as the TIMI Study Group, one of the premier cardiovascular clinical trials group. For more information, resources and to follow us on social media, please visit BWH's online newsroom.

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