Laboratory Test Utilization Strategies
Part 2: The Clinical Chemistry Laboratory
Beyond Hot Topic is an opportunity for viewers to submit questions to the Hot Topic presenter. The opportunity to submit questions for this topic is now closed.
The following questions were submitted by viewers and answered by the presenter, Amy K. Saenger, PhD, Assistant Professor of Laboratory Medicine and Pathology and Director of Cardiovascular Laboratory Medicine in the Department of Laboratory Medicine and Pathology, both at Mayo Clinic in Rochester, Minnesota.
Questions are presented as submitted (unedited).
- Have you looked at BNP utilization at all? If so, any guidance what is appropriate utilization and how to get physicians to then order the test appropriately?
We have reviewed utilization of NT-proBNP and are currently working on implementing best ordering practices, focusing first on inpatient testing. All evidence regarding frequency of ordering for either BNP or NT-proBNP indicates a maximum of 2 orders is all that is required (admission and at discharge if relevant). Daily or standing orders should be discouraged due to shifts in BNP/NT-proBNP consistent with fluid and volume changes and/or with changes in patient’s medications (particularly diuretics). The utility of natriuretic peptides in the outpatient setting is often debated and most clinical trials show benefit for a “target” BNP/NT-proBNP in patients under the age of 70 to 75 which is not a majority of the heart failure population. Those data, in combination with biological variability, suggest there is little to no utility in outpatients with chronic heart failure. Furthermore, assessment of their symptoms and quality of life often accurately predicts what the BNP/NT-proBNP will be.
I believe stronger methods are needed to stop physicians from ordering inappropriately and should be combined with education (continuous education). This really depends on the size of your facility and resources; pairing up with a clinical colleague to be an advocate helps tremendously.
- Januzzi JL, Troughton R: Are Serial BNP Measurements Useful in Heart Failure Management? Serial Natriuretic Peptide Measurements Are Useful in Heart Failure Management. Circulation 2013;127:500-508
- Desai AS: Are Serial BNP Measurements Useful in Heart Failure Management?: Serial Natriuretic Peptide Measurements Are Not Useful in Heart Failure Management: The Art of Medicine Remains Long. Circulation 2013;127:509-516