Clin Chem Lab Med 2021; 59(1): 39–50

Mini Review

Tim Lang*

Minimum retesting intervals in practice: 10 years

experience
https://doi.org/10.1515/cclm-2020-0660 Keywords: cost per test; demand management;
Received May 6, 2020; accepted June 22, 2020; published online harmonization; inappropriate testing; minimum retesting
September 7, 2020 intervals.
Abstract
Abbreviations: APPT, activated partial thromoplastin time;
ALT, alanine aminotransferase; AFP, α-foetoprotein; ADNA,
Background: Minimum retesting intervals (MRI) are a pop-
anti-double-stranded DNA antibody; AENA, anti-enteric
ular demand management solution for the identification and
neuronal antibodies; AGPC, anti-gastric parietal cell
reduction of over-utilized tests. In 2011 Association of Clin-
antibody; AMA, anti-mitochondrial antibodies; ANCA,
ical Biochemistry and Laboratory Medicines (ACB) pub-
antineutrophil cytoplasmic antibodies; ANA, anti-nuclear
lished evidence-based recommendations for the use of MRI.
antibodies; ASM, anti-smooth muscle antibody; ASO,
Aim: The aim of the paper was to review the use of MRI
antistreptolysin O titre; AST, aspartate aminotransferase;
over the period since the introduction of these recom-
ACB, Association for Clinical Biochemistry and Laboratory
mendations in 2011 to 2020 and compare it to previous
Medicine; AUS, Australian; BCR-ABL1, breakpoint cluster
published data between 2000-2010.
region protein ABL proto-oncogene 1; Ca, calcium; CA 125,
Methods: A multi-source literature search was performed
cancer antigen 125; CA 15.3, cancer antigen 15-3; CA 19.9,
to identify studies that reported the use of a MRI in the
cancer antigen 19.9; CEA, carcinoembryonic antigen; C Diff,
management or identification of inappropriate testing be-
Clostridium difficile; CPOE, computerized physician order
tween the years prior to (2000–2010) and after imple-
entry; CRP, C-reactive protein; CMV, cytomegalovirus; EIA,
mentation (2011–2020) of these recommendations.
enzyme-immunoassay; ESR, erythrocyte sedimentation
Results: 31 studies were identified which met the accep-
rate; EUR, Euros; FISH, fluorescent in situ hybridization;
tance criteria (2000–2010 n=4, 2011–2020 n=27). Between
FT4, free thyroxine; FBC, full blood count; GGT, gamma-
2000 and 2010 4.6% of tests (203,104/4,425,311) were iden-
glutamyl transferase; Hb, haemoglobin; HbA1c,
tified as failing a defined MRI which rose to 11.8% of tests
haemoglobin A1C; IFA, immunofluorescence assay; IgA,
(2,691,591/22,777,288) in the 2011–2020 period. For those
immunoglobulin A; IgE, immunoglobulin E; IgG,
studies between 2011 and 2020 reporting predicted savings
immunoglobulin G; IgM, immunoglobulin M; LIMS,
(n=20), 14.3% of tests (1,079,972/750,580) were cancelled,
laboratory information system; LFT, liver function tests;
representing a total saving of 2.9 M Euros or 2.77 Euro/test.
Mg, Magnesium; MRI, minimum retesting interval; NHS,
The most popular rejected test was Haemoglobin A1c which
National Health Service; PTT, partial thromboplastin time;
accounted for nearly a quarter of the total number of rejected
Phos, phosphate; PCR, polymerase chain reaction; PSA,
tests. 13 out 27 studies used the ACB recommendations.
prostate specific antigen; PT, prothrombin time; RF,
Conclusions: MRI are now an established, safe and sus-
rheumatoid factor; SAR, Saudi Arabian Riyal; SAD, South
tainable demand management tool for the identification
African Dollar; TFT, thyroid function tests; TSH, thyroid
and management of inappropriate testing. Evidence based
stimulating hormone; UK, United Kingdom; USD, United
consensus recommendations have supported the adoption
States Dollar; U&E, urea and electrolytes.
of this demand management tool into practice across
multiple healthcare settings globally and harmonizing
laboratory practice.
Introduction
*Corresponding author: Dr. Tim Lang, Consultant Clinical Scientist,
Department of Clinical Biochemistry, University Hospital of North
The landscape and scope of laboratory testing continues
Durham, North Road, Durham, County Durham, DH1 5TW, UK, to expand with new testing pathways and methodologies
E-mail: [email protected] to wider markets than ever before [1]. With this expansion
40 Lang: Minimum retesting intervals in practice

comes the potential for more inappropriate laboratory [15, 25–30]. However, these solutions rely on the user being
testing, therefore wasting potential resources and more able to correctly identify the patient and match them to
worryingly affecting patient care and safety [2]. In addi- their electronic patient record. This is made easier if the
tion, most laboratories are working in an environment patient has a unique patient identifier such as the NHS
where there is a limited budget and an expectation to number in the UK. A CPOE or order communication solu-
continue to make cost saving despite an increasing tion can be used as a gate keeping tool that automatically
workload [3, 4]. Defining inappropriate testing can be blocks or challenges a request for an over-requested test
difficult and doesn’t just include those over-utilized tests [15].
but those under-utilized tests too where not performing a Choosing the right MRI for the chosen patient popu-
test at the optimal time may affect long term management lation is important to ensure that they are not too restrictive
of a patient’s condition [5–7]. Several mechanisms exist and miss too many clinically abnormal results [31]. It is also
for managing this inappropriate testing including de- important that the solution implemented is shown not to
mand management tools [8], harmonization initiatives [9, cause any adverse effect on the patient’s management so
10] and government advocacy [8, 9, 11, 12]. It is ideal that that it is more likely to be accepted by the clinician using
these are implemented at the earliest possible stage in the the test. However, the major outcomes measured when
clinical decision process, that is in the pre-preanalytical implementing a demand management solution in the ma-
phase of the brain to brain cycle in order that the least jority of studies are the number or percentage of tests that
amount of wastage occurs [11, 13]. It is also important that are not processed and their associated costs. There is very
these solutions are either evidence-based or in the limited data about the actual clinical outcomes associated
absence representative of best practice so that when “a with the implementation of MRIs and other demand man-
test is used it has value if it provides benefit to patients at agement tools. Zemlin et al. in a subset of 100 cases, where
acceptable cost” [14]. a test was rejected, reported that in 80% there was no
Minimum retesting intervals (MRI) are an example of a adverse care noted [15]. Of those cases that were affected
successful and sustainable demand management tool [15, (11%), discharge/further laboratory investigations were
16]. A MRI can be defined as the minimum time before a test delayed or a result was not available for a planned pro-
should be re-tested based on the properties of the test and cedure. Information was lacking in the notes of the
the clinical situation in which it is used [17, 18]. Prior to remaining 9% of patients to be able to draw any valid
2010 there was limited evidence of the use of MRI in prac- conclusion about patient care being affected. A small study
tice, however there were some large studies reporting in a Paediatric Cardiac Intensive Care Unit showed that
promising data [19–22] (see Table 1). For example Van through the implementation of CPOE testing rule the length
Walraven and Raymond reported the potential saving of up of stay on the unit and in hospital was significantly reduced
to $35.9 M Canadian dollars (16.7%) from the pathology whilst not affecting mortality rate [32]. Conversely it is re-
budget of the province of Ontario through the imple- ported by excessive testing can lead to potential over-
mentation repeat intervals on eight common tests that treatment with medication, particularly in diabetes [33].
resulted in a reduction of the workload by 3.2% (128,183
tests out of a total workload of 3,978,761 tests) [19]. With the
implementation of a demand management tool there is Aim
sometimes resistance from the clinician requesting the test
and the evidence to support its introduction. In 2011, the The aim of the paper was to review the use of MRI over the
Clinical Practice Section of the Association for Clinical period since the introduction of the UK’s National MRI
Biochemistry and Laboratory Medicine (ACB) prepared a recommendations in 2011 to 2020 and compare it to pre-
set of consensus/evidence based recommendations on vious published data between 2000–2010.
when a test should be repeated in Clinical Biochemistry
using a “state of the art” approach [18, 23]. Where evidence
was lacking recommendations were prepared based on the
Materials and methods
consensus opinion of the panel. In 2015, this project was
expanded to include all areas of pathology [24]. There are a Method
number of ways to implement MRI in practice but the
introduction of computerized physician order entry (CPOE) A multi-source literature search was performed to identify studies that
and order communication software linked to a laboratory reported the use of a MRI in the management or identification of
information system (LIMS) has shown the most success inappropriate testing between the years of 2000–2010 and 2011–2020.
 Lang: Minimum retesting intervals in practice 41

Table : Summary of minimum retesting intervals papers detailing study population and time period that MRI applied, actual MRI used for
each test in parentheses, total number of requests and number and percentage of rejected requests and calculated savings.

Paper Year of Population Time Test and MRI Total num- Total % of total Total
reference publication applied period ber of tests numbers workload savings
reduced reduced

[]  Canadian  year Hemoglobin ( days) ,, , . $.M–.M
province Creatinine ( days) , ,  (Canadian
Sodium ( days) , , . dollars)
Total cholesterol , , .
( weeks)
TSH ( weeks) , , .
HDL-Cholesterol , , .
( weeks)
HbAc ( weeks) , , .
Ferritin ( weeks) ,  .
[]  Teaching Hospital  year ANA ( weeks) , , . $, (USD)
AENA ( weeks) , , .
ADNA ( weeks) , , .
RF ( weeks) , , .
AMA ( weeks) ,  .
ASM ( weeks) ,  .
AGPC ( weeks)   .
IgA, IgM, IgG ( weeks) , , .
AFP ( weeks) , , .
CEA ( weeks) , , .
CA. ( weeks) , , .
PSA ( weeks) ,  .
[]  Teaching Hospital  year FBC ( h) , , . $, (USD)
Basic metabolic panel , , .
( h)
Calcium ( h) , , .
Magnesium ( h) , , .
Phosphate ( h) , , .
[]  Teaching Hospital  year HbAc ( days) , , . , EUR
[]  Tertiary Hospital  months Lipid profile ( weeks) , , . , EUR
[]  Teaching Hospital  year HbAc with initial value , , . £, (UK)
of <.% ( months)
HbAc with initial value
of ≥.% ( months
[]  Tertiary Hospital  months C Diff by PCR ( days) ,  . $, (USD)
[]  Not stated  years All tests ( h) , , . $, (USD)
[]  Teaching Hospital  year CRP ( h) ,  . £, (UK)
[]  Teaching Hospital  months U&E IP ( h) ,  . £, (UK)
U&E Op ( days)
CRP ( h) , , .
LFT ( h) ,  .
Ca, Phos, Mg IP ( h) ,  .
Ca, Phos, Mg OP
( days)
HbAc ( months) ,  .
Lipid profile ( months) ,  .
[]  City population  years Total cholesterol , , . $K–$.M
( weeks) (Canadian
HbAc ( month if , , . dollars)
abnormal OR  year if
normal)
TSH ( weeks) , , .
Vitamin B ( year) , , .
42 Lang: Minimum retesting intervals in practice

Table : (continued)

Paper Year of Population Time Test and MRI Total num- Total % of total Total
reference publication applied period ber of tests numbers workload savings
reduced reduced

Vitamin D ( year) , , .

Ferritin ( year) , , .
, , .
[]  Two inpatient  months ,   , EUR
wards at Gen-
eral Hospital
[]  Inpatients and  months IP , EUR
outpatients in Vitamin D ( days)   
Teaching Vitamin B ( days)   
Hospital Folate ( days)   
Op
Vitamin D ( days) , , 
Vitamin B ( days)   
Folate ( days)   
[]  General Hospital  year Total cholesterol , , . Not calculated
( weeks)
[]   inpatient wards  month Total bilirubin ( h) ,  . , HRK (,
at General Direct bilirubin ( h)   . EUR)
Hospital ALT ( h) ,  .
AST ( h) ,  .
GGT ( h) ,  .
CRP ( h) ,  .
FBC ( h) ,  .
PT ( h) ,  .
APTT ( h) ,  .
Fibrinogen ( h) ,  .
[]  Veterans Hospital  years Basic metabolic panel , , . $, (USD)
( day)
Comprehensive meta- , , .
bolic panel ( days)
Complete blood counts , , 
[]  Adult patient in  months GGT ( h,  h) , ,– – Not calculated
General ,
Hospital
[]  Teaching Hospital  years Total cholesterol , , . , EUR
( months)
Ferritin ( months) , , .
Vitamin D (months) , , .
Vitamin B , , .
( months)
Folate ( months) , , .
[]  Community and  year TSH ( weeks) ,, , . Not calculated
Hospital work HbAc ( months) ,, , .
Lipid profile ( months) ,, , .
Serum protein electro- , , .
phoresis ( months)
Immunofixation , , .
(quantitative)
Immunoglobulins , , .
( months)
Vitamin D ( months) , , .
Vitamin B ( months) ,, , .
Folate ( year) , , .
 Lang: Minimum retesting intervals in practice 43

Table : (continued)

Paper Year of Population Time Test and MRI Total num- Total % of total Total
reference publication applied period ber of tests numbers workload savings
reduced reduced

[]   General  month Total Total , Total . ,. EUR
Hospitals , (Average)
APTT ( h) .
Calcium (not quoted) .
Vancomycin ( h)
Blood count ( h) .
CRP ( h) .
PT ( h) .
Ferritin ( months)
TSH ( months)
Sodium (not quoted) .
Urea (not quoted) .
Ft (not quoted) .
[]  Community and  months IP U&E ( h) , , . $, (SAD)
Hospital work OP U&E ( days)
IP LFT ( h) , , .
OP LFT ( days)
Ip Ca, Phos, Mg ( h) , , .
OP Ca, Phos, Mg
( days)
CRP ( h) ,  .
Troponin I ( h) ,  .
Abnormal Lipid Profile , , .
( days)
Normal Lipid Profile
( days)
TFT ( days) , , .
HbAc ( days) , , .
[]  Tertiary Hospital  year Lipid Panel ( days) ,  . $, (USD)
TSH ( days) ,  .
HbAc ( days) ,  .
CRP ( day) ,  .
Iron ( days) ,  .
Ferritin ( days) ,  .
Folate (No repeats)   .
OH Vit D ( days) ,  .
, DiOH Vit D   .
( days)
C.Diff by PCR ( days) ,  .
Procalcitonin ( day) ,  .
[]  Tertiary Hospital  months CMV antigenemia, ,  . ,, (SAR)
direct IFA ( h)
Stool culture ( h) ,  .
Ova and parasites ,  .
( week)
FBC ( h) , , .
PT ( h) ,  .
Gram stain (genital)   .
and culture ( week)
Biochemistry profile ,  .
( h)
Respiratory culture and ,  .
Gram stain ( h)
44 Lang: Minimum retesting intervals in practice

Table : (continued)

Paper Year of Population Time Test and MRI Total num- Total % of total Total
reference publication applied period ber of tests numbers workload savings
reduced reduced

Viral acute diarrheal   .

EIA ( week)
BCR-ABLa FISH   .
( months)
Hb electrophoresis ,  .
( months)
PTT ( h) , , .
ESR ( h) , , .
[]  Urology Clinic  years PSA ( weeks) ,  . Not calculated
[]  Teaching Hospital  year  tests , EUR
Biochemistry (– , , .
 days)
Haematology and , , .
Coagulation ( day)
Autoimmunity (– ,  .
 days)
[]  Tertiary Hospital  months HbAc ( days) , , . $, (USD)
Lipid panel ( days) , , . (average over 
Iron panel ( days) , , . year)
Thyroid function , , .
( days)
Vitamin D ( days) , , .
[]  Teaching Hospital  years AST ( h) , , . $,. (USD)
ALT ( h) , , .
Vitamin D ( days) ,  .
GGT ( days) , , .
Conjugated bilirubin , , .
( days)
Total cholesterol , , .
( days)
HDL-cholesterol , , .
( days)
LDL-cholesterol , , .
( days)
TSH ( weeks) , , .
Ferritin ( days) ,  .
Immunoglobulin A   .
( days)
Immunoglobulin E ,  .
( days)
Immunoglobulin G   .
( days)
Immunoglobulin M   .
( days)
CRP ( h) , , .
Procalcitonin ( h) ,  .
ESR ( days) , , .
Alpha-fetoprotein ,  .
( days)
Total PSA ( weeks) ,  .
CA  ( month) ,  .
CA. ( month) ,  .
CA. ( month) ,  .
ANCA ( month)   .
 Lang: Minimum retesting intervals in practice 45

Table : (continued)

Paper Year of Population Time Test and MRI Total num- Total % of total Total
reference publication applied period ber of tests numbers workload savings
reduced reduced

ASO ( days) ,  .

Vitamin B ( months)   .
[]  Teaching Hospital  years Teaching Hospital
and Rural U&E ( h) , , . $, (AUS)
Hospital U&E ( h) , , .
FBC ( h) , , . $, (AUS)
FBC ( h) , , .
Rural Hospital
U&E ( h) ,  . Not calculated
U&E ( h) , , .
FBC ( h) ,  . Not calculated
FBC ( h) , , .
[]  Teaching Hospi- . years CRP ( h)   . Not calculated
tal. Admission
to emergency
room.
[]   Teaching  months HbAc ( days) st site Not calculated
Hospitals , , .
nd site
,  .
[]  Teaching Hospital  year Vitamin B ( months) Not quoted  Not quoted , EUR

Studies were included in the review if they stated the population the saving for this period was 9,235,667 Euros, equating to a
MRI was used in, the MRI applied to the specific test or test profile, the saving of 45.7 Euro/test. The total number of requests for all
time period of the study, the total number of tests requested during the
studies in the 2011–2020 review period was 22,777,288 tests
stated time period and the number of tests rejected. If an actual or
with 2,691,591 (11.8%) requests for specific tests being
predicted cost saving was reported associated with the MRI this was
also recorded. The percentage of total workload reduced was calcu- cancelled. For those studies reporting predicted savings
lated by dividing the number of tests rejected against the total number (n=20), the total number of requests was 7,505,802 with
of tests performed. Where reported the cost of the savings was con- 1,079,972 tests being cancelled, representing a total saving
verted into Euros to allow for direct comparison of costs using the of 2,993,922 Euros or 2.77 Euro/test. The combined total
exchange rate for the individual currency on 20/04/2020 Table number of requests over the two periods studied was
Appendix. Where a range of predicted savings was quoted the lower
27,202,599 tests with 2,894,695 (10.6%) requests for specific
value was used in calculating the overall cost savings and cost/test
saving. The total number of tests rejected for each defined test for each
tests being cancelled.
time period was calculated together the percentage of rejected tests for The total number of requests for each test and the
that defined workload and rank in order of total number of tests number which were rejected was summarised and ranked in
rejected. order of largest number of test requests rejected (Table 2A
and 2B). The largest number of requests rejected for an
individual test in the 2000–2010 period was Hb with 58883.
Results The top five tests (Hb, creatinine, sodium, AFP and FBC)
accounted for 142,334 rejected requests, 3.2% of the total
Four studies from between 2000 and 2010 and 27 studies number of requested tests and nearly two thirds of all
between 2011 and 2020, were identified which met the rejected tests (Figure 1A). In the 2011–2020 period HbA1c
criteria, which 4 and 20 respectively included predicted had the largest number of requests rejected for an indi-
or calculated savings. These are reported in Table 1. vidual test with 642,770 requests being rejected. The top
The total number of requests for all studies in the re- five tests (HbA1c, Lipid profile, TSH, Vitamin B12 and U&E)
view period from 2000 to 2010 was 4,425,311 tests with accounted for 1,968,480 rejected requests, 8.6% of the total
203,104 (4.6%) requests for specific tests being cancelled number of requested tests (Table 2B). If this was extended
due to failing a defined MRI. The total predicted costs to include the top 10 tests (FBC, total cholesterol, ferritin,
46 Lang: Minimum retesting intervals in practice

Table A: Summary of rejected individual tests from  to  Table B: Summary of rejected individual tests from  to 
studies. studies.

Test Range of Total % of total Test Range of MRI Total % of total

MRI quoted number workload quoted number of workload
of tests rejected tests rejected
rejected for specific test rejected for specific
test
Haemoglobin  days , .
Creatinine  days ,  HbAc  days to  , .
Sodium  days , . year
AFP  weeks , . Lipid profile  days to , .
FBC  h , .  months
Magnesium  h ,  TSH – weeks , .
Basic metabolic panel  h , . Vitamin B  month to  , .
Phosphate  h ,  year
CEA  weeks , . U&E  h to  days , .
TSH  weeks ,  FBC – h , .
Total cholesterol  weeks , . Total cholesterol  days to , .
IgA, IgM, IgG  weeks , .  months
HbAc  weeks , . Ferritin  days to  , .
CA.  weeks ,  year
ADNA  weeks , . Folate  days to  , .
ANA  weeks , . year
AENA  weeks , . Vitamin D  days to  , .
HDL-cholesterol  weeks , . year
RF  weeks , . ALT – h , .
Calcium  h , . AST – h , .
PSA  weeks   Direct bilirubin – days , .
Ferritin  weeks  . LFT – h , .
AGPC  weeks  . CRP – h , .
AMA  weeks  . GGT  h to  days , .
ASM  weeks  . ESR – days , .
PTT – h , .
Serum protein  months , .
electrophoresis
folate and vitamin D) then a total of 2,496,242 requests
TFT – days , .
would be rejected, representing 11% of the total number of Immunofixation  months , .
requested tests and 92.7% of all rejected tests. Immunoglobulins  month , .
Calcium, phosphate, – h , .
magnesium
LDL-cholesterol  days , .
Discussion Iron – days , .
CMV antigenemia, direct  h  .
MRIs continue to be a successful demand management tool IFA
to assist in identifying and reducing inappropriate testing. Troponin I h  .
Since the introduction of evidence-based recommenda- Procalcitonin  h  .
PSA  weeks  .
tions in 2011 this review has shown that there has been an
Stool culture  h  .
increase in the implementation of this solution globally in a Ova and parasites  week  .
variety of clinical settings [18]. The percentage of identified Alpha-fetoprotein  days  .
repeat testing, as a function of overutilization, for all C Diff by PCR  days  .
studies included was 11.8% (n=27, 2011–2020) an increase Respiratory culture and  h  .
on the previously published figure of 7.4% (n=12, 1997– Gram stain
IgE  days  .
2012) [6] and that of the 2000–2010 period in this review.
Total bilirubin  h  .
There was tenfold increase in total number of tests identi- CA.  month  .
fied as inappropriate through published studies in the CA   month  .
second period mirroring the seven fold increase in pub- APTT  h  .
lished studies. However, there was an reduction in the Fibrinogen  h  .
 Lang: Minimum retesting intervals in practice 47

Table B: (continued) platforms. There was also a doubling of the number of
different type of tests which a MRI was used in (n=25 to
Test Range of MRI Total % of total n=52), potentially reflecting the availability of evidence
quoted number of workload
based guidelines to assist with their implementation. In this
tests rejected
rejected for specific
review 20 studies quoted using published recommenda-
test tions/guidelines on retesting intervals with 13 studies using
the ACB/RCPath recommendations [18, 24]. There was a
BCR-ABLa FISH  months  .
ASO  days  .
wide range of percentage requests rejected ranging from
CA.  month  . 0.2% of pro-thrombin time (PT) [47] to 94% of inpatient
Hb electrophoresis  months  . Vitamin B12 requests [28]. The wide range observed in this
Viral acute diarrheal EIA  week  . review probably reflects the wide range of individual prac-
Gram stain (genital) and  week  . tice of the clinicians using the tests in different scenarios and
culture
locations. This is not a new phenomenon and it is widely
IgA  days  .
recognized that requesting patterns can differ in the same
IgM  days  .
IgG  days  . clinical location [55, 56] and in different clinical and regional
ANCA  months  . locations [7, 56, 57]. The requesting behaviour of the same
physician, particularly in a specialist area is recognised to be
more prone to requesting a test too soon, based on specific
amount of savings identified, 9.2 M Euros vs. 2.9 M Euro guidelines [45]. The age of the patient has also been shown
respectively but is probably due to the influence of the to independently associated with increased rates of repeat
large study performed by the Canadian group in 2003 [19]. requesting with patients older than 65 years old [51].
A limitation of this in the review and literature is that The most popular rejected tests in this review were
different healthcare systems are funded differently and as a HbA1c and components of the lipid profile, which accounted
consequence their reported laboratory costs may be for nearly a half of the total number of rejected tests
calculated differently, which is reflected in the total saving (Figure 1B). These tests are associated with the management
published and possibly representing an under or over of long term conditions such as diabetes, hypertension and
estimation of potential savings [15, 16, 19, 34–37]. heart disease so it is essential that the patient is monitored at
The increased identification of inappropriately the correct interval, neither too soon or late, to ensure
requested tests, based on a defined MRI, probably reflects optimal management and better long term prognosis [7, 33].
the increase in awareness of this demand management It is important to remember that to successfully
tools and others allowing laboratories to manage work- implement a minimum retesting interval it is best coupled
loads particularly through more advanced LIMS and CPOE to an education strategy to support its continued and

Figure 1: Proportion of total rejected requests by test type.

A Proportion of total rejected requests by test type between 2000–2010. B Proportion of total rejected requests by test type between 2011–2020.
48 Lang: Minimum retesting intervals in practice

sustained use and ideally delivered via an order commu- Appendix:

nication or CPOE system. Through this type of strategy the
effect of reducing inappropriate testing can be maximised Exchange rate to EURO on //
and particularly improve the behaviour of individual’s
 Canadian Dollar .
requesting [28]. A multiple intervention approach,  South African Rand .
including MRI, can also be another successful strategy to  US Dollar .
use to achieve a sustained reduction in inappropriate re-  UK Sterling .
quests, especially if supported with education [58, 59].  Saudi Arabian Riyal .
 Australian Dollar .
Finally sponsorship/buy in from senior decision makers/
leader is essential for changing behaviour to be able to
implement a single or multiple intervention demand
Research funding: None declared.
management solution [16].
Author contributions: All authors have accepted
The success of a demand management tool, in this
responsibility for the entire content of this manuscript
review MRI, is not just measured by the number of rejected
and approved its submission.
tests and associated cost savings. It is important that there
Competing interests: Authors state no conflict of interest.
are no adverse effects on patient care. However, there is
very limited data reporting any clinical outcome on patient
care. A few studies have shown that MRI have had no
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