Minimum retesting intervals in practice 10 years
Minimum retesting intervals in practice 10 years
Mini Review
Tim Lang*
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)
HbAc ( 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 HbAc ( days) , , . , EUR
[] Tertiary Hospital months Lipid profile ( weeks) , , . , EUR
[] Teaching Hospital year HbAc with initial value , , . £, (UK)
of <.% ( months)
HbAc 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)
HbAc ( months) , .
Lipid profile ( months) , .
[] City population years Total cholesterol , , . $K–$.M
( weeks) (Canadian
HbAc ( 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
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) , , .
HbAc ( days) , , .
[] Tertiary Hospital year Lipid Panel ( days) , . $, (USD)
TSH ( days) , .
HbAc ( 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
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
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.
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-ABLa 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
Laboratory Medicine (EFLM) Working Group for Preanalytical based on re-testing intervals for limiting the appropriateness of
Phase (WG-PRE). Clin Chem Lab Med 2015;53:357–70. laboratory tests requests. Clin Biochem 2015;48:1174–6.
12. Malhotra A, Maughan D, Ansell J, Lehman R, Henderson A, Gray M, 30. Gothheil S, Khemani E, Copley K, Keeney M, Chin-Yee I, Gob A.
et al. Choosing wisely in the UK: the Academy of Medical Royal Reducing inappropriate ESR testing with computerized clinical
Colleges’ initiative to reduce harm of too much medicine. BMJ decision support. BMJ Open Qual 2016;5:u211376.
2015;350:h2308. 31. Hure A, Palazzi K, Peel R, Geraghty D, Collard P, De Malmanche T,
13. Plebani M, Laposata M, Lundberg GD. The brain-to-brain loop et al. Identifying low value pathology test ordering in hospitalised
concept for laboratory testing 40 years after its introduction. Am J patients: a retrospective cohort study across two hospitals.
Clin Path 2011;136:829–33. Pathology 2019;51:621–7.
14. Horvath AR. From evidence to best practice in laboratory 32. Pageler NM, Franzon D, Longhurst CA, Wood M, Shin AY, Adams
medicine. Clin Biochem Rev 2013;34:47–60. ES, et al. Embedding time-limited laboratory orders within
15. Smit I, Zemlin AE, Eramus RT. Demand management: an audit of computerized provider order entry reduces laboratory utilization.
chemical pathology test rejections by an electronic gate-keeping Pedatr Crit Care Med 2013;14:413–9.
system at an academic hospital in Cape Town. Ann Clin Biochem 33. McCoy RG, Van Houten HK, Ross JS, Montoni VM, Shah ND. HbA1c
2015;52:481–7. overtesting and overtreatment among US adults with controlled
16. Eaton KP, Levy K, Soong C, Pahwa AK, Petrilli C, Ziemba JB, et al. type 2 diabetes, 2001–13: observational population based study.
Evidence-based guidelines to eliminate repetitive laboratory BMJ 2015;351:h6138.
testing. JAMA Int Med 2017;177:1833–9. 34. Mahomed OH, Lekalakala R, Asmail S, Cassim N. Implications of
17. Lang T. Laboratory demand management of repetitive testing – the introduction of laboratory demand management at primary
time for harmonisation and an evidenced based approach. Clin care clinics in South Africa on laboratory expenditure. Afr J Lab
Chem Lab Med 2013;51:1139–40. Med 2016;5:339.
18. Lang TF. National Minimum Re-testing Intervals Project: a final 35. Hueth KD, Jackson BR, Schmidt RL. An audit of order patterns with
report detailing consensus recommendations for minimum re- recommendations and potential cost savings. Am J Clin Path
testing intervals for use in Clinical Biochemistry. London: 2018;150:27–33.
Association for Clinical Biochemistry; 2013, p. 2012. 36. Morgan EK, Naugler C. Inappropriate repeats of six common
19. Van Walraven C, Raymond M. Population-based study of repeat tests in a Canadian city: a population cohort study within a
laboratory testing. Clin Chem 2003;49:1997–2005. laboratory informatics framework. Am J Clin Pathol 2015;144:
20. Kwok J, Jones B. Unnecessary repeat requesting of tests: an audit 704–12.
in a government hospital immunology laboratory. J Clin Path 37. Konger Rl, Ndekwe P, Jone G, Schmidt RP, Trey M, Baty EJ, Wilhite
2005;58:457–62. D, Munshi IA, Sutter BM, Rao M, Bashir Cm. Reduction in
21. May TA, Clancy M, Critchfield J, Ebeling F, Enriquez A, Gallagher C, unnecessary clinical laboratory testing through utilization
Genevro J, Kloo J, Lewis P, Smith R, Ng VL. Reducing unnecessary management at a US Government Veterans Affairs Hospital. Am J
inpatient laboratory testing in a teaching hospital. Am J Clin Path Clin Path 2016;145:355–64.
2006;126:200–6. 38. Iliadi V, Kastanioti C, Maropoulos G, Niakas D. Inappropriately
22. Akan P, Cimrin D, Ormen M, Kume T, Ozkaya A, Ergor G, et al. repeated lipid tests in a tertiary hospital in Greece: the
The inappropriate use of HbA1c testing to monitor glycemia: is magnitude and cost of the phenomenon. Hippokratia 2012;16:
there evidence in laboratory data?. J Eval Clin Pract 2007;13: 261–6.
21–4. 39. Procop GW, Yerian LM, Wyllie R, Harrison AM, Kottke-Marchant K.
23. Glaser EM. Using behavioral science strategies for defining the Duplicate laboratory test reduction using a clinical decision
state-of-the-art. J Appl Behav Sci 1980;16:79–92. support tool. Am J Clin Pathol 2014;141:718–23.
24. Lang TF, Croal B National Minimum Re-testing Intervals in 40. Waldron JL, Ford C, Dobie D, Danks G, Humphrey R, Rolli A, Gama
Pathology Project: a final report detailing consensus R. An automated minimum retest interval rejection rule reduces
recommendations for minimum retesting intervals for use in repeat CRP workload and expenditure, and influences clinician-
pathology. London: Royal College of Pathologists; 2015. p. 1–59. requesting behaviour. J Clin Pathol 2014;67:731–3.
25. Janssens PMW, Wasser G. Managing laboratory test ordering 41. Demir S, Zorbozan N, Basak E. Unnecessary repeated total
through test frequency filtering. Clin Chem Lab Med 2013;51: cholesterol tests in biochemistry laboratory. Biochem Med 2016;
1207–15. 26:77–81.
26. Luo RF, Spradley S, Banaei N. Alerting physicians during 42. Galovic R, Fucek M, Rogic D. Minimum retesting intervals –
electronic order entry effectively reduces unnecessary repeat application through electronic order forms on common
PCR testing for clostridium difficile. J Clin Micro 2013;51:3872–4. laboratory tests. Signa Vitae 2016;11:77–9.
27. Bellodi E, Vagnoni E, Bonvento B, Lamma E. Economic and 43. Hawkins R. Audit of inpatient gamma glutamyl transferase repeat
organizational impact of a clinical decision support system on testing. Clin Chem Lab Med 2017;55:S817.
laboratory test ordering. BMC Med Inform Decis Making 2017;17: 44. Lanzoni M, Fornili M, Felicetta I, Maiavacca R, Biganzoli E, Castali S.
179–87. Three-year analysis of repeated laboratory tests for the markers
28. Pelloso M, Basso D, Padoan A, Fogar P, Plebani M. Computer- total cholesterol, ferritin, vitamin D, vitamin B12, and folate, in a
based-limited and personalised education management large research and teaching hospital in Italy. J Eval Clin Pract 2017;
maximise appropriateness of vitamin D, vitamin B12 and folate 23:654–61.
restesting. J Clin Path 2015;69:777–83. 45. Chami N, Simons JE, Don-Wauchope AC. Rates of inappropriate
29. Lippi G, Brambilla M, Bonelli P, Aloe R, Balestrino A, Nardelli A, laboratory test utilization in Ontario. Clin Biochem 2017;50:
Ceda GP, Fabi M. Effectiveness of a computerized alert system 822–7.
50 Lang: Minimum retesting intervals in practice
46. Pema AK, Kiabilua O, Pillay TS. Demand management by Felder TK, Cadamuro J. Reducing the probability of falsely
electronic gatekeeping of test requests does not influence elevated HbA1c results in diabetic patients by applying
requesting behaviour or save costs dramatically. Ann Clin automated and educative HbA1c re-testing intervals. Clin
Biochem 2018;55:244–53. Biochem 2020, in press.
47. Morris TF, Ellison TL, Mutabagani M, Althawadi SI, Heppenheimer 54. Salinas M, Lopez-Garrigos M, Flores E, Blasco A, Leiva-Salinas
M. Demand management and optimization of clinical laboratory C. Less is more: two automated interventions to increase
services in a tertiary referral center in Saudi Arabia. Ann Saudi vitamin B12 measurement when long-term proton pump
Med 2018;38:299–304. inhibitor and decrease redundant testing. Clin Chim Acta 2020;
48. Zorbozan N, Akarken I. Unnecessary repeated total PSA tests and 506:176–9.
evaluation with minimum retest interval and reference change 55. Salinas M, Lopez-Garrigos M, Uris J. Differences in laboratory
value. J Clin Chem Lab Med 2019;2:119. requesting patterns in emergency departments in Spain. Ann Clin
49. Lapić I, Rogić D, Fuček M, Galović R. Effectiveness of minimum Biochem 2013;50:353–9.
retesting intervals in managing repetitive laboratory testing: 56. Salinas M, Lopez-Garrigos M, Flores E, Blasco A, Leiva-Salinas
experience from a Croatian university hospital. Biochem Med C. Temporal and regional variability in the request of vitamin D
(Zagreb) 2019;29:030705. from general practitioners in Spain. Clin Chem Lab Med 2017;
50. Ko SQ, Quah P, Lahiri M. The cost of repetitive laboratory testing 55:1754–60.
for chronic disease. Int Med J 2019;49:1168–70. 57. Salinas M, Lopez-Garrigos M, Flores E, Blasco A, Leiva-Salinas C.
51. Kilincarslan MG, Sahin Em, Korkmazer B. Prevalence and Urinary albumin: a risk marker under-requested in primary care in
associated factors of inappropriate repeat testing. Postgrad Med Spain. Ann Clin Biochem 2018;55:281–6.
J 2019;95:595–600. 58. Hutton HD, Drummond HS, Fryer AA. The rise and fall of C-reactive
52. Vrijsen BEL, Naaktgeboren CA, Vos LM, van Solinge WW, protein: managing demand within clinical biochemistry. Ann Clin
Kaasjager HAH, ten Berg MJ. Inappropriate laboratory testing in Biochem 2009;46:155–8.
internal medicine patients: Prevalence, causes and 59. Brady H, Piggott L, Dunne S, O’Connell NH, Dunne CP.
interventions. Ann Med Surg 2020;51:48–53. Clustered interventions to reduce inappropriate duplicate
53. Mrazek C, Stechemesser L, Haschke-Becher E, Holzl B, laboratory testing in an Irish tertiary hospital. Clin Biochem
Paulweber B, Keppel MH, Simundic A-M, Oberkofler H, 2018;52:26–32.