What’s your lab’s procedure for getting rid of an obsolete test, or bringing in a new one? Any change to the test menu has some level of difficulty associated with it, however my opinion is that replacing a test with a new method that gives different results is the easiest to accomplish, followed by introducing a completely new test, and lastly removing an obsolete test. In that last case I’m specifically talking about removal of a test that is no longer the best way to diagnose a disease or monitor treatment.
In any of these cases, does your lab use the “rip the band aid off” method? For example, do you send a succinct notification that as of the first of the month this test will no longer be available in your lab, or this test will have results 33% higher than the doctors have been previously seeing? Or do you use a more gentle method, such as offering to run the old and new method together for 2-6 months to let the doctors get used to the new values? Or in the case of removing a test, do offer to try to find them an alternative lab which is still running the old test? Or do you simply leave the old test in place and hope it eventually dies a natural death from lack of use? Unfortunately, some tests never seem to die – like CKMB and bleeding time.
A lot of the difficulty, both in getting rid of old tests and in bringing in completely new ones, can probably be laid on the doorstep of human nature. Just like other humans, doctors like what they’re used to and don’t like changing their routine. Even when overwhelming evidence suggested that a new test is better (troponin), they want to use what they have always used to diagnose and treat their patients (CKMB). When the evidence for a test’s utility is not so clear cut, it’s even more difficult to introduce a new test. Examples of this include Cystatin C and fructosamine. Cystatin C is becoming more widely used and will no doubt survive as a test, but fructosamine? Part of the issue with fructosamine may have been the silly name they gave it. Fructosamine? Really? If they had called it glycated proteins/albumin it may have fared better. Fructosamine sounds too much like a fruit drink.
Maintaining a test menu that is appropriate for your population and that doesn’t include unnecessary or obsolete tests is an interesting balancing act. It definitely requires having a good rapport with your clinicians and getting their input along the way.
-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.