The successful diagnostic stewardship interventions described above can serve as models for populations and settings in which problems with the testing process contribute to diagnostic error. Conditions that are known to be frequently misdiagnosed and have testing-related contributing factors are good candidates for further applications of diagnostic stewardship.
For example, in an analysis of recurring diagnostic “pitfalls,” Schiff and colleagues identified multiple cases of wrong (false positive) diagnoses of systemic lupus erythematosus based on misinterpretation of antinuclear antibody (ANA) testing.95 While interventions have been developed to reduce inappropriate use of ANA testing and followup testing,96,97 it is less clear whether they ultimately reduce the occurrence of false positive diagnoses that reach the patient and cause harm.
Establishing the effect of these and similar interventions on diagnostic safety measures is an important next step toward defining their role in improving diagnosis. Interventions can take a variety of forms, but a common underlying element is the close collaboration of laboratory testing experts and clinicians.
Healthcare leaders can advance diagnostic stewardship by addressing barriers to effective clinician-laboratory interfaces within their own organizations. A national survey of U.S. physicians revealed that, even when access to diagnostic expertise is desired, physicians often face difficulty contacting the laboratory, uncertainty about whom to contact, and lack of time to make contact.98 Developing channels for communication and collaboration with the laboratory might entail additional effort and resources, but they can be justified by the benefits these partnerships create.
To sustain these interventions, healthcare leaders are encouraged to look beyond cost savings alone and consider the total value of diagnostic stewardship, including downstream effects on length of stay, adverse events, clinician satisfaction, and patient experience. Clinicians, diagnostic experts, and quality and safety professionals should be involved in efforts to measure these organization-level outcomes as well as those directly related to diagnostic error.
National-level initiatives to promote diagnostic stewardship include champions from professional societies, regulatory agencies, payers, and patient advocates. The American Board of Internal Medicine Foundation’s Choosing Wisely campaign was one example. Choosing Wisely promoted recommendations for diagnostic stewardship, among others,99 that have been adopted within and outside the United States. However, it has been noted that the success of the Choosing Wisely campaign was due in part to the engagement of medical societies in cocreating practice recommendations to reduce overtesting and waste, in contrast to “top-down” edicts from payers and regulators.100
Regulators and payers could incentivize diagnostic stewardship while maximizing autonomy and intrinsic motivation to improve care. Healthcare organizations can be encouraged to identify their own targets for improvement based on internal quality and safety measures or feedback from clinicians and laboratory professionals. For example, van Moll and colleagues described an analysis of voluntary incident reports at an academic teaching hospital to understand diagnostic errors resulting from problems in the testing process.101
An emphasis on general principles and core features of diagnostic stewardship, rather than prespecified improvement targets, will allow innovation and flexibility to meet local needs. CDC’s Core Elements of Antibiotic Stewardship72 is an example of flexible implementation guidance. While the Core Elements document provides some specifications and priorities for stewardship programs, decisions about which treatment courses to monitor and which specific stewardship practices to implement are left to the organization’s discretion.
Successful implementation of diagnostic stewardship in other systems has been slow to translate nationally and may not reach all patients equitably. One potential challenge is that diagnostic stewardship policies and procedures are often organization or even facility specific, making translation across systems difficult.
Multicenter quality improvement collaboratives have shown promise for disseminating diagnostic stewardship interventions and may enable greater reach of these practices. One instance of such a dissemination effort was the Bright STAR Quality Improvement Collaborative, which supported implementation of diagnostic stewardship for blood cultures across 14 pediatric intensive care units.65
Another approach is to implement standardized quality measures. For example, CDC released a quality measure to prevent blood culture contamination and improve laboratory diagnosis of bloodstream infections.43,102,103
Other barriers to implementing diagnostic stewardship reflect structural challenges, including limited infrastructure to deliver interventions and constraints on reimbursement for recommended testing, which may also disproportionately burden underserved populations. For instance, for recommended genetic testing, such as rapid genomic sequencing for diagnosis in critically ill newborns, scientific evidence of benefit104-106 has not translated to consistent payer and state-level coverage policies.34,78,104 Assessing outcomes that matter to clinicians and patients, such as reductions in preventable harm, can help bring to light the impact of diagnostic stewardship interventions.
