LFT Ordering BehaviorPayam ParvinchihaDSR 2

Guidelines• No guidelines for ordering of LFT• Should not be a screening test for liver disease

• population-based survey in the United States conducted between 1999 and 2002 estimated that an abnormal ALT was present in 8.9 percent of respondents• ALT level correlates with body mass index (BMI) and waist

circumference, and the BMI of Americans has increased significantly over time

• Am J Gastroenterol. 2006;101(1):76.

• Abnormal serum aminotransferase levels (ALT >2.25 SD above normal; >55 int. unit/L) were detected in 99 of 19,877 (0.5 percent) Air Force recruits beginning basic training [7]. Of these, a cause was found in only 12 (including chronic hepatitis B and C, autoimmune hepatitis, and cholelithiasis). No specific diagnosis was established in the remaining 87 patients.

• Dig Dis Sci. 1993;38(12):2145.

Most likely Dx• Another study focused on 81 of 1124 patients who were

referred for abnormal serum aminotransferase levels in whom a diagnosis could not be inferred noninvasively [11]. A liver biopsy revealed steatosis or steatohepatitis in the majority of patients (84 percent); six patients had fibrosis or cirrhosis, and eight had normal histologic findings.

• Am J Gastroenterol. 1999;94(10):3010.

Fluctuations• Individual patients can have baseline fluctuation in serum

aminotransferase levels. In a large, cross-sectional population-based study, more than 30 percent of adults with abnormal LFTS were reclassified as being normal upon retesting [14].

• Ann Intern Med. 2008;148(5):348.

False positive• Normal reference values-arbitrarily determined to be 2 SD

above the mean• 5 percent of healthy individuals who have a single screening

test will have an abnormal result (2.5 percent will have an abnormally high result). As more tests are ordered, the likelihood of a false positive test increases; a screening panel containing 20 independent tests in a patient with no disease will yield at least one abnormal result 64 percent of the time

Cost of LFT• $25-$35• Hepatitis Panel: $125• RUQ Ultrasound: $125

Cross sectional Analysis• All patients on Ward Teams A/B on 3/25• Admission Days, LFT on admission, # of LFT total, Hx of Liver

Dx, Indication for LFT charted, New Abnormalities found, further w/u ordered

• 23 Patients• Avg LOS: 6.5 days• #LFT/Admission: 4.7• #LFT/Day of admission: .8• LFT on admission: 18/23• Hx Liver Dx: 4/23• Indications: 5/23• New Abn: 14/23• Further w/u: 6

• If $25 / LFT then $20 spent / patient/day on LFT given this sample

• $120 per admission on LFT’s • Most patient’s w/o indication for LFT’s• Minimal further w/u done in this population of ts