Position Statement
Subject:
Inappropriate Pathology Requesting
Approval Date:
November 2014
Review Date:
November 2018
Review By:
Board of Directors
Number:
3 /2014
__________________________________________________________________________
The Royal College of Pathologists of Australasia is committed to the promotion of the
appropriate use of pathology. Diagnostic tests that are provided in accredited laboratories have
undergone a rigorous process of assessment to confirm that each test has analytical validity,
clinical validity, clinical utility and is cost-effective however not every one of these elements is
satisfied every time a test is requested. It is important that health practitioners understand
enough about a test’s characteristics to be confident that the result or report arising from a
particular test will enhance their patient's care and is an appropriate use of finite health
resources.
In various jurisdictions there are efforts to improve the appropriateness of pathology requesting.
For example governments may apply restrictions, blocks or specific criteria to the requesting of
certain tests in order to fund those services. Efforts are also made in the education and training
of medical students, nurse practitioners, junior doctors, registrars and specialists. For example
the College has Position Statements on the use of Vitamin D testing, Prostate Specific Antigen
Testing and, jointly with the Australian College of Emergency Medicine, Pathology Requesting
in the Emergency Department. Increasingly other initiatives including web-based guidelines
such as the RCPA Manual and Decision Support for pathology requesting, much of it integrated
with information systems to enhance electronic requesting, are being employed.
Agencies such as NPS in Australia, previously focussed on assisting general practitioners with
appropriate prescribing, are beginning to turn their focus towards appropriate requesting in both
pathology and radiology. Internationally, a successful campaign in the United States called
“Choosing Wisely” has drawn on the collective knowledge of medical Colleges and Associations
to produce lists of “top ten” inappropriate practices in their respective fields. In the spirit of such
campaigns, the College Fellowship offers the following list to enhance pathology requesting and
address current inappropriate requesting trends:
1. Do not perform surveillance urine cultures or treat asymptomatic bacteruria in older
patients unless there are urinary tract signs and symptoms
2. Do not perform population based screening for Vitamin D deficiency
3. Do not perform PSA testing for prostate cancer screening in men with no symptoms
and whose life expectancy is less than 10 years *
4. Do not perform routine pre-operative screening tests for low-risk surgery
5. Do not perform IgG4 allergy tests, total IgE (or indiscriminate batteries of IgE tests) in
the investigation of allergy
6. Do not perform heavy metal tests for non-specific symptoms in the absence of exposure
7. Do not test for Lyme disease for non-specific symptoms in the absence of exposure
(travel to endemic areas)
8. Do not perform serum tumour marker tests except for the monitoring of a cancer known
to produce these markers
9. Do not routinely test and treat hyperlipidemia in those with a limited life expectancy
10. Do perform high sensitivity D-dimer assay in outpatients rather than imaging to exclude
venous thrombo-embolism in patients with a low clinical probability
Clearly such lists require updating from time-to-time and do not replace clinical decision-making
in individual circumstances. However it helps clarify, from a consensus pathology providers
perspective, current areas in need of training and consideration by requestors.
*PSA is the only tumour marker supported for screening purposes
References:
1. RCPA Position Statement:
Use and Interpretation of Vitamin D Testing
2. RCPA Position Statement:
Prostate specific antigen testing – age-related interpretation
3. RCPA Position Statement:
Diagnostic Laboratory Testing for Borreliosis (‘Lyme Disease’
or similar in Aust and NZ
2