Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter February 24, 2018

Employing a results-based algorithm to reduce laboratory utilization in ACTH stimulation testing

  • Ryan J. McDonough EMAIL logo , Patria Alba , Kavitha Dileepan and Joseph T. Cernich



The High Dose Adrenocorticotropic Hormone (ACTH) Stimulation Test is the gold standard to diagnose adrenal insufficiency. Normal adrenal function is defined as a peak cortisol response to pharmacologic stimulation with cosyntropin of ≥18 μg/dL. Our practice was to obtain cortisol levels at 0, 30 and 60 min after cosyntropin administration. Once a value of ≥18 μg/dL has been obtained, adrenal insufficiency is ruled out and there is little diagnostic utility in subsequent stimulated levels.


We aimed to decrease laboratory utilization by developing a results-based algorithm in the electronic medical record (EMR). Cortisol levels were analyzed on the 0 and 60 min samples; then an EMR discern rule automatically generated an order to analyze the 30-min sample if the 60-min cortisol level was subnormal.


Exclusion of adrenal insufficiency was excluded using one stimulated cortisol level in 8% prior to algorithm development. After several plan-do-study-act cycles, 99% of normal tests were performed using only one stimulated cortisol level.


This laboratory-based algorithm resulted in reduced laboratory utilization, and aligned our practice to recommendations of the Pediatric Endocrine Society. Similar algorithms could be created for other dynamic tests to reduce unnecessary laboratory utilization.

Corresponding author: Ryan J. McDonough, DO, Division of Endocrinology and Diabetes, Children’s Mercy – Kansas City, 3101 Broadway Boulevard Suite 900, Kansas City, MO 64111, USA, Phone: 816-960-8892


Special thanks to Dr. Marilyn Hamilton, Malcolm McIntyre, Karla Williams, and Sarah Goodman, RN, BSN for their contributions to this project.

  1. Author contributions: Ryan J. McDonough: Dr. McDonough conceptualized and designed the study, drafted the initial manuscript, reviewed and revised the initial manuscript, and approved the final manuscript as submitted. Patria M. Alba Aponte: Dr. Alba Aponte helped with the concept and design of the study, drafted the initial manuscript, reviewed and revised the initial manuscript, and approved the final manuscript as submitted. Kavitha Dileepan: Dr. Dileepan helped with the concept and design of the project, critically reviewed the manuscript, and approved the final manuscript as submitted. Joseph T. Cernich: Dr. Cernich helped with the concept and design of the project, critically reviewed the manuscript, and approved the final manuscript as submitted. All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

  2. Research funding: None declared.

  3. Employment or leadership: None declared.

  4. Honorarium: None declared.

  5. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.


1. Arlt W, Allolio B. Adrenal insufficiency. Lancet 2003;361:1881–93.10.1093/med/9780199235292.003.0599Search in Google Scholar

2. Shulman DI, Palmert MR, Kemp SF, Lawson Wilkins Drug and Therapeutics Committee. Adrenal insufficiency: still a cause of morbidity and death in childhood. Pediatrics 2007;119:e484–94.10.1542/peds.2006-1612Search in Google Scholar PubMed

3. Mushtq T, Shakur F, Wales JK, Wright NP. Reliability of the low dose synacthen test in children undergoing pituitary function testing. J Pediat Endocrinol Metabol 2008;21:1129–32.10.1515/JPEM.2008.21.12.1129Search in Google Scholar

4. Sarafoglou K. Pediatric endocrinology and inborn errors of metabolism. New York, NY: McGraw-Hill, 2009.Search in Google Scholar

5. Dorin RI, Qualls CR, Crapo LM. Diagnosis of adrenal insufficiency. Ann Intern Med 2003;139:194.10.7326/0003-4819-139-3-200308050-00009Search in Google Scholar PubMed

6. Zueger T, Jodi M, Laimer M, Stettler C. Utility of 30 and 60 minute cortisol samples after high-dose synthetic ACTH 1-24 injection in the diagnosis of adrenal insufficiency. Swiss Med Wkly 2014;144:w13987.10.4414/smw.2014.13987Search in Google Scholar PubMed

7. Lexicomp Online®, Pediatric & Neonatal Lexi-Drugs®, Hudson, Ohio: Lexi-Comp, Inc, 2014.Search in Google Scholar

8. Husebye ES, Allolio B, Artl W, Badenhoop K, Bensing S, et al. Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency. J Intern Med 2014;275:104–15.10.1111/joim.12162Search in Google Scholar PubMed

9. Man A, Shojania K, Phoon C, Pal J, de Badyn MH, et al. An evaluation of autoimmune antibody testing patterns in a Candian health region and an evaluation of laboratory algorithm aimed at reducing unnecessary testing. Clin Rheumatol 2013;32:601–8.10.1007/s10067-012-2141-ySearch in Google Scholar PubMed

10. Ibrahim H, McKenna MJ, Feldkamp CS. A thyroid testing algorithm: results of a pilot study. Henry Ford Hospital Med J 1991;39:30–4.Search in Google Scholar

Received: 2017-9-1
Accepted: 2018-1-29
Published Online: 2018-2-24
Published in Print: 2018-3-28

©2018 Walter de Gruyter GmbH, Berlin/Boston

Downloaded on 23.3.2023 from
Scroll Up Arrow