Abstract
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
Acknowledgments
Special thanks to Dr. Marilyn Hamilton, Malcolm McIntyre, Karla Williams, and Sarah Goodman, RN, BSN for their contributions to this project.
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.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
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.
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