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Reducing Inappropriate H. pylori Antibody Testing: A Quality Improvement Initiative

David Anjelly, Steven Moss, Victoria Brown, Michelle Lally

It has been well-established that inappropriate and excessive laboratory testing presents a credible threat to patient safety and imposes unnecessary added costs to the healthcare system. This case report details our experience at the Providence VA Medical Center with a seemingly benign test with significant potential for misuse—the serology-based antibody screen for H. pylori infection. Although GI professional society guidelines--as early as 1998--have advocated use of urea breath testing or stool antigen testing as the standard of care for diagnosing active H. pylori infection, the antibody test remains in widespread use despite poor performance characteristics in lower prevalence populations, such as in much of the United States. In the past few years, in an attempt to minimize morbidity associated with treating false-positive patients, the antibody test has been discontinued from testing 'menus' of the major diagnostic labs and is increasingly no longer reimbursed by insurers. In light of this and since our facility still continued to offer the antibody test, a quality improvement initiative was undertaken to characterize our current H. pylori testing practices and use that data to effect change--ideally in eliminating the test from our roster. In our study of 551 patients who presented for H. pylori testing over a 5 year period, we found that nearly 70% were initially diagnosed with the incorrect (antibody) test, and of those seropositive patients ultimately treated with antibiotics, approximately 80% were essentially mismanaged in that they received no other confirmatory testing before therapy was initiated. We furthermore noted that inappropriate ordering of antibody testing was concentrated in the primary care setting, likely by providers not familiar with current guidelines or the unfavorable performance characteristics of the antibody test in our low-prevalence, Veteran population. Sharing these data with our Laboratory Utilization Committee directly led to discontinuation of the antibody test at our facility.