Assessing Utilization of the Cerebrospinal Fluid Venereal Disease Research Laboratory Test for Diagnosis of Neurosyphili
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Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; 2Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; 3Division of Infectious Disease, Mayo Clinic, Rochester, MN, USA; 4Department of Neurology, Mayo Clinic, Rochester, MN, USA.
BACKGROUND: Inappropriate use of diagnostic tests contributes to rising healthcare expenditures, and improving appropriate utilization rates is important for high-value patient care. The Venereal Disease Research Laboratory (VDRL) test performed in cerebrospinal fluid (CSF) has historically been improperly utilized, although there is no recent evaluation of its use in clinical practice. OBJECTIVES: Quantify the rates of appropriate CSFVDRL testing, determine the CSF-VDRL false-positivity rate, and describe the causes of false-positive CSF-VDRL reactivity. DESIGN: Retrospective cohort study PATIENTS: A total of 32,626 patients with CSF-VDRL testing at one of three Mayo Clinic sites (Rochester, MN; Jacksonville, FL; and Scottsdale, AZ) from January 1, 1994, to February 28, 2018. MAIN MEASURES: Rate of appropriate CSF-VDRL test utilization from January 1, 2011, to December 31, 2017, and CSF-VDRL true- and false-positivity rates from January 1, 1994, to February 28, 2018. KEY RESULTS: Among 8553 persons with negative CSFVDRL results, testing was inappropriately ordered for 8399 (98.2%) of these patients. The word “syphilis” or “neurosyphilis” appeared in the notes of 1184 (13.8%) individuals with a negative CSF-VDRL result. From January 1994 through February 2018, 33,933 CSF-VDRL tests were performed on 32,626 individual patients. Among the 60 positive CSF-VDRL results, 43 (71.7%) were true-positives and 17 (28.3%) were false-positives. All patients with false-positive CSF-VDRL results were tested unnecessarily. Neoplastic meningitis was a common cause of false-positive CSF-VDRL results. CONCLUSIONS: Inappropriate use of CSF-VDRL testing for the diagnosis of neurosyphilis remains problematic in clinical practice. Following recommended testing algorithms would prevent unnecessary testing and minimize false-positive results. KEY WORDS: appropriate use; syphilis; non-treponemal; lumbar puncture; neoplastic meningitis.
Prior presentations: A portion of this material was presented at Society for General Internal Medicine, 2019 Received June 1, 2020 Accepted August 10, 2020
J Gen Intern Med DOI: 10.1007/s11606-020-06127-z © Society of General Internal Medicine 2020
INTRODUCTION
Appropriate use of diagnostic testing is crucial to providing high-value healthcare. In 2018, national healthcare expenditures in the USA grew to $3.6 trillion, approximately $11,172 per person.1 The overuse or misuse of screening and diagnostic tests is an important contributor to healthcare expenditures, and with the ever-growing concern that rising healthcare costs are unsustainable, many medical associations emphasize practice patterns that reflect high-value care.2–4 The rates of syphilis in the USA have been increasing, but the o
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