A retrospective observational study of mNGS test utilization to examine the role of diagnostic stewardship at two academic medical centers.

IF 6.1 2区 医学 Q1 MICROBIOLOGY Journal of Clinical Microbiology Pub Date : 2024-09-11 Epub Date: 2024-08-20 DOI:10.1128/jcm.00605-24
Ryan C Shean, Elizabeth Garrett, James Malleis, Joshua A Lieberman, Benjamin T Bradley
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Abstract

Given the cost and unclear clinical impact of metagenomic next-generation sequencing (mNGS), laboratory stewardship may improve utilization. This retrospective observational study examines mNGS results from two academic medical centers employing different stewardship approaches. Eighty mNGS orders [54 cerebrospinal fluid (CSF) and 26 plasma] were identified from 2019 to 2021 at the University of Washington (UW), which requires director-level approval for mNGS orders, and the University of Utah (Utah), which does not restrict ordering. The impact of mNGS results and the relationship to traditional microbiology orders were evaluated. Nineteen percent (10/54) of CSF and 65% (17/26) of plasma studies detected at least one organism. Compared to CSF results, plasma results more frequently identified clinically significant organisms (31% vs 7%) and pathogens not detected by traditional methods (12% vs 0%). Antibiotic management was more frequently impacted by plasma versus CSF results (31% vs 4%). These outcome measures were not statistically different between study sites. The number and cumulative cost of traditional microbiology tests at UW were greater than Utah for CSF mNGS testing (UW: 46 tests, $6,237; Utah: 26 tests, $2,812; P < 0.05) but similar for plasma mNGS (UW: 31 tests, $3,975; Utah: 21 tests, $2,715; P = 0.14). mNGS testing accounted for 30%-50% of the total microbiology costs. Improving the diagnostic performance of mNGS by stewardship remains challenging due to low positivity rates and difficulties assessing clinical impact. From a fiscal perspective, stewardship efforts should focus on reducing testing in low-yield populations given the high costs of mNGS relative to overall microbiology testing expenditures.

Importance: Metagenomic next-generation sequencing (mNGS) stewardship practices remain poorly standardized. This study aims to provide actionable insights for institutions that seek to reduce the unnecessary usage of mNGS. Importantly, we highlight that clinical impact remains challenging to measure without standardized guidelines, and we provide an actual cost estimate of microbiology expenditures on individuals undergoing mNGS.

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对两个学术医疗中心使用 mNGS 检验的情况进行回顾性观察研究,以考察诊断监管的作用。
鉴于元基因组下一代测序(mNGS)的成本和临床影响尚不明确,实验室管理可提高利用率。这项回顾性观察研究考察了两家采用不同管理方法的学术医疗中心的 mNGS 结果。在华盛顿大学(UW)和犹他大学(Utah),前者的 mNGS 订单需要主任级别的批准,后者则不限制订单。评估了 mNGS 结果的影响以及与传统微生物订单的关系。19%(10/54)的 CSF 和 65%(17/26)的血浆研究检测到至少一种微生物。与 CSF 结果相比,血浆结果更常发现有临床意义的微生物(31% 对 7%)和传统方法未检测到的病原体(12% 对 0%)。抗生素管理更经常受到血浆和 CSF 结果的影响(31% 对 4%)。这些结果指标在不同研究地点之间没有统计学差异。对于 CSF mNGS 检测,华盛顿大学的传统微生物学检测次数和累计成本均高于犹他州(华盛顿大学:46 次检测,6237 美元;犹他州:26 次检测,2812 美元;P < 0.05),但对于血浆 mNGS,两者相近(华盛顿大学:31 次检测,3975 美元;犹他州:21 次检测,2715 美元;P = 0.14)。由于阳性率低且难以评估临床影响,通过监管来提高 mNGS 的诊断性能仍具有挑战性。从财政角度看,鉴于 mNGS 的成本相对于微生物检测总支出较高,监管工作应侧重于减少低收益人群的检测:元基因组下一代测序(mNGS)监管实践的标准化程度仍然很低。本研究旨在为寻求减少不必要使用 mNGS 的机构提供可行的见解。重要的是,我们强调,在没有标准化指南的情况下,衡量临床影响仍然具有挑战性。
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来源期刊
Journal of Clinical Microbiology
Journal of Clinical Microbiology 医学-微生物学
CiteScore
17.10
自引率
4.30%
发文量
347
审稿时长
3 months
期刊介绍: The Journal of Clinical Microbiology® disseminates the latest research concerning the laboratory diagnosis of human and animal infections, along with the laboratory's role in epidemiology and the management of infectious diseases.
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