ESR testing has therefore been the target of test utilization initiatives by the American Society of Clinical Pathology (ASCP) as part of the American Board of Internal Medicine's (ABIM's) Choosing Wisely campaign, which recommends against ESR testing in favor of CRP testing for inflammation in patients with undiagnosed conditions. While ESR remains in the diagnostic guidelines for some rheumatologic diseases, the known limitations of ESR have diminished its general diagnostic utility and impact on clinical decision-making when compared with CRP, ,, ]. Discordant testing is most often due to elevated ESR and normal CRP these discrepancies are largely attributable to resolving inflammatory disorders or elevated serum gamma globulins (false positive ESRs). Overall, co-testing of ESR and CRP reveals high concordance rates. CRP concentrations are measurable by common automatable chemistry analyzers already in routine use in most clinical laboratories. CRP levels do not vary with sex or age and the only major factor impacting CRP kinetics is advanced liver disease, which impairs CRP synthesis (false negative CRP). CRP rises within 4–6 h of an inflammatory stimulus and has a 4–7 h half-life, allowing for rapid clearance after a source of inflammation is resolved. Synthesized by the liver, CRP binds to the surface of bacteria or dying host cells to trigger complement activation and opsonization. ĬRP was discovered in 1930 by Tillet and Francis as a serum protein that reacts with the polysaccharide cell wall (fraction C) of Streptococcus pneumoniae. Automated ESR methodologies for high-throughput clinical laboratories are available, but require dedicated analyzers. The standardization of ESR as a clinical test was spearheaded by Alf Westergren using a 2.5 mm vertical tube and 3.8% sodium citrate anticoagulated blood measured over a one-hour time period this approach remains the gold standard methodology today. Moreover, baseline ESR is higher in females (requiring sex-specific reference ranges) and increases with age. As fibrinogen and immunoglobulins have long serum half-lives, ESR remains elevated weeks after a triggering event resolves. ESR is therefore an indirect measure of inflammation, and increased by other non-inflammatory factors including hyperglobulinemia, hypoalbuminemia, renal insufficiency, ischemic stroke, or the use of intravenous immunoglobulins. Indeed, an individual's ESR depends on the balance between factors promoting sedimentation (e.g., fibrinogen, an acute phase reactant synthesized by the liver and produces erythrocyte rouleaux) and factors hindering sedimentation (e.g., repulsive negatively-charged erythrocyte membranes). The observation that the rate of erythrocyte clumping and settling varies between individuals due to inflammation or pregnancy was first described by Van der Kolk in 1820 subsequently, Herman Nasse and Robin Fahraeus attributed this phenomenon to variations in plasma proteins. To demonstrate the potential impact of such a CPOE rule within other healthcare settings, ESR/CRP ordering data from a multi-site tertiary care practice and from the commercially insured population in the OptumLabs® Data Warehouse (OLDW) were analyzed and the relative reduction in ESR/CRP co-ordering achieved within the community health system was projected onto these populations.Įrythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are two common laboratory assays used to assess a patient's inflammatory state.
This study describes the impact of a computerized provider order entry (CPOE) decision support rule against ESR/CRP co-ordering within a community health system that predates the ABIM's Choosing Wisely national guidance. To that end, the American Board of Internal Medicine's (ABIM's) Choosing Wisely campaign has recommended against ESR testing for those with undiagnosed conditions in favor of CRP testing. ESR suffers from higher false positive and false negative rates than CRP.
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are common laboratory assays used as markers of inflammation.
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