BIDMC researchers show that, on average, 30% of all lab tests may be unnecessary and that an equal percentage of tests should not be ordered at all
Every pathologist and clinical laboratory professional knows how often physicians order a medical laboratory test that is inappropriate or unnecessary. That is a problem because, each time a clinician orders an inappropriate test, patient harm is possible. Yet this issue gets little attention from the medical profession at large.
Thus, it is significant that researchers at Beth Israel Deaconess Medical Center (BIDMC), published a study last fall showing that 30% of all medical laboratory tests throughout medicine are overused! A different 30% of medical laboratory tests are underused, as well.
Review of 1.6 Million Medical Laboratory Tests over Past 15 Years
Researchers reviewed clinical studies done over 15 years that included a review of 1.6 million results from 46 of the 50 most commonly ordered clinical laboratory tests. Included were common tests, such as the complete blood count and basic metabolic panels, along with less common tests such as the D-dimer (for pulmonary embolism) and tests for HIV.
Published in the journal PLOS ONE, results of the study showed that, on average, 30% of all tests may be unnecessary and that an equal percentage of tests should not be ordered at all. The article, The Landscape of Inappropriate Laboratory Testing: A 15-Year Meta-Analysis, is available online.
Goal Was to Identify Errors Involving a High-Volume of Clinical Activity
When working with other clinicians at BIDMC, pathologist and senior author Ramy Arnaout, M.D., Ph.D., often had wondered about the appropriateness and inappropriateness of medical laboratory tests he orders. “In developing this study, my coauthors and I wanted to learn more about overall lab test utilization so that we could better understand how and where errors were occurring in this extremely high-volume activity,” he commented in a press release BIDMC issued on the study.
Arnaout is Associate Director of the Clinical Microbiology Laboratories in the Department of Pathology at BIDMC and Assistant Professor of Pathology at Harvard Medical School (HMS).
As a result of this study, Arnaout said, the most important question clinicians, pathologists and lab directors should ask is: How can clinicians order the proper tests for each patient? “It’s not ordering more tests or fewer tests that we should be aiming for,” he explained. “It’s ordering the right tests, however few or many that is.”
Arnaout went on to observe that discussions among physicians about inappropriate lab testing generally center around the subject of too many repeat tests being ordered. “But, unexpectedly, on a per-test basis, we actually found that the main problem was [medical laboratory] tests being over-ordered during a patient’s initial examination, rather than during repeat tests. This indicates to us that ordering the right test during the initial evaluation may lead to fewer errors and better patient care,” he said.
Asking ‘Why Not’ instead of ‘Why’?
Generally, every physician has a reason for doing any test or procedure, and almost always health systems use guidelines to prevent overuse, Arnaout said. “However, as our findings showed, laboratory medicine is the exception to this rule,” he explained. “In ordering blood tests, we too often tend to be permissive, asking ‘why not?’ instead of ‘why?’”
Jeffrey Saffitz, M.D., Ph.D., Chairman of Pathology at BIDMC, agreed with Arnaout’s assessment. “Many times, the reason for ordering tests seems to be based on dogma, the way it’s always been done,” he said. “This comprehensive and meticulous analysis shows that there are patterns in laboratory test utilization that can reveal when we do a good job at ordering tests and where we need to do better.”
Upon completing this research, first author Ming Zhi, M.D., an intern at Kaiser Permanente Santa Clara Medical Center, said he now questions the need for certain medical laboratory tests. “I think there’s often a mindset of ‘just go ahead and order the tests,’” he explained in the BIDMC press release. “But I’ve now discovered that it’s a lot more nuanced in the clinical setting. Working on this project has had a direct impact on my own behavior. I find myself asking, ‘Do my patients really need another set of tests? Do they really need another needle stick? Is there a test they may need that I left out?”
Physicians Commented About Study in an Online Forum
After the study was published, Neel Shah, M.D., MPP, the founder of Costs of Care, a nonprofit organization that helps physicians and others keep healthcare costs down, asked in an online forum for physicians to comment on the study. Shah practices in the Division of Quality, Safety, and Performance Improvement in the Department of Obstetrics and Gynecology at BIDMC and is a co-author of the forthcoming textbook from McGraw-Hill, Understanding Value-Based Care.
“In another indictment of the value gap in American healthcare, researchers at Beth Israel Deaconess Medical Center in Boston analyzed 1.6 million blood tests and found that only one third hit the mark. By contrast, [another] one-third are either overused or underused. Why do we misfire so often?” he asked. “What does everyone think of the study conclusions? Are they fair?” Those who responded were unable to offer solutions to the problem.
For pathologists, this research study provides them an opportunity to consult with referring physicians to ensure that appropriate medical laboratory testing is done for all patients. “These findings offer the field of pathology both an opportunity and challenge for the future,” Saffitz said. “When it comes to appropriate lab testing I think the pathologist has as much responsibility to get it right as the doctor who is ordering the test. This paper focuses attention on this important issue.”
—by Joseph Burns