Testing, Testing and over testing…
Dr. C.N. Srinivas MD (Path), DNB (Path), IFCAP, Head – Clinical Lab, Head Transplantation Immunology and Consultant Pathologist at MIOT Hospitals, Chennai
A patient attends OP in physician clinic with fever and obviously in pain and but with such nonspecific symptoms.
After careful examination of the patient, the doctor decides to take support from laboratory. The answer, for many care providers, lies in laboratory tests – and the more, the better, in some cases. Who knows what might turn up in the patient’s blood counts, metabolic panels, or renal function? Why risk not testing for something that might provide an answer, when it’s so easy to tick every box on the requisition sheet?
Laboratories and clinicians should know that more isn’t always better. Unnecessary tests cost the laboratory time and resources. They cost the patient withanxiety, discomfort, and even more severe consequences, such as hospital-induced anemia arising from too many blood draws. Moreover, benefits are never guaranteed; increased testing may not actually reveal the issues affecting the patient, whereas it can result in unnecessary interventions or feed into a never-ending cycle of tests. So why do doctors continue to order tests their patients don’t need?
THE DANGERS OF EXCESSIVE TESTING
Several studies have shown that excessive lab testing can lead to hospital-acquired anemia. which in turn can lead to unnecessary blood transfusions and worse patient outcomes. Additionally, labs ordered without a high pre-test probability for a disease state are difficult to interpret and often lead to more unnecessary testing, which further contributes to rising costs and patient harm. It’s a vicious cycle. And, of course, whether one test or a dozen too many, phlebotomy can be a painful experience for patients, so it can lead to patient dissatisfaction. In this era of patient-centered care, our first priority is the physical health of those entrusted to us – but we must also be aware of the psychological stressors of hospitalization, and that includes those that arise from medical testing
OVER-TEST: DESPITE RECOMMENDATIONS TO THE CONTRARY
Many reasons for the overtesting are quoted in literature and survey to lack of knowledge of lab costs, provider inexperience, change in clinical status, fear of missing a diagnosis, or diagnostic uncertainty. In some cases, the practice is actually patient-driven(Googlified patient); patients want to know if they have a particular problem, and they request or even pressure doctors to do the testing for them, even in situations where it may not be necessary. In addition the “kickbacks”, “Discounted packages” , “Clubbing” “ Free tests “ are a force for over utilisation.
WHAT EDUCATIONAL INITIATIVES MIGHT ENCOURAGE PHYSICIANS TO ORDER FEWER TESTS?
The key is to focus on educating providers about the appropriate indications for various laboratory tests. These recommendations can be decided by collaborating with various subspecialty experts to form a unified set of indications for various lab tests (perhaps starting with the most expensive and frequently misused).
It’s also important to educate providers on the downstream effects of unnecessary testing. Ordering lab tests without a clinical reason makes the results difficult to interpret. If there is an abnormal value, additional unnecessary testing is often ordered – only to find out, ultimately, that there wasn’t even a problem in the first place. These “cascade” effects contribute to wasted value, patient dissatisfaction, and possibly unintended complications.
A major contributing factor to over-testing is that labs like CBCs and Profiles are ordered to repeat daily on patients admitted to the hospital – but patients don’t necessarily need these tests every single day of their hospitalization.
The most common lab tests(CBC, Renal package, LFT and so on) are the ones often ordered as daily repeating labs for hospitalized patients – but they have the potential for significant downsides if the patient has been clinically stable. In the setting of clinical stability, abnormalities on these lab tests are difficult to interpret and often prompt additional testing, which can lead to excessive phlebotomy and hospital-acquired anemia. Anecdotally, I also feel as though rheumatologic tests (such as ANA, dsDNA, or anti-Smith antibody) are also frequently ordered inappropriately and can lead to further unjustified testing on patients. Both pathologists and primary care providers should pay attention to ordering patterns for these kinds of labs – and speak up when excessive testing carries the potential for harm. Be aware, though, that your mileage may vary. Over-utilized lab tests often differ between institutions depending on patient population and providers’ preferences.
They can collaborate with other subspecialty experts to determine standard indications for different lab tests – perhaps starting by targeting the tests that are most expensive, or most often misused. They can educate providers on appropriate indications for different lab tests to help avoid unnecessary testing. They can even help develop safe testing algorithms – for instance, to build lab test orders that reflex to additional tests if (and only if) the first result is abnormal. These initiatives can potentially save a lot of tests from being ordered in the first place, improving the overall health and happiness of our patients.