Rates of inappropriate laboratory test utilization in Ontario

Non-indicated vitamin B12- and D-testing among Dutch hospital clinicians: a cross-sectional analysis in data registries

OBJECTIVES

To assess the extent of non-indicated vitamin B12- and D-testing among Dutch clinicians and its variation among hospitals.

DESIGN

Cross-sectional study using registration data from 2015 to 2019.

PARTICIPANTS

Patients aged between 18 and 70 years who received a vitamin B12- or D-test.

PRIMARY AND SECONDARY OUTCOME MEASURES

The proportion of non-indicated vitamin B12- and D-testing among Dutch clinicians and its variation between hospitals (n=68) over 2015-2019.

RESULTS

Between 2015 and 2019, at least 79.0% of all vitamin B12-tests and 82.0% of vitamin D-tests lacked a clear indication. The number of vitamin B12-tests increased by 2.0% over the examined period, while the number of D-tests increased by 12.2%. The proportion of the unexplained variation in non-indicated vitamin B12- and D-tests that can be ascribed to differences between hospitals remained low. Intraclass correlation coefficients ranged between 0.072 and 0.085 and 0.081 and 0.096 for non-indicated vitamin B12- and D-tests, respectively. The included casemix variables patient age, gender, socioeconomic status and hospital size only accounted for a small part of the unexplained variation in non-indicated testing. Additionally, a significant correlation was observed in non-indicated vitamin B12- and D-testing among the included hospitals.

CONCLUSION

Hospital clinicians order vitamin B12- and D-tests without a clear indication on a large scale. Only a small proportion of the unexplained variation could be attributed to differences between hospitals.

Diabetes detection in women with gestational diabetes and polycystic ovarian syndrome

Gestational diabetes mellitus (GDM) and polycystic ovarian syndrome (PCOS) represent two of the highest risk factors for development of type 2 diabetes mellitus in young women. As these increasingly common conditions generally affect younger women, early detection of dysglycemia is key if preventative measures are to be effective. While international guidance recommends screening for type 2 diabetes, current screening strategies suffer from significant challenges.First, guidance lacks consensus in defining which tests to use and frequency of monitoring, thereby sending mixed messages to healthcare professionals.Second, conformity to guidance is poor, with only a minority of women having tests at the recommended frequency (where specified). Approaches to improve conformity have focused on healthcare related factors (largely technology driven reminder systems), but patient factors such as convenience and clear messaging around risk have been neglected.Third, and most critically, current screening strategies are too generic and rely on tests that become abnormal far too late in the trajectory towards dysglycemia to offer opportunities for effective preventative measures. Risk factors show wide interindividual variation, and insulin sensitivity and β cell function are often abnormal during pre-diabetes stage, well before frank diabetes.New, consistent, targeted screening strategies are required that incorporate early, prevention focused testing and personalised risk stratification.

Patient, hospital and environmental costs of unnecessary bloodwork: capturing the triple bottom line of inappropriate care in general surgery patients

OBJECTIVE

To characterise the extent of unnecessary care in general surgery inpatients using a triple bottom line approach.

DESIGN

Patients with uncomplicated acute surgical conditions were retrospectively evaluated for unnecessary bloodwork according to the triple bottom line, quantifying the impacts on patients, healthcare costs and greenhouse gas emissions. The carbon footprint of common laboratory investigations was estimated using PAS2050 methodology, including emissions generated from the production, transport, processing and disposal of consumable goods and reagents.

SETTING

Single-centre tertiary care hospital.

PARTICIPANTS

Patients admitted with acute uncomplicated appendicitis, cholecystitis, choledocholithiasis, gallstone pancreatitis and adhesive small bowel obstruction were included in the study. 304 patients met inclusion criteria and 83 were randomly selected for in-depth chart review.

MAIN OUTCOME MEASURES

In each patient population, the extent of over-investigation was determined by comparing ordered laboratory investigations against previously developed consensus recommendations. The quantity of unnecessary bloodwork was measured by number of phlebotomies, tests and blood volume in addition to healthcare costs and greenhouse gas emissions.

RESULTS

76% (63/83) of evaluated patients underwent unnecessary bloodwork resulting in a mean of 1.84 phlebotomies, 4.4 blood vials, 16.5 tests and 18 mL of blood loss per patient. The hospital and environmental cost of these unnecessary activities was $C5235 and 61 kg CO₂e (974 g CO₂e per person), respectively. The carbon footprint of a common set of investigations (complete blood count, differential, creatinine, urea, sodium, potassium) was 332 g CO₂e. Adding a liver panel (liver enzymes, bilirubin, albumin, international normalised ratio/partial thromboplastin time) resulted in an additional 462 g CO₂e.

CONCLUSIONS

We found considerable overuse of laboratory investigations among general surgery patients admitted with uncomplicated acute surgical conditions resulting in unnecessary burden to patients, hospitals and the environment. This study identifies an opportunity for resource stewardship and exemplifies a comprehensive approach to quality improvement.

Best practice for LDL-cholesterol: when and how to calculate

The lipid profile is important in the risk assessment for cardiovascular disease. The lipid profile includes total cholesterol, high-density lipoprotein (HDL)-cholesterol, triglycerides (TGs) and low-density lipoprotein (LDL)-cholesterol (LDL-C). LDL-C has traditionally been calculated using the Friedewald equation (invalid with TGs greater than 4.5 mmol/L and is based on the assumption that the ratio of TG to cholesterol in very- low-density lipoprotein (VLDL) is 5 when measured in mg /dL). LDL-C can be quantified with a reference method, beta-quantification involving ultracentrifugation and this is unsuitable for routine use. Direct measurement of LDL-C was expected to provide a solution with high TGs. However, this has some challenges because of a lack of standardisation between the reagents and assays from different manufacturers as well as the additional costs. Furthermore, mild hypertriglyceridaemia also distorts direct LDL-C measurements. With the limitations of the Friedewald equation, alternatives have been derived. Newer equations include the Sampson-National Institutes of Health (NIH) equation 2 and the Martin-Hopkins equation. The Sampson-NIH2 equation was derived using beta-quantification in a population with high TG and multiple least squares regression to calculate VLDL-C, using TGs and non-HDL-C as independent variables. These data were used in a second equation to calculate LDL-C. The Sampson-NIH2 equation can be used with TGs up to 9 mmol/L. The Martin-Hopkins equation uses a 180 cell stratification of TG/non-HDL-C to determine the TG:VLDL-C ratio and can be used with TGs up to 4.5 mmol/L. Recently, an extended Martin-Hopkins equation has become available for TGs up to 9.04 mmol/L.This article discusses the best practice approach to calculating LDL-C based on the available evidence.

Overordering of tumor marker for outpatients revealed by performance indicators and the impact of a health policy intervention: An observational study using administrative records

PURPOSE

The overuse of laboratory tests contributes to impair health systems effectiveness, tumor markers (TMs) being a paradigmatic example. In the present study we applied indicators of TMs appropriateness developed from administrative datasets to appraise regionwide overordering in the clinical practice.

PATIENTS AND METHODS

TMs ordered to outpatients in the Veneto Region over 6 years were obtained from the eletronic Outpatients' Records of Diagnostic and Therapeutic Procedures. TMs orders were examined as aggregated data or stratified according to disease codes, gender, age, and requests per patient. TMs recommended only for specific malignancies were examined using epidemiological data obtained from Veneto Tumor Registry.

RESULTS

A total of 5,821,251 TMs were ordered in 4,382,159 patients over 6 years. Overall, 3,252,389 (55.9%) TMs were ordered without appropriate disease codes (ranging from 77.0% for PSA to 17.5% for CA15.3). TM orders declined over 6 years (-13.4%), with a noticeable reduction of orders without appropriate disease codes (-21.3%). Orders decreased sharply from 2015 to 2016, after the enactment of a national Decree-Law aimed at improving appropriateness, and remained stable thereafter. However, the rate of inappropriate TMs requests still remained elevated (44.4%) in the last year of observation, with orders of TMs being much higher than expected on the basis of prevalence and incidence figures of specific malignancies.

CONCLUSIONS

Indicators developed from administrative datasets were effective in assessing the overordering of TMs and the impact of interventions to improve appropriateness. The developed indicators could be considered for other diagnostic tests.

A Multimodal Intervention for Reducing Unnecessary Repeat Glycated Hemoglobin Testing

OBJECTIVES

Reducing unnecessary tests that do not enhance quality can promote health-care value. Glycated hemoglobin (A1C) is often ordered at a frequency exceeding the recommendation of once every 3 months. We conducted a quality improvement (QI) initiative aimed to reduce unnecessary repeat testing by 75% at a tertiary care academic hospital.

METHODS

A retrospective baseline analysis was conducted on laboratory data from 2019 that enumerated unnecessary A1C tests, defined as repeat tests ordered within 60 days. A multifaceted change intervention with iterative plan-do-study-act cycles was introduced in March 2019 to educate providers and to automatically cancel A1C tests requested within 60 days. Monthly totals of A1C testing processed were plotted on statistical process control charts.

RESULTS

In 2019, 11% of all A1C tests ordered were unnecessary. Between March 2020 and January 2021, 11% of the tests (N=14,247 tests) were unnecessary, of which 84% were cancelled with our intervention. Providers in cardiology and nephrology accounted for over half (55%) of the unnecessary tests ordered.

CONCLUSIONS

A 2-pronged approach informed by root-cause analysis, and comprised of gatekeeping and provider education, can effectively promote resource stewardship for reducing unnecessary A1C testing.

The Impact of COVID-19 on Laboratory Test Utilization at a Pediatric Medical Center

Background

The epidemiology and clinical manifestation of coronavirus disease 2019 (COVID-19) in the pediatric population is different from the adult population. The purpose of this study is to identify effects of the COVID-19 pandemic on laboratory test utilization in a pediatric hospital.

Methods

We performed retrospective analysis on test utilization data from Ann & Robert H. Lurie Children’s Hospital of Chicago, an academic pediatric medical center. Data between two 100-day periods prior to (prepandemic) and during the pandemic (mid-pandemic) were analyzed to evaluate changes in test volume, lab utilization, and test positivity rate. We also evaluated these metrics based on in- vs outpatient testing and performed modeling to determine what variables significantly impact the test positivity rate.

Results

During the pandemic period, there was an expected surge in COVID-19 testing, while over 84% of lab tests studied decreased in ordering volume. The average number of tests ordered per patient was not significantly different during the pandemic for any of the laboratories (adjusted P value > 0.05). Thirty-three studied tests showed significant change in positivity rate during the pandemic. Linear modeling revealed test volume and inpatient status as the key variables associated with change in test positivity rate.

Conclusions

Excluding severe acute respiratory syndrome coronavirus 2 tests, the COVID-19 pandemic has generally led to decreased test ordering volume and laboratory utilization. However, at this pediatric hospital, the average number of tests performed per patient and test positivity rates were comparable between pre- and mid-pandemic periods. These results suggest that, overall, clinical test utilization at this site remained consistent during the pandemic.

Pursuing appropriateness of laboratory tests: a 15-year experience in an academic medical institution

Appropriateness in Laboratory Medicine has been the object of various types of interventions. From published experiences, it is now clear that to effectively manage the laboratory test demand it is recommended to activate evidence-based preventative strategies stopping inappropriate requests before they can reach the laboratory. To guarantee appropriate laboratory test utilization, healthcare institutions should implement and optimize a computerized provider order entry (CPOE), exploiting the potential of electronic requesting as "enabling factor" for reinforcing appropriateness and sustaining its effects over time. In our academic institution, over the last 15 years, our medical laboratory has enforced various interventions to improve test appropriateness, all directly or indirectly based on CPOE use. The following types of intervention were implemented: (1) applying specific recommendations supported by monitoring by CPOE as well as a continuous consultation with clinicians (tumour markers); (2) removing outdated tests and avoiding redundant duplications (cardiac markers, pancreatic enzymes); (3) order restraints to selected wards and gating policy (procalcitonin, B-type natriuretic peptide, homocysteine); (4) reflex testing (bilirubin fractions, free prostate-specific antigen, aminotransferases, magnesium in hypocalcemia); and (5) minimum retesting interval (D-Dimer, vitamin B₁₂, C-reactive protein, γ-glutamyltranspeptidase). In this paper, we reviewed these interventions and summarized their outcomes primarily related to the changes in total test volumes and cost savings, without neglecting patient safety. Our experience confirmed that laboratory professionals have an irreplaceable role as "stewards" in designing, implementing, evaluating, and maintaining interventions focused to improving test appropriateness.

Diagnostic Value of Anti-Nuclear Antibodies: Results From Korean University-Affiliated Hospitals

BACKGROUND

Unnecessary and inappropriate laboratory testing accounts for a significant portion of waste in health care utilization. The aim of this study was to examine the diagnostic value of the anti-nuclear antibody (ANA) test by examining the rate of ANA associated rheumatic disease (AARD) diagnosis among ANA tested and ANA positive subjects and positive predictive value (PPV) of ANA test leading to AARD diagnosis in different ANA titers and different subsets of patients in 5 hospitals affiliated with a university.

METHODS

We retrospectively extracted data from all subjects who were tested for ANA from year 2010 to 2019. Those who were first evaluated at or referred to rheumatology were further evaluated with extraction of data including ANA titer and ultimate diagnosis. PPVs for ANA test were evaluated after stratification according to clinically relevant key parameters, such as patient age (younger < 65 years vs. older), sex, and requesting department.

RESULTS

From 2010 to 2019, A total of 94,153 patients were tested for ANA, of which 13,600 (14.4% of the total) were positive. AARD was diagnosed in only 0.69% among all ANA tested patients and 4.74% among ANA positive patients. The AARD diagnosis rate of ANA positive patients varied widely from 0.1% to 8.7% by requesting department. Using cutoff values above 1:320 yielded PPVs of 15.6 and 7.8% for all AARs and systemic lupus erythematosus. The PPV was significantly higher in young age (< 65 years) and in women, and when it was requested from internal medicine vs other departments.

CONCLUSION

AARD was diagnosed in less than 1% of all ANA tested patients in university-affiliated hospitals. This result shows that careful consideration before ordering the screening ANA is needed to improve the utility of the test for providers and patients and to reduce health costs spurred by unnecessary testing and its consequences.

The 10 most frequently requested blood tests in the Capital Region of Denmark, 2010-2019 and simulated effect of minimal retesting intervals

As healthcare costs continue to rise throughout the world, critical assessment of the appropriateness of expenses gain focus.

OBJECTIVES

We aimed to describe the developments in test numbers of the 10 most frequently requested tests, and to simulate the effect of introducing minimal retesting intervals.

DESIGN & METHODS

Data from the blood tests - albumin, alanine transaminase, cholesterol, creatinine, C-reactive protein, hemoglobin, hemoglobin A_1c, potassium, sodium, and thyrotropin - from 2,687,589 patients handled by the Capital Region of Denmark from 2010 to 2019 was used. Tallies of each test per year were graphed. A simulation of the effect of minimal retesting intervals on test count and blood sampling volume was performed by virtually removing requests made prior to a set of possible minimal retesting intervals.

RESULTS

Increases in requests were observed both from hospitals and general practitioners. The number of requests for hemoglobin A_1c increased more than the other tests. The increases could not be accounted for by an increase in population size and aging of the population, and therefore suggests possible inappropriate increase in monitoring of patients. The simulated effect of applying minimal retesting intervals showed large reductions in tests and blood sampled.

CONCLUSIONS

For hospitals, the simulation suggested that applying minimal retesting intervals could lead to significant reductions in both the number of blood tests performed and in the amount of blood drawn for testing. For general practitioners, the simulation showed only minimal reductions in number of tests and blood volume drawn.

Vitamin D retesting by general practitioners: a factor and cost analysis

OBJECTIVES

Vitamin D testing by Primary Care doctors is increasing, placing greater workloads on healthcare systems. There is little data though on vitamin D retesting in Ireland. This study aims to investigate the factors associated with vitamin D retesting by Irish General Practitioners (GPs) and examine the resulting costs.

METHODS

This is a retrospective analysis over 5 years (2014-2018) of GP requested 25-hydroxyvitamin D (25(OH)D) results in 36,458 patients at a major city hospital in Dublin, Ireland. Those with one test were compared with individuals who were retested and samples categorised to determine changes in status between tests.

RESULTS

Nearly one in four patients (n=8,305) were retested. Positive predictors of retesting were female (p<0.001), age (60-69 years, p<0.001), location (Co. Kildare, p<0.001) and initial deficiency (<30 nmol/L, p<0.001) or insufficiency (30-49.9 nmol/L, p<0.001). Vitamin D status improved on retesting, with deficiency halving on first retest (9 vs. 18%, p<0.001) and dropping to 6% on further retests. About 12.2% of retests were done within 3 months and 29% had ≥2 retests within 1 year. 57% of retests were in those initially vitamin D replete (>50 nmol/L). The annual cost of inappropriate testing was €61,976.

CONCLUSIONS

One in four patients were retested and this varied by age, gender and patient location. Over 10% of retests were inappropriately early (<3 months), a third too frequent and over half were in replete individuals incurring significant costs. Clear guidance for GPs on minimum retesting intervals is needed, as well as laboratory ordering systems to limit requests using pre-defined criteria.

Evaluation of Inappropriate COVID-19 RT-PCR Test Utilization at an academic medical center

Background

An evolving COVID-19 testing landscape and issues with test supply allocation, especially in the current pandemic, has made it challenging for ordering providers. We audited orders of the Xpert® Xpress SARS-CoV-2 RT-PCR platform—the fastest of several other testing modalities available—to illuminate these challenges utilizing a multidisciplinary laboratory professional team consisting of a pathology resident and microbiology lab director.

Methods

Retrospective review of the first five hundred Xpert® Xpress SARS-CoV-2 RT-PCR test orders from a 2-week period to determine test appropriateness based on the following indications: emergency surgery, emergent obstetric procedures, initial behavioral health admission, and later including discharge to skilled care facilities and pediatric admissions. Our hypothesis was that a significant proportion of orders for this testing platform were inappropriate.

Results

Upon review, a significant proportion of orders were incorrect, with 69.8% (n = 349, p < 0.0001) not meeting indications for rapid testing. Of all orders, 249 designated as emergency surgery were inappropriate, with 49.0% of those orders never proceeding with any surgical intervention; most of these were trauma related (64.6% were orders associated with a trauma unit).

Conclusions

Significant, pervasive inappropriate ordering practices were identified at this center. A laboratory professional team can be key to identifying problems in testing and play a significant role in combating inappropriate test utilization.

Overused laboratory test of haemoglobin A1c at one medical centre in southern Taiwan

AIMS

To investigate overused laboratory test of haemoglobin Ac1 (HbA1c) in one medicine centre in southern Taiwan.

METHODS

Data were extracted from the database of the Medical Center from March 2013 to March 2015. These patients were classified into five groups, including group A (diabetic patients with HbA1c value ≥7), group B (healthy people with HbA1c value ≥7), group C (diabetic patients with HbA1c test value <7), group D (healthy people with HbA1c value <6.5) and group E (prediabetic people with HbA1c value 6.5-7). The divisions requested for HbA1c test were divided into four categories, including endocrinology, internal medicine, surgery and the others. Repeat testing at the time of the second test was investigated using survival analysis.

RESULTS

The percentage of overall inappropriate repeat testing was as high as 34%. The percentages among the five patient groups were relatively different. Group C had the largest percentage of inappropriate repeat testing (48%) and group A had the second largest (30%), followed by groups D (25%), E (13%) and B (10%). The percentages of inappropriate repeat testing of the five patient groups were also relatively different among the four categories of division, with Kaplan-Meier curves showing significant differences. The time to repeat testing was the shortest for group A and was the second shortest for group C, followed by groups B, E and D.

CONCLUSIONS

The results provided detailed information about the percentages of inappropriate repeat testing of HbA1c of the five patient groups among the four categories of division.

Cerebrospinal Fluid Cultures in Traumatic Brain Injury: Is It Worth It? A Two-Center Study

Background: Patients with traumatic brain injury (TBI) frequently develop leukocytosis, fever, and tachycardia that may lead to extensive medical investigations to rule out an infectious process. Cerebrospinal fluid (CSF) is often acquired during this workup, however, the utility of this practice has not been studied previously. We hypothesized that CSF cultures would unlikely yield positive results in patients with TBI. Patients and Methods: A retrospective review was conducted of all patients with TBI admitted to two level 1 trauma centers at urban, academic institutions from January 2009 to December 2016. Data collected included patient demographics, presenting Glasgow Coma Score (GCS), injury profile, injury severity scores (ISS), regional abbreviated injury scale (AIS), hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, and culture results. For purposes of the analysis, CSF cultures with Staphylococcus epidermidis, Staphylococcus aureus, or Candida underwent a chart review and were considered contaminates if indicated. Results: There were 145 patients who had CSF cultures obtained with a median age of 39 years; 77.2% were male. The majority of patients presented after blunt trauma with median GCS of 6, head AIS of 4, and ISS of 25. These patients had prolonged median ICU and hospital stays at 13 and 22 days, respectively. Six (4.1%) CSF cultures demonstrated growth. Four (2.8%) were deemed contaminants, with two growing Staphylococcus epidermidis only, one with both Staphylococcus epidermidis and Staphylococcus aureus, and one with Candida. Two cultures (1.4%) were positive and grew Enterobacter cloacae. Of note, both patients had prior instrumentation with an external ventricular drain. Conclusion: Obtaining CSF cultures in patients with TBI is of low yield, especially in patients without prior external ventricular drain. Other sources of infectious etiologies should be considered in this patient population.

Adoption of a laboratory EMR system and inappropriate laboratory testing in Ontario: a cross-sectional observational study

Background

Electronic medical record (EMR) systems have the potential to facilitate appropriate laboratory testing. We examined three common medical tests in primary care—hemoglobin A1c (HbA1c), lipid, and thyroid stimulating hormone (TSH)— to assess whether adoption of a laboratory EMR system in Ontario had an impact on the rate of inappropriate testing among primary care physicians.

Methods

We used FY2016–17 population-level laboratory data to estimate the association between adoption of a laboratory EMR system and the rate of inappropriate testing. Inappropriate testing was assessed based on recommendations for screening, monitoring, and follow-up that take into account risk factors related to patient age and certain clinical conditions. To overcome the problem of potential endogeneity of physician choice to use the EMR, the EMR penetration rate in the physician’s geographical area of practice was used as an instrumental variable in an ordinary least squares (OLS) regression. We then simulated the change in the rate of inappropriate testing, by physician payment model, as the EMR penetration rate increased from the baseline percentage.

Results

The simulation models showed that an increase in the rate of EMR penetration from a baseline average was associated with a statistically significant decrease in inappropriate hbA1c and lipid testing, but a statistically insignificant increase in inappropriate TSH testing. The impact of EMR penetration also varied by payment model.

Conclusions

This study demonstrated a positive association between availability of an EMR system and appropriate service utilization. Varying impacts of the EMR system availability by primary care payment model may be reflective of different incentives or attributes inherent in payment models. Policies to encourage physicians to increase their use of laboratory EMR systems could improve the quality and continuity of patient care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06296-5.

Overutilization in laboratory medicine: tackling the problem with quality improvement science

Overutilization of tests and treatments is a widespread problem in contemporary heath care, and laboratory medicine is no exception. It is estimated that 10-70% of laboratory tests may be unnecessary, with estimates in the literature varying depending on the situation and the laboratory test. Inappropriate use of laboratory tests can lead to further unnecessary testing, adverse events, inaccurate diagnoses, and inappropriate treatments. Altogether, this increases the risk of harm to a patient, which can be physical, psychological, or financial in nature. Overutilization in healthcare is driven by complex factors including care delivery models, litigious practice environments, and medical and patient culture. Quality improvement (QI) methods can help to tackle overutilization. In this review, we outline the global healthcare problem of laboratory overutilization, particularly in the developed world, and describe how an understanding of and application of quality improvement principles can help to address this challenge.

Inappropriate requests for tumor markers in patients aged 50 years and older: lessons not learned

OBJECTIVE: To investigate, within a private health insurance, the ordering frequency and the costs related to inappropriate TM test orders. METHODS: This study analyzed data regarding TM requests within a private health insurance between 2010 and 2017. Patients included in this analysis were ≥ 50 years old, had available medical records, and had at least 1 TM tested within the study period. Tests were considered inappropriate when TMs were used in screening for neoplasms, ie, when there was no previous diagnosis. We evaluated data regarding age, sex, the ordering physician’s medical specialty, and test costs. RESULTS: Between 2010 and 2017, 1,112 TM tests were performed and increased from 52 to 262 per year. Our sample consisted mostly of women (69.50%) with a mean age of 59.40 (SD, 8.20) years. Most orders were inappropriate (87.80%) and represented 79.40% of all expenses with TM tests. Cardiology professionals were the medical specialty that requested the most TM tests (23.90%), followed by internal medicine specialists (22.70%) and gynecologists (19.20%). CONCLUSIONS: We observed a high percentage of inappropriate test orders in the study period, resulting in elevated costs. Studies of this nature deserve the attention of health care managers, and interventions should be performed in order to reduce the inappropriate use of TM tests in clinical practice.

Trends in Micronutrient Laboratory Testing in Switzerland: A 7-Year Retrospective Analysis of Healthcare Claims Data

Background

Micronutrient laboratory tests (MLT) are increasing in many healthcare systems. This study assessed time trends of annual MLT incidence in the Swiss population and examined the frequency of specific MLT, defined as the number of yearly tests performed in individual persons.

Methods

For annual time trends, we used a longitudinal design with a seven-year observation period (2012–2018) and for yearly testing frequency we used a cross-sectional design (2018 only). The database consisted of nationwide insurance claims from adult persons.

Results

Persons with MLT compared to persons without were older (mean age 57.1 years vs 48.6 years) and to a higher proportion female (65.1% vs 45.5%). Between 2012 and 2018, we included 6.7 million person years and found an increase in the proportion of persons receiving any MLT from 24.5% to 35.0%. Tests with strongest absolute increase during the observation period were vitamin D (from 7.4% of persons to 20.4%), vitamin B12 (from 9.0% to 17.6%) and ferritin (from 17.4% to 26.6%). In 2018, vitamin D and vitamin B12 tests were performed more than once in 4.5% and 3.3% of the population, respectively.

Conclusion

We found that the Swiss population undergoes MLT with high and increasing frequency. Testing for vitamin D, vitamin B12 and ferritin is very common and of questionable appropriateness.

What methods are being used to create an evidence base on the use of laboratory tests to monitor long-term conditions in primary care? A scoping review

BACKGROUND

Studies have shown unwarranted variation in test ordering among GP practices and regions, which may lead to patient harm and increased health care costs. There is currently no robust evidence base to inform guidelines on monitoring long-term conditions.

OBJECTIVES

To map the extent and nature of research that provides evidence on the use of laboratory tests to monitor long-term conditions in primary care, and to identify gaps in existing research.

METHODS

We performed a scoping review-a relatively new approach for mapping research evidence across broad topics-using data abstraction forms and charting data according to a scoping framework. We searched CINAHL, EMBASE and MEDLINE to April 2019. We included studies that aimed to optimize the use of laboratory tests and determine costs, patient harm or variation related to testing in a primary care population with long-term conditions.

RESULTS

Ninety-four studies were included. Forty percent aimed to describe variation in test ordering and 36% to investigate test performance. Renal function tests (35%), HbA1c (23%) and lipids (17%) were the most studied laboratory tests. Most studies applied a cohort design using routinely collected health care data (49%). We found gaps in research on strategies to optimize test use to improve patient outcomes, optimal testing intervals and patient harms caused by over-testing.

CONCLUSIONS

Future research needs to address these gaps in evidence. High-level evidence is missing, i.e. randomized controlled trials comparing one monitoring strategy to another or quasi-experimental designs such as interrupted time series analysis if trials are not feasible.

Determinants of Medical Practice Variation Among Primary Care Physicians: Protocol for a Three Phase Study

BACKGROUND

One of the greatest challenges of modern health systems is the choice and use of resources needed to diagnose and treat patients. Medical practice variation (MPV) is a broad term which entails the differences between health care providers inclusive of both the overuse and underuse. In this paper, we describe a 3-phase research protocol examining MPV in primary care.

OBJECTIVE

We aim to identify the potential targets for behavioral modification interventions to reduce the variation in practice patterns and thus improve health care, decrease costs, and prevent disparities in care.

METHODS

The first phase will delineate the variation in primary care practice over a wide range of services and long follow-up period (2003-2017), the second will examine the 3 determinants of variation (ie, patient, physician, and clinic characteristics), and attempt to derive the unexplained variance. In the third phase, we will assess a novel component that might contribute to the previously unexplained variance - the physicians' personal behavioral characteristics (such as risk aversion, fear of malpractice, stress from uncertainty, empathy, and burnout).

RESULTS

This work was supported by the research grant from Israel National Institute for Health Policy Research (Grant No. 2014/134). Soroka University Medical Center Institutional Ethics Committee has approved the updated version of the study protocol (SOR-14-0063) in February 2019. All relevant data for phases 1 and 2, including patient, physician, and clinic, were collected from the Clalit Health Services data set in 2019 and are currently being analyzed. The evaluation of the individual physician characteristics (eg, risk aversion) by the face-to-face questionnaires was started on 2018 and remains in progress. We intend to publish the results during 2020-2021.

CONCLUSIONS

Based on the results of our study, we aim to propose a list of potential targets for focused behavioral intervention. Identifying new targets for such an intervention can potentially lead to a decrease in the unwarranted variation in the medical practice. We suggest that such an intervention will result in optimization of the health system, improvement of health outcomes, reduction of disparities in care and savings in cost.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18673.

Minimum retesting intervals in practice: 10 years experience

Background

Minimum retesting intervals (MRI) are a popular demand management solution for the identification and reduction of over-utilized tests. In 2011 Association of Clinical Biochemistry and Laboratory Medicines (ACB) published evidence-based recommendations for the use of MRI.

Aim

The aim of the paper was to review the use of MRI over the period since the introduction of these recommendations in 2011 to 2020 and compare it to previous published data between 2000-2010.

Methods

A multi-source literature search was performed to identify studies that reported the use of a MRI in the management or identification of inappropriate testing between the years prior to (2000–2010) and after implementation (2011–2020) of these recommendations.

Results

31 studies were identified which met the acceptance criteria (2000–2010 n=4, 2011–2020 n=27). Between 2000 and 2010 4.6% of tests (203,104/4,425,311) were identified as failing a defined MRI which rose to 11.8% of tests (2,691,591/22,777,288) in the 2011–2020 period. For those studies between 2011 and 2020 reporting predicted savings (n=20), 14.3% of tests (1,079,972/750,580) were cancelled, representing a total saving of 2.9 M Euros or 2.77 Euro/test. The most popular rejected test was Haemoglobin A1c which accounted for nearly a quarter of the total number of rejected tests. 13 out 27 studies used the ACB recommendations.

Conclusions

MRI are now an established, safe and sustainable demand management tool for the identification and management of inappropriate testing. Evidence based consensus recommendations have supported the adoption of this demand management tool into practice across multiple healthcare settings globally and harmonizing laboratory practice.

The Value Proposition for Pathologists: A Population Health Approach

The transition to a value-based payment system offers pathologists the opportunity to play an increased role in population health by improving outcomes and safety as well as reducing costs. Although laboratory testing itself accounts for a small portion of health-care spending, laboratory data have significant downstream effects in patient management as well as diagnosis. Pathologists currently are heavily engaged in precision medicine, use of laboratory and pathology test results (including autopsy data) to reduce diagnostic errors, and play leading roles in diagnostic management teams. Additionally, pathologists can use aggregate laboratory data to monitor the health of populations and improve health-care outcomes for both individual patients and populations. For the profession to thrive, pathologists will need to focus on extending their roles outside the laboratory beyond the traditional role in the analytic phase of testing. This should include leadership in ensuring correct ordering and interpretation of laboratory testing and leadership in population health programs. Pathologists in training will need to learn key concepts in informatics and data analytics, health-care economics, public health, implementation science, and health systems science. While these changes may reduce reimbursement for the traditional activities of pathologists, new opportunities arise for value creation and new compensation models. This report reviews these opportunities for pathologist leadership in utilization management, precision medicine, reducing diagnostic errors, and improving health-care outcomes.

Inappropriate repeat testing of complete blood count (CBC) and electrolyte panels in inpatients from Alberta, Canada

INTRODUCTION

The avoidance of repeat chemistry testing such as Complete Blood Count (CBC) and Electrolyte Panel (EP) on clinically stable patients was identified as important utilization goals by Choosing Wisely Canada. The purpose of this study was to assess the volume of overutilization of CBC and EP in an inpatient setting in Alberta, Canada, and provide an estimated cost assessment of unnecessary testing.

METHODS

The total laboratory testing volumes of two common test panels were collected retrospectively for one-year from January to December 2018. Data was collected on test panels performed in an emergency room (ER) and inpatient setting from three separate Laboratory Information Systems covering the provincial population in Alberta, Canada. Total initial test panel instances, total repeated panels, repeated panels that were previously normal or abnormal, and estimated costs were examined. Cost assessment was completed based on Reference Median Cost (RMC) analysis for each of these two common test panels.

RESULTS

During the study period, 2,020,467 (CBC) and 1,455,983 (EP) initial test panel instances were recorded, of which 67.7% and 73.5% were repeated for the CBC and EP, respectively. There was a higher proportion of EP repeated inappropriately (previously normal; 35.6%) compared to CBCs (5.4%). The cost to the province for inappropriately repeating CBC and EP were estimated to be RMC $0.52 million and RMC $1.90 million CAD, respectively.

CONCLUSION

Results from this study can assist policy makers in implementing utilization management initiatives and update clinical practice guidelines to reduce costs to healthcare without compromising patient care.

Implementation of an educational province-wide intervention to reduce redundant vitamin B12 testing: A cross-sectional study

INTRODUCTION

We describe the implementation of an Alberta-wide intervention aimed at educating clinicians about redundant vitamin B₁₂ testing. We hypothesized that the introduction of an educational comment outlining recommended vitamin B₁₂ test intervals would reduce the annual number of vitamin B₁₂ tests performed.

MATERIALS AND METHODS

We performed a cross-sectional observational study that included all vitamin B₁₂ tests ordered in Alberta between May 1, 2017 and April 30, 2018. An educational comment was appended to all vitamin B₁₂ test results in Alberta beginning May 2, 2017. Using a simple seasonal model, we compared predicted versus observed vitamin B₁₂ test volumes for the 12-month period following the introduction of the educational comment. The sole outcome measured was the monthly change in volume of vitamin B₁₂ testing. A cost-analysis of the effects of the intervention on test volumes was also performed.

RESULTS

Over the sum of the first 12 months of the intervention, 18,000 more vitamin B₁₂ tests were ordered compared to the predicted value in Alberta. With an estimated cost of $7 per test, this resulted in a $126,000 increase in costs for vitamin B₁₂ testing provincially.

CONCLUSIONS

An educational intervention aimed at limiting inappropriate vitamin B₁₂ testing in Alberta did not alter testing as desired. Multiple utilization management strategies and a longer observation period may be needed to reduce redundant vitamin B₁₂ testing.

Payment models in primary health care: A driver of the quantity and quality of medical laboratory utilization

Physician payment models' incentives regarding many aspects of primary health care are not well understood. We focus on the case of medical laboratory utilization and examine how physicians' laboratory test ordering patterns change following a switch to a blended capitation payment model from one with fee for service enhanced with pay for performance. Also, within blended capitation, we examine differences between traditional staffing and interdisciplinary teams. Using a propensity score weighted fixed-effects specification to address selection, it is estimated that the switch to capitation leads to a short-run average of 3% fewer laboratory requisitions per patient. Patients' laboratory utilization also becomes more concentrated with the rostering physician. More importantly, using diabetes-related laboratory tests as a case study, after joining the blended model, physicians order 3% fewer inappropriate/redundant tests, and the addition of an interdisciplinary care team makes the reduction about 9%. Advances in both continuity and quality seem to be associated with blended capitation.

Prevalence and associated factors of inappropriate repeat test

Background

The rate of laboratory test utilisation has been increasing unsustainably. Evaluating inappropriately repeated laboratory tests is promising because objective criteria are available to measure the rates while causes can be manipulated easily. In this study, we aimed to evaluate the prevalence, associated factors and financial burden of inappropriate repeat tests.

Methods

A cross-sectional study was conducted on the results of 26 types of laboratory tests recorded in a laboratory database of a tertiary hospital between 1 July 2014 and 30 June 2017. Minimum retest intervals were determined from the literature for each type of tests. If the time interval between the two tests was shorter than the minimum retest interval, then the later test was accepted an inappropriate repeat test. Binary logistic regression was performed after univariate analyses.

Results

Of a total of 673 794 tests, 109 370 (16.2%) were inappropriate repeat tests. Male gender, being ≥65 years old, being an inpatient, high-volume test and surgical clinic as the test-requesting clinic were associated with inappropriate repeat tests. Also, it was determined that US$66 761.3 had been wasted on inappropriate repeat tests for 3 years.

Discussion

There are several factors that increase the rate of inappropriate repeat tests. They should be considered during health policy making or planning interventions to reduce inappropriate repeat tests.

Evaluating practice variance among family physicians to identify targets for laboratory utilization management

BACKGROUND

There is widespread variation in testing practice among practitioners, however there has been no objective way to pinpoint target tests for utilization management. We propose to take advantage of inter-physician variance in clinical practice as a quantitative measure to generate lists of potentially misutilized tests.

METHODS

Testing frequencies from a database of clinical testing volumes for outpatients in Calgary, Canada, were obtained for the study period of 2016. For each chemistry, microbiology or hematology test, an arithmetic coefficient of variation (CV) was calculated from family physicians' ordering frequencies.

RESULTS

The mean CV for all 358 tests considered was 219% (95% CI 206-231%) with a range of 52-729%. The highest variance was observed for human T-lymphotropic virus antibody testing and several tests for heavy metal levels (mercury, copper, zinc and chromium). Among the 100 most commonly run tests, high variance was found for several endocrinology tests including cortisol.

CONCLUSIONS

The utility of ranking clinical tests by ordering variance presents a practical approach to evaluate relative variation in physician practice strategy and to identify potential areas of misutilization.

Accuracy-Based Vitamin D Survey: Six Years of Quality Improvement Guided by Proficiency Testing

CONTEXT.—

The goal of the College of American Pathologists Accuracy-Based Proficiency Testing Program is to promote the quality, standardization, and harmonization of clinical laboratory results through proficiency testing specimens that are free from matrix effects, have target values that are traceable to reference methods, and that probe the limitations of current methods.

OBJECTIVE.—

To summarize the first 6 years of the Accuracy-Based Vitamin D Survey and highlight key insights from the data generated as it relates to assay performance.

DESIGN.—

Accuracy-based challenges were created by using pooled human serum samples. Certain samples were derived from participants in an institutional review board-approved protocol in which vitamin D-deficient participants were treated with ergocalciferol (vitamin D₂). Reference targets for the survey were set by the Centers for Disease Control and Prevention using isotope-dilution liquid chromatography-tandem mass spectrometry. Each method was compared with the reference method procedure over the course of the program (n = 43 proficiency testing samples).

RESULTS.—

Linear regression versus the reference method procedure revealed proportional biases across the methods, ranging from 0.0% to 16.7%. Pearson correlation coefficients (r²) ranged from 0.902 to 0.996. Results were influenced by the concentration of 25-hydroxyvitamin D₂ as well as the C-3 epimer of 25-hydroxyvitamin D₃. During the 6 years, 2 manufacturers altered their assays to match the reference method procedure more closely.

CONCLUSIONS.—

There is considerable bias, both proportional bias and sample-specific matrix effects, affecting many assays. This ongoing accuracy-based proficiency testing program for vitamin D will provide the data needed for laboratories and manufacturers to improve their assays and thereby patient care.

Temporal trends in use of tests in UK primary care, 2000-15: retrospective analysis of 250 million tests

OBJECTIVES

To assess the temporal change in test use in UK primary care and to identify tests with the greatest increase in use.

DESIGN

Retrospective cohort study.

SETTING

UK primary care.

PARTICIPANTS

All patients registered to UK General Practices in the Clinical Practice Research Datalink, 2000/1 to 2015/16.

MAIN OUTCOME MEASURES

Temporal trends in test use, and crude and age and sex standardised rates of total test use and of 44 specific tests.

RESULTS

262 974 099 tests were analysed over 71 436 331 person years. Age and sex adjusted use increased by 8.5% annually (95% confidence interval 7.6% to 9.4%); from 14 869 tests per 10 000 person years in 2000/1 to 49 267 in 2015/16, a 3.3-fold increase. Patients in 2015/16 had on average five tests per year, compared with 1.5 in 2000/1. Test use also increased statistically significantly across all age groups, in both sexes, across all test types (laboratory, imaging, and miscellaneous), and 40 of the 44 tests that were studied specifically.

CONCLUSION

Total test use has increased markedly over time, in both sexes, and across all age groups, test types (laboratory, imaging, and miscellaneous) and for 40 of 44 tests specifically studied. Of the patients who underwent at least one test annually, the proportion who had more than one test increased significantly over time.

Explaining variations in test ordering in primary care: protocol for a realist review

INTRODUCTION

Studies have demonstrated the existence of significant variation in test-ordering patterns in both primary and secondary care, for a wide variety of tests and across many health systems. Inconsistent practice could be explained by differing degrees of underuse and overuse of tests for diagnosis or monitoring. Underuse of appropriate tests may result in delayed or missed diagnoses; overuse may be an early step that can trigger a cascade of unnecessary intervention, as well as being a source of harm in itself.

METHODS AND ANALYSIS

This realist review will seek to improve our understanding of how and why variation in laboratory test ordering comes about. A realist review is a theory-driven systematic review informed by a realist philosophy of science, seeking to produce useful theory that explains observed outcomes, in terms of relationships between important contexts and generative mechanisms.An initial explanatory theory will be developed in consultation with a stakeholder group and this 'programme theory' will be tested and refined against available secondary evidence, gathered via an iterative and purposive search process. This data will be analysed and synthesised according to realist principles, to produce a refined 'programme theory', explaining the contexts in which primary care doctors fail to order 'necessary' tests and/or order 'unnecessary' tests, and the mechanisms underlying these decisions.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. A complete and transparent report will be produced in line with the RAMESES standards. The theory developed will be used to inform recommendations for the development of interventions designed to minimise 'inappropriate' testing. Our dissemination strategy will be informed by our stakeholders. A variety of outputs will be tailored to ensure relevance to policy-makers, primary care and pathology practitioners, and patients.

PROSPERO REGISTRATION NUMBER

CRD42018091986.

An Audit of Repeat Testing at an Academic Medical Center: Consistency of Order Patterns With Recommendations and Potential Cost Savings

OBJECTIVES

To evaluate the prevalence of potentially unnecessary repeat testing (PURT) and the associated economic burden for an inpatient population at a large academic medical facility.

METHODS

We evaluated all inpatient test orders during 2016 for PURT by comparing the intertest times to published recommendations. Potential cost savings were estimated using the Centers for Medicare & Medicaid Services maximum allowable reimbursement rate. We evaluated result positivity as a determinant of PURT through logistic regression.

RESULTS

Of the evaluated 4,242 repeated target tests, 1,849 (44%) were identified as PURT, representing an estimated cost-savings opportunity of $37,376. Collectively, the association of result positivity and PURT was statistically significant (relative risk, 1.2; 95% confidence interval, 1.1-1.3; P < .001).

CONCLUSIONS

PURT contributes to unnecessary health care costs. We found that a small percentage of providers account for the majority of PURT, and PURT is positively associated with result positivity.