The number of tests ordered by physicians or clinicians has increased several folds in the past few decades. Many times, ordering providers request for certain routine tests as soon as a patient is hospitalized without evaluating the necessity of those tests. Repetitive testing in clinical diagnostic laboratories is responsible for the overutilization of daily labs. A clinical diagnostic test is considered as unnecessary if it is unlikely to influence a patient’s clinical diagnosis, determine ideal treatment, establish disease prognosis, or reduce patients’ hospital stay. Today, hospitals and healthcare institutions are under intense pressure to cut costs and at the same time, provide high-quality patient care and minimize the duration of patients’ stay. To curb repetitive testing, physicians must order the right tests by evaluating previous test results and medical history of individual patients, at the right time, and in the right sequence.
What are the Negative Impacts of Repetitive Testing?
The overuse of diagnostic tests has adverse clinical and financial implications. Some of them are outlined below.
Iatrogenic Anemia in Patients: Phlebotomy or frequent withdrawal of blood samples from hospitalized patients for diagnostic testing may cause iatrogenic anemia in patients, leading to reduced hematocrit and hemoglobin count. This may also lead to increased mortality in certain patient populations.
Increased Expenditure: Unnecessary repeated tests not only increase the cost to the healthcare system but also increases the laboratory’s workload.
Exposure to Toxic Treatments or Radiations: Patients may be exposed to toxic treatments or radiations, such as X-Rays, which can be detrimental to their health.
False Positives: Repetitive tests increase the chances of false positives, leading to a cascade of unnecessary downstream testing or laboratory investigations.
Why do Clinicians Order Repetitive Diagnostic Tests?
Clinicians or ordering providers over order diagnostic tests due to several factors. These include inexperience or lack of knowledge to determine appropriate tests for individual patients, failure to evaluate previous test results or medical history of patients, besides challenges in altering the routine of ordering tests. Sometimes, patients themselves request laboratory tests. For optimal and high-quality patient care, the judicious ordering of laboratory tests is crucial.
Approaches to Reduce Repeat Tests
Repetitive testing is one of the key areas of laboratory utilization that needs improvement because a majority of healthcare and clinical decisions are influenced by laboratory tests. Reducing large volumes of repetitive diagnostic tests can significantly bring down laboratory expenditures without compromising patient care. Some of the approaches to prevent overutilization of daily labs are described below.
Education: Both providers and patients must be educated about the negative implications of repetitive tests and potential areas of overuse. Healthcare institutions must have predefined guidelines to assist physicians in ordering tests. Education must be provided to the resident and attending physicians, advanced-practice physicians, and medical students. Senior attending or resident physicians should follow high-quality patient care practices so that they can also be the role-model for the medical students.
Audits: Healthcare institutions should implement an auditing system to provide regular feedback on test ordering practices to clinicians or ordering providers in real-time. The objective behind implementing such a system is to encourage providers to adopt best practices that eliminate unnecessary ordering of laboratory tests. Some studies indicate that clinicians dashboards that indicate the number of tests ordered by each provider also help reduce the frequency of repetitive tests.
Decision-support Systems: In some healthcare institutions, test orders are entered by different individuals, including nurses, assistants of physicians, and house staff at different training levels. Hence, there are more chances of reordering tests or errors if the actual physician is not placing the order. Healthcare institutions must implement decision-support systems to prevent errors in ordering tests.Information technology can play a crucial role in avoiding repeat testing. Electronic Health Records (EHR) can be a vital resource to aid healthcare institutions in preventing repetitive tests. EHRs can collect clinical data from a patient’s visit in real-time. EHRs can also help providers in making decisions at the time of ordering tests. Furthermore, it can restrict the ordering of diagnostic tests based on location, patient population, cost, ordering providers, or the date when a diagnostic test was previously performed. These support tools can be configured to restrict repetitive tests based on various criteria, such as frequency, gender, or expense.An EHR can also be integrated with a Clinical LIMS for comprehensive laboratory data management. A LIMS serves as a unified data repository enabling diagnostic laboratories to not only manage patient data, but also manage test results, perform automated test data collection and track workflows, share test reports with clinicians in real-time, minimize turnaround time, enhance productivity, and seamlessly follow various regulatory compliance, such as HIPAA, CLIA, and ISO 15189. A LIMS System can also help clinical laboratories to monitor the usage of laboratory inventory for each test to track laboratory expenditure. The decision support committee of healthcare centers should determine the best way to implement decision support systems.
Peer Comparison of Ordering Practices: A comparison of ordering practices among clinicians or providers can motivate them to improve their ordering practices and to avoid repetitive tests. Some healthcare institutions regularly send emails to providers containing details of individual and team test ordering practices and a detailed comparison of these ordering practices with their colleagues and other teams. Healthy competition among individual clinicians and different teams leads to the improvement of ordering practices.
Diagnostic tests influence around 60-70% of the clinical decision-making process. It is important to avoid repetitive tests to minimize laboratory expenditure and to provide high-quality patient care. Laboratory personnel, physicians, and healthcare institutions, such as hospitals, must work coherently to design processes that minimize cost by avoiding expensive tests that are of questionable clinical significance. Furthermore, the processes should be set up to help physicians make better-informed decisions, enabling them to order only clinically relevant tests.
There is no single standard approach to minimize the overutilization of daily labs. Different healthcare institutions have experienced varying degrees of success by adopting one or multiple approaches mentioned above. The approaches described above do not work on the principle of one-size-fits-all. The approaches are multimodal and healthcare institutions should combine different approaches to determine the right mix of initiatives or approaches that work for their institution. The objective is not to minimize essential tests but to adopt a targeted and personalized approach while ordering tests for individual patients.