New Studies ID Strategies to Address Overuse of Laboratory Testing

The cost and quality of care are the focus of improvement initiatives happening at health systems across the country. Like imaging and other procedures, the necessity of laboratory testing, too, is being examined.

Two recently published studies highlight how resident training and electronic medical record (EMR) order prioritization can impact potential overuse of laboratory testing.

EMR Sequence Impacts Test Ordering
Reprioritizing the sequence of test names in EMR laboratory order search results can reduce the overutilization of more expensive tests, according to a study published Sept. 22 in the American Journal of Clinical Pathology.

A complete blood count (CBC) with leukocyte differential (CBC-DIFF) is frequently ordered in the emergency department, but the DIFF component of the test often does not impact clinical decision-making. Previous internal analysis at the Cleveland Clinic, showed that CBC-DIFF accounted for up to 98 percent of all CBC orders originating in the emergency department, compared with 53 percent of orders from the inpatient service.

"Performing a slightly more expensive test that will not offer the provider any additional information may appear harmless in the short term but can easily result in a large waste in resources over time," writes lead author Michael Phelan, M.D., from the Cleveland Clinic in Ohio. "With the myriad of reasons for test overutilization, it can be difficult to identify where cost-savings measures can be implemented. The simplest place to start may be to assess the appropriateness of the most commonly ordered tests in the department."

Phelan and colleagues conducted a two-stage performance improvement project and assessed its impact on CBC ordering during pre- and post-intervention periods. The intervention included both an educational component (passive, web-based educational initiative) and a reprioritization of CBC and CBC-DIFF in the EMR orders. (Previously CBC-DIFF was listed first.) The educational component discussed differences between the two tests regarding method, current utilization, and turnaround time, as well as potential alternative tests, including a CBC with absolute granulocyte count and individual component tests (hemoglobin concentration, platelet count).

Orders were identified through the institution's laboratory information system. The pre-intervention period was three months before the educational initiative. The two post-intervention periods included the three months following the educational initiative and then the three months following the changes to the EMR.

The researchers found that there was no difference in the proportion of CBC tests performed after the education intervention. However, there was a significant increase in CBC samples ordered following the EMR intervention, compared to both the education intervention period and the control period.

The authors explain that this saves not just costs, but also time within the laboratory. Reporting additional items (e.g., the differential) increases the likelihood of an abnormal finding (e.g., abnormal ganulocyte scatter using flow cytometry) that will require additional examination (e.g., a peripheral blood smear requiring manual review) by laboratory personnel.

"Our study shows that EMR optimization, in the form of the reprioritization of order entry search menu results to return overused tests at a lower rank when generic queries are used, can help reduce such waste," concludes Phelan.

Resident Training Could Impact Long-Term Ordering
Residents have large variation in laboratory ordering practice, according to a research published Oct. 8 in JAMA Internal Medicine.

Researchers from Columbia University analyzed electronic diagnostic test orders placed in the inpatient medical record by 139 internal medicine residents during the academic year 2016-2017. Over the study period the residents ordered 579,935 laboratory tests for 10,707 patients over 13,469 unique patient hospitalizations.

But, there was great variation in ordering practices by resident. The resident who ordered the most laboratory tests (n = 13,604) ordered more than 7 times the tests than the resident who ordered the least (n = 1,870). The resident who ordered the most tests per unique patient hospitalization ordered 41.2 tests per patient versus 9.0 tests per patient for the resident who ordered the least.

There was an association between residents' postgraduate year (PGY) and the total number of laboratory tests ordered, as well as between PGY and the number of laboratory tests per patient. As might be expected, residents in their first PGY residents tended to order more laboratory tests than the residents in their second or third PGY, however, surprisingly, the top three residents by laboratory test ordering volume included individuals from each PGY.

"Even excluding outliers, we observed much more variation in diagnostic test ordering volume than expected given that there were minimal differences in resident schedules among each PGY cohort during the 1-year period," write the authors led by Joshua Geleris, M.D., from Columbia University in New York. "Because residents are 'imprinted' by their training environment, even small reductions in diagnostic test ordering habits during training could translate to years of higher-value care."

Takeaway: Relatively easy solutions, like EMR sequencing of tests and resident training, can potentially curb unnecessary ordering of common laboratory tests.