Addressing Redundant Laboratory Testing for Better Patient Care
Clinical laboratory testing provides the information needed for healthcare providers to manage their patients. Indeed, it is estimated laboratory results may influence > 70% of clinical decisions. However, it is also estimated that 20% of laboratory testing is unnecessary. The downstream negative impact of redundant laboratory testing may include a higher false positive rate, unnecessary medical interventions, and higher financial burden on the patient and payers.
Regulatory institutions like the Clinical Laboratory Improvement Amendments (CLIA) and the College of American Pathologists (CAP) provide industry standards for running a lab. Laws in the United States like the Stark law and False Claims Act are intended to provide an ethical framework for labs and physicians. There are also professional medical societies like the American Association of Clinical Chemistry (AACC) and the American Society of Addiction Medicine (ASAM) that publish practice guidelines for healthcare providers and labs. Despite this legal and regulatory structure in the United States, lab testing over utilization is still problematic. Specifically, the issue of redundant testing for clinical toxicology (drug testing) is especially challenging.
Healthcare providers may use toxicology testing to manage medications for patients with chronic pain or mental health conditions. Additionally, toxicology lab results are critical for the treatment of patients who are in addiction rehabilitation. Toxicology testing is typically a two-step process. The first step is presumptive testing, which is a broad screen with many analytes. Presumptive testing checks for the presence or absence of a drug. For example, when a patient is first enrolled into a substance abuse program, a healthcare provider may want to cast a “wide net” to screen for many different substances as a baseline. The second step is definitive or confirmatory drug testing, which may confirm a positive presumptive test, but will also quantify the amount of a substance in a patient’s system. Confirmatory testing may not have clinical utility in a treatment program. However, it may be critical when testing for prescribed medicine, such as lithium, which is used to manage bipolar disorder among other mental health conditions.
Definitive or confirmatory testing may be expensive because of the technology required to perform these tests such as gas chromatography and mass spectrometry. One study from 2018 reported the cost per specimen was $600 for definitive testing, while the cost of presumptive testing was $25. The financial burden can multiply almost exponentially as the number of patients and the number of tests per patient increase. The testing expense is likely higher than these numbers given the date of the study.
Similarly, laboratory testing associated with thyroid disorders may seem routine. However, the cumulative burden to the healthcare system is substantial, and has been discussed previously in this article series. In 2020, the Department of Health and Human Services reported spending almost half a billion dollars on testing linked to the evaluation of thyroid disease. Given the cost burden to payers, it is logical to conclude thyroid disease testing may be overutilized by healthcare providers. Therefore, it is a candidate to determine if there is room for cost savings without compromising patient care.
Strategies to Help Overutilization of Lab Testing
Evidence-based guidelines are available to reduce redundant testing. Professional medical societies such as AACC and ASAM (and others) intermittently publish evidence-based guidelines to assist clinicians in caring for patients. These guidelines may be reinstated or updated periodically and typically provide guidance without telling exactly what to do in all clinical scenarios. The healthcare provider still must use their clinical judgement; however, guidelines provide suggestions for patient management. While evidence-based guidelines have been around for decades, there are other more recent resources that may also be available.
Computerized Provider Order Entry (CPOE) systems and Clinical Decision Support Systems (CDSS) integrated in the Electronic Health Record (EHR) have shown a positive impact on redundant testing. CPOE uses computerized algorithm(s) to prevent unnecessary testing. For example, a block or flag may appear in the EHR when the patient has previously had a test performed. This block/flag prevents the ordering provider from placing the order via the EHR. Electronic algorithms integrated into the EHR are cost-effective and efficient for medical staff. For example, one study demonstrated a 39.1% reduction in thyroid testing by implementing CDSS. However, it may require Information Technology (IT) resources to facilitate EHR integration with CPOE and CDSS.
Beacon LBS owns and maintains a provider decision support system which can be seamlessly integrated with lab ordering systems and EHRs, which is an efficient solution to redundant lab testing. Lab results impact most healthcare provider clinical management decisions, as previously stated. Beacon’s CDSS lowers lab costs by reducing unnecessary testing and thereby improving patient care. Furthermore, Beacon’s CDSS also increases adherence to evidence-based guidelines and improves appropriate lab testing. The result is better patient care at a lower cost. Beacon’s CDSS is the perfect solution to the problem of redundant lab testing, which can be applied to many specialties in addition to toxicology or thyroid testing.
Redundant laboratory testing, overutilization, and inappropriate lab orders have plagued laboratory medicine for decades. Ordering providers may use evidence-based practice guidelines to reduce unnecessary lab testing. Adding electronic CPOE and CDSS may further reduce testing that is not needed. All of these tools are needed for ordering providers to reduce unnecessary testing to maximize the use of healthcare dollars and to lower the risk of potential harm to patients.
References
Bindraban RS, Ten Berg MJ, Naaktgeboren CA, Kramer MHH, Van Solinge WW, Nanayakkara PWB. Reducing Test Utilization in Hospital Settings: A Narrative Review. Ann Lab Med. 2018 Sep;38(5):402-412. PMID: 29797809.
https://pubmed.ncbi.nlm.nih.gov/29797809/
Dalal S, Bhesania S, Silber S, Mehta P. Use of Electronic Clinical Decision Support and Hard Stops to Decrease Unnecessary Thyroid Function Testing. BMJ Qual Improv Rep. 2017 Apr 28;6(1):u223041.w8346. PMID: 28469901.
https://pubmed.ncbi.nlm.nih.gov/28469901/
Melanson SEF, Petrides AK. Economics of Pain Management Testing. J Appl Lab Med. 2018 Jan 1;2(4):587-597. PMID: 33636889.
https://pubmed.ncbi.nlm.nih.gov/33636889/
Rubinstein M, Hirsch R, Bandyopadhyay K, Madison B, Taylor T, Ranne A, Linville M, Donaldson K, Lacbawan F, Cornish N. Effectiveness of Practices to Support Appropriate Laboratory Test Utilization: A Laboratory Medicine Best Practices Systematic Review and Meta-Analysis. Am J Clin Pathol. 2018 Feb 17;149(3):197-221. PMID: 29471324.
https://pubmed.ncbi.nlm.nih.gov/29471324/
Zare S, Meidani Z, Shirdeli M, Nabovati E. Laboratory test ordering in inpatient hospitals: a systematic review on the effects and features of clinical decision support systems. BMC Med Inform Decis Mak. 2021 Jan 18;21(1):20. PMID: 33461548.
https://pubmed.ncbi.nlm.nih.gov/33461548/
American Association of Clinical Chemistry (AACC)
https://www.aacc.org/science-and-research/practice-guidelines
American Society of Addiction Medicine (ASAM)
https://www.asam.org/quality-care/clinical-guidelines
Clinical Laboratory Improvement Amendments (CLIA)
https://www.cdc.gov/clia/index.html
College of American Pathologists (CAP)
False Claims Act
https://www.justice.gov/civil/false-claims-act
Data Brief: COVID-19 Tests Drove an Increase in Total Medicare Part B Spending on Lab Tests in 2020, While Use of Non-COVID-19 Tests Decreased Significantly, OEI-09-21-00240. Available at:
https://oig.hhs.gov/oei/reports/OEI-09-21-00240.pdf
Stark Law
https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/index
Content that was obtained from previous articles related to this topic:
Redundant genetic testing:
https://www.beaconlbs.com/blog/solutions-to-redundant-laboratory-testing/
Fraud in toxicology:
https://www.beaconlbs.com/blog/fraud-in-toxicology-labs/
Thyroid overutilization:
https://www.beaconlbs.com/blog/thyroid-testing-overutilization-possible-solutions/