Contributing lab leaders: Michael Laposata, MD, PhD
Ordering the right lab tests at the right time is a crucial component of patient care, essential to achieving accurate diagnoses and expediting access to treatment. But if providers don't have the input and scope of knowledge they need to order the most appropriate lab tests in any given scenario, patients and healthcare organizations can face serious consequences.
Improper test utilization results in billions of wasted dollars each year within the medical industry, not to mention countless diagnostic errors. With Medicare and other payers continually looking for ways to reduce costs, it behooves organizations to seek out new and innovative ways to demonstrate financial prudence. Encouraging better communication and collaboration between laboratorians and ordering physicians holds the potential to improve patient care while also saving organizations time and money.
Dr. Michael Laposata, Professor and Chairman of the Department of Pathology at the University of Texas Medical Branch in Galveston, shares his views on the issues surrounding laboratory testing and how collaboration can provide a solution to the problem at hand.
Improper utilization of lab tests and laboratory resources wastes billions of dollars each year.
Underutilization can lead to delayed or missed diagnosis, which can have life threatening results.
An estimated 70 percent of decisions that affect diagnosis or treatment involve lab testing.
Several studies suggest that underutilization of laboratory testing happens on a much more regular basis than overutilization. When providers struggle to decide which tests are truly necessary to order for each individual patient, they often wind up erring on the side of caution, underutilizing available supports. This, in turn, can hinder patients from quickly getting access to treatments they may need.
Three papers indicate that underutilization occurs in approximately 55 percent of cases with greater than low-level complexity, while overutilization occurs in at least 25 percent of patients,” said Dr. Michael Laposata, Professor and Chairman of the Department of Pathology at the University of Texas Medical Branch in Galveston.
A 2003 study published in the New England Journal of Medicine1 found diagnostic tests to be underutilized 45.1 percent of the time; in close agreement, a 2013 Harvard study2 indicated 44.8 percent. While underutilization of laboratory tests occurs with greater frequency than overutilization, Dr. Laposata said it can be more difficult to measure in terms of dollars and cents.
“It's not particularly difficult to quantify the money spent on overutilization of laboratory tests — you can add up the dollars spent performing the unnecessary tests,” he explained. “With regard to underutilization, however, it's difficult to know how much money might have been spent if the patient was diagnosed and treated sooner. Although underutilization cost estimates are speculative by nature, they are much more likely to be greater than the costs of overutilization.”
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Laboratory testing can be over or underutilized in many different instances, but certain health conditions do tend to be more often associated with inappropriate testing. Physicians often order complete blood counts and basic and complex metabolic panels for nearly every patient who requires any sort of diagnostic evaluation, even if such tests may not always be necessary or helpful in making a diagnosis.
“The more complex the case, the more likely it is that the treating physicians will miss the test required to establish the correct diagnosis, or they will order the necessary tests along with many others that are unnecessary,” Dr. Laposata said. “A commonly cited example for underutilization involves the diagnosis of pulmonary embolism. This is a frequently missed diagnosis; the initial D-dimer test is often not performed when the patient could have been diagnosed with a pulmonary embolus if the test results were positive. Consequences in this case can include recurrent pulmonary embolism, lifelong pulmonary hypertension, or death.”
Other lab tests which may often be underutilized involve thyroid-stimulating hormone, hemoglobin A1c, and tests used for therapeutic drug monitoring purposes.3
Organizations put themselves at risk for possible financial effects stemming from improper utilization of laboratory testing, but patients are the ones whose very lives hang in the balance. Importantly, many doctors and virtually all patients do not know this.
The deleterious effects of overutilization are money wasted on tests that are unnecessary and follow-up testing when an unnecessary test is abnormal, leading to an additional test or an additional procedure,” Dr. Laposata explained. “There is an additional unknown cost associated with overutilization because many truly necessary tests are delayed. The impact of such delay depends upon the specific delayed tests and the extent of the delay, which likely varies each time it occurs. Thus, it is extremely difficult to measure.”
Underutilization, on the other hand, can lead to a delayed or missed diagnosis, sometimes with potentially life-threatening results.
“It's impossible to know how much more was spent when an essential test was not ordered because there's no way to perform a comparison,” Dr. Laposata continued. “Speculations on cost roughly estimate the financial impact of underutilization. However, we know with a much better degree of certainty that delayed and missed diagnoses result in at least 64,000 deaths in the United States annually. This enormous loss of life, and the larger morbidity associated with diagnostic errors, should itself allow for the development of diagnostic expert teams even if the exact dollars wasted cannot be determined.”
Despite their extensive medical training, many providers still find laboratory test menus overwhelming and confusing to navigate. For that reason, they often order tests that are unnecessary, or neglect to order those that are. This creates an opportunity for laboratorians to step in and provide guidance.
“Laboratorians have a voice that can help ordering physicians determine the right tests at the right time,” Dr. Laposata said. “Many laboratorians are very familiar with the correct tests that should be ordered for a particular diagnosis. Clinical laboratory scientists can interrupt an evaluation and have a discussion with the physician to point out necessary tests they may be missing and delete unnecessary tests from the order.”
Statistics estimate 70 percent of all healthcare decisions that affect diagnoses or treatment involve lab testing, which reinforces the value of the lab's role in achieving an accurate assessment of the patient's condition.4 Taking down the walls between providers, administrators, and laboratorians would seem to be a logical step in promoting more collaborative efforts to improve patient care and save lives.
Forming a Diagnostic Management Team (DMT) within your organization can help address issues of lab testing over and underutilization. By definition, DMTs are groups of medical experts in different specialties that meet on a regular basis to evaluate current cases and provide an easy-to-understand written report that becomes part of the patient's medical record. Among other functions, DMTs recommend only the most appropriate test options. To achieve the most meaningful decisions on whether over or underutilization is occurring, DMT experts must make conclusions about individual cases within a clinical context and in real-time. A DMT meeting provides an ideal setting for these discussions to take place.
“Outside of the clinical laboratory scientists, the doctoral-level leaders of the diagnostic management team can provide timely, expert-driven recommendations on test selection and result interpretation,” Dr. Laposata added. “However, the hospital must provide the support needed to permit these meetings to happen and to promote access to experts, either within their own institutions or to healthcare providers outside their institutions who need DMT-level expertise but do not have it.”
Additional initiatives labs and DMTs may want to consider in order to reduce laboratory test ordering inefficiencies include examining protocols to identify strengths and weaknesses and collaborating with physicians to provide education about appropriate test utilization.
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