Managing Laboratory Test Use: Principles and Tools

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It is difficult for unaided physicians to keep up with the scientific advances and changing practice guidelines relevant to ordering and interpreting laboratory tests. Overordering, underordering, and misordering of tests are all common, and specific practices vary tremendously from community to community. Pathologists and clinical laboratory scientists have valuable knowledge that can help treating physicians provide higher-quality and more cost-effective care. Laboratorians can use online test catalogs to steer physicians toward optimal test algorithms, with hyperlinking to journal articles, clinical guidelines, and other reference materials. Retrospective audit of ordering patterns can efficiently pinpoint educational needs specific to a physician community.

Section snippets

Evidence for suboptimal use

One study of academic medical centers found marked variations in the quantity of care provided to Medicare patients for several common diagnoses [5]. The quintile of centers with the highest overall use rates performed 60% more services than the lowest-use quintile. When these costs were subcategorized, diagnostic testing was the category with the largest observed variation (versus physician charges, imaging, diagnostic tests, minor procedures, and major procedures). This paper's methodology of

Drivers of suboptimal ordering

Although most decisions about ordering laboratory tests are at the discretion of individual physicians, these decisions take place within a complex framework involving patients, facilities, insurers, and other participants. The pace of technologic change is arguably the biggest factor contributing to suboptimal decision-making; others include economic pressures on physicians and the diagnostics industry, malpractice fear, overestimation of test accuracy, and cultural pressure [13].

Physicians

Impact of suboptimal ordering

Diagnostic testing is a relatively upstream process in patient care. Virtually all of the clinical impact and much of the financial impact of a laboratory test is determined by how the test result changes patient management. In principle, a test can have no impact, positive impact, or negative impact on the care of a particular patient. In the no-impact category is redundant testing, such as when a test is inadvertently repeated. Depending on the tests analyzed and the strictness of criteria,

Strategies for improving ordering

Given the complexity of medical decision-making and the range of factors influencing decisions about laboratory tests, not to mention the heterogeneity of clinical settings in which tests are ordered, it is simplistic to think that there could be a single “magic bullet” solution to improving ordering. A mixture of complementary interventions is more likely to be successful, particularly when the interventions are matched to the culture, information technology infrastructure and other local

Roles of specific groups

Just as effective utilization management requires coordination of multiple approaches, it also requires coordination among the various participants in the laboratory diagnostic process. Each of the groups listed next has a different perspective and set of available resources, and each can play a constructive role in promoting high-quality laboratory diagnosis.

Summary

For laboratory testing to achieve its potential for supporting high-quality patient care, tests need to be used in a scientifically and medically appropriate manner. Rapid technologic change alongside myriad clinical pressures makes it unrealistic for unaided physicians to stay up to date on the indications for all available tests. Laboratories and clinical pathologists can improve patient care by monitoring test use and then responding to suboptimal use through a coordinated portfolio of

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    This work was supported by the ARUP Institute for Clinical and Experimental Pathology.

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