25 Physicians’ perceptions of inappropriate laboratory testing in clinically admitted patients

Abstract

Background Overtesting in laboratory medicine is common. We set up this study to ascertain the appropriateness of laboratory test ordering in admitted patients and to investigate staff’s perceptions of, attitudes towards and reasons for the inappropriateness. Methods Information was collected on all laboratory tests ordered for patients admitted to the internal medicine ward of our hospital, a large university medical center, from January 2011 to December 2016. Several prespecified measures of inappropriate testing were assessed using these data including the number of fixed combinations of tests, the rate of repetition of laboratory test results within normal range, the number of laboratory test orders per week, and the time to repetition of CRP measurement and its clinical consequences. A survey was performed to investigate perceptions of and attitudes towards the appropriateness. The results of this survey were used as starting point in a series of focus group discussions. Results In 97% of orders that included an ALT, AST was also measured. For sodium and potassium, thus occurred in 95% of orders. Laboratory test results within the normal range are repeated in up to 85% of cases. Admitted patients on average have 5.7 laboratory test orders per week. In 59% of patients in whom a CRP was measured in the Emergency Department directly prior to admittance, CRP was repeated within 24 hours. In 88% of cases, this did not lead to changes in patient management. In the survey, respondents’ estimates of the number of laboratory test orders per week are substantially lower than the actual number (3.9 vs 5.7). Nevertheless, the majority of respondents think the number of laboratory test orders is too high. Most point to the residents as being most responsible for ordering laboratory tests. In focus groups the causes of excessive laboratory test ordering were explored. Most prominently, the residents felt they did not receive enough feedback. At the same time they considered laboratory test ordering to be too trivial to ask for more feedback from their supervisors. Conclusion Inappropriate laboratory test ordering is common and underestimated. Residents working on the wards are considered to be most responsible for inappropriate laboratory test orders. They feel they need more feedback to change their behaviour, yet think the subject is too trivial to ask for feedback themselves. This implies that interventions to reduce inappropriate laboratory test ordering should focus on facilitating feedback.