Inappropriate Laboratory Testing Research Articles

Reducing Inappropriate Laboratory Testing in the Hospital Setting: How Low Can We Go?

Reducing Inappropriate Laboratory Testing in the Hospital Setting: How Low Can We Go?

MON-118 Reducing Unnecessary Repeat HbA1c Testing in a Tertiary Academic Hospital

BackgroundGlycated hemoglobin (HbA1c) is a surrogate marker of glycemia over the preceding three months, where the last 30 days contributes to 50% of the value (1). Therefore guidelines often recommend repeating HbA1c only after 3 months in most situations (2), but repeat testing of HbA1c is often conducted earlier when not warranted (3). We aimed to conduct a Quality Improvement (QI) initiative to reduce unnecessary repeat testing of HbA1c at a large tertiary care academic hospital in Toronto, Ontario by 50% by May 2020.Methods:The Model for Improvement Quality Improvement (QI) framework was used in the design of the QI project to reduce repeat HbA1c. Problem characterization was conducted to understand root causes and iterative Plan-Do-Study-Act cycles were used to develop a change intervention. Unnecessary HbA1c tests were the primary outcome and defined as repeat HbA1c testing within 60 days; the top three specialities that ordered unnecessary HbA1c tests were targeted for education prior to implementation of the change intervention.Results:Baseline data on all HbA1c tests in 2018 revealed repeat testing in approximately 10% of 15,290 HbA1c tests, with estimated potential savings of more than $11,000 based on the provincial reimbursement rate. The top 3 ordering specialities targeted for education included Nephrology (n=410 repeat HbA1c tests), Cardiology (n=246 repeat HbA1c tests), and Endocrinology (n=136 repeat HbA1C tests). Root cause analysis revealed that providers often ordered repeat HbA1c tests due to being unaware of prior results and a knowledge gap of testing recommendations. A laboratory forced function will be implemented on December 1, 2019 to cancel any repeat HbA1c tests within 60 days and calls to the lab to add HbA1c testing will be tracked.Conclusions:Repeat HbA1c testing is frequent in hospital settings and can be an important target for QI efforts. A forced function to cancel processing of repeat HbA1c may be an appropriate QI intervention to reduce repeat testing to promote high-value care. Ongoing data analysis will be conducted to assess the impact of this intervention.References(1) Goldstein DE, Little RR, Lorenz RA, Malone JI, Nathan D, Peterson CM, Sacks DB. Tests of Glycemia in Diabetes. Diabetes Care 2004;27(7): 1761-1773.(2) Berard LD, Siemens R, Woo V. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Monitoring Glycemic Control. Can J Diabetes 2018;42(Suppl 1):S47-S53.(3) Chami N, Simons JE, Sweetman A, Don-Wauchope AC. Rates of inappropriate laboratory test utilization in Ontario. Clinical Biochemistry 2017;50: 822-827.

Inappropriate laboratory testing in internal medicine inpatients: Prevalence, causes and interventions.

BackgroundTo reduce overutilization of laboratory testing many interventions have been tried, but selecting the most effective intervention for a given setting is challenging. To be sustainable, interventions need to align with healthcare providers' needs and daily practices. This study aimed to assess the extent of overutilization and the perspectives of healthcare providers, which may be used to guide the choice of intervention.MethodsThe extent of inappropriate laboratory testing in internal medicine inpatients was evaluated using a database. Surveys and focus groups were used to investigate healthcare providers' perceptions on its causes and solutions.ResultsOn average, patients had 5.7 laboratory orders done during the first week of admission, whereas guidelines advise performing laboratory testing no more than twice per week. Repeat testing of normal test results occurred in up to 85% of patients. The frequency of laboratory testing was underestimated by survey responders, even though the majority of responders (78%) thought that laboratory tests are ordered too frequently. Residents were considered to be most responsible for laboratory test ordering.The primary causes of overutilization discussed were personal factors, such as a lack of awareness and knowledge, as well as feelings of insecurity. Regarding possible solutions, residents generally recommended educational interventions, whereas specialists tended to favour technical solutions such as lockouts.ConclusionInappropriate laboratory testing is common in internal medicine. The most important causes are a lack of awareness and knowledge, especially in residents. The intervention most favoured by residents is education, suggesting educational interventions may be most applicable.

Is the Climb Worth the View? The Savings/Alert Ratio for Reducing Vitamin D Testing.

Despite guideline recommendations, vitamin D testing has increased substantially. Clinical decision support (CDS) presents an opportunity to reduce inappropriate laboratory testing. To reduce inappropriate testing of vitamin D at the Vanderbilt University Medical Center, a CDS assigned providers to receive or not receive an electronic alert each time a 25-hydroxyvitamin D assay was ordered for an adult patient unless the order was associated with a diagnosis in the patient's chart for which vitamin D testing is recommended. The CDS ran for 80 days, collecting data on number of tests, provider information, and basic patient demographics. During the 80 days, providers placed 12,368 orders for 25-hydroxyvitamin D. The intervention group ordered a vitamin D assay and received the alert for potentially inappropriate testing 2,181 times and completed the 25-hydroxyvitamin D order in 89.9% of encounters, while the control group ordered a vitamin D assay (without receiving an alert) 2,032 times and completed the order in 98.1% of encounters, for an absolute reduction of testing of 8% (p < 0.001). This CDS reduced vitamin D ordering by utilizing a soft-stop approach. At a charge of $179.00 per test and a cost to the laboratory of $4.20 per test, each display of the alert led to an average reduction of $14.70 in charges and of $0.34 in spending by the laboratory (the savings/alert ratio). By describing the effectiveness of an electronic alert in terms of the savings/alert ratio, the impact of this intervention can be better appreciated and compared with other interventions.

Reducing Inappropriate Serum T3 Laboratory Test Ordering in Patients with Treated Hypothyroidism

Objective: Choosing Wisely is a campaign of the American Board of Internal Medicine that aims to promote evidence-based practices to reduce unnecessary ordering of tests or procedures. As part of this campaign, the Endocrine Society advises against ordering a serum total or free triiodothyronine (T3) level when assessing levothyroxine dosing in hypothyroid patients. This study was performed to assess and reduce inappropriate laboratory ordering practices among providers who manage patients with hypothyroidism within a large U.S. academic health system. Methods: A best practice alert (BPA) in the health record was developed and implemented following the collection of baseline data. This alert consisted of a popup window that was triggered when a serum T3 laboratory test was ordered for patients prescribed levothyroxine. The alert required user acknowledgement before the serum T3 laboratory test could be ordered. Results: During the 6-week period prior to launching the BPA, serum T3 tests were ordered a mean of 162.3 ± 15.4 (standard deviation) occurrences per 10,000 patients per week. Over a 15-week period following implementation of the BPA, the frequency of serum T3 orders steadily decreased and resulted in >44% fewer inappropriate tests being ordered. Conclusion: Although national societal guidelines recommend against ordering serum T3 concentrations while monitoring patients with hypothyroidism managed with levothyroxine, these laboratory tests are frequently ordered. Development of a triggered alert in the health record may reduce inappropriate monitoring practices, decrease costs, and improve utilization of limited health-care resources for this common clinical condition. Abbreviations: ATA = American Thyroid Association; BPA = best practice alert; T3 = triiodothyronine; TSH = thyroid-stimulating hormone.

Evidence-Based Duplicate Order Alerts Promote Effective Test Utilization and Reduce Unnecessary Laboratory Testing

Abstract Introduction Unnecessary and inappropriate laboratory testing contributes to increased health care costs, increases length of stay, and increases odds for blood product transfusion. The Choosing Wisely campaign recommends a judicious use of laboratory blood testing to combat iatrogenic anemia. Reducing the number of duplicate test orders may help address these issues. We evaluated duplicate order alert thresholds in our electronic health record for 10 common laboratory tests at an academic medical center. Methods In January 2019, alert intervals for 10 common inpatient laboratory tests (thyroid stimulating hormone, complete blood count, hemoglobin A1c, troponin, lactic acid, hemoglobin and hematocrit, urinalysis, vitamin D, urine beta HCG, and triglycerides) were adjusted to evidence-based, disease-specific thresholds. If a test was ordered within a timeframe shorter than this threshold, an alert interrupted the provider’s workflow. The provider was allowed to override the alert based on clinical judgment. This is a change from the previous settings, which alerted any test if ordered more frequently than 8 hours. Postintervention duplicate order alerts were compared to baseline rates and adjusted for number of inpatient discharges. Results In total, 914 orders were cancelled in 1 month as a result of tailored duplicate order alerts versus the baseline mean of 710 (95% CI, 633-786) and a predicted 552 (95% CI, 475-628) when adjusted for number of inpatient discharges, with the majority of cancelled orders being for CBC (530 accepted alerts). Overall, this reduction in unnecessary duplicate tests is equivalent to 3,092 mL of blood not collected from patients per month. Conclusion Tailoring duplicate order alert interval thresholds to evidence-based criteria helps reduce unnecessary testing, reduces costs, and may play an important role in reducing hospital-acquired anemia.

Reducing Hospitalizations: Institution of Outpatient Infusional EPOCH-Based Chemotherapy at a Safety Net Hospital.

EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) -based chemotherapy is traditionally administered inpatient because of its complex 96-hour protocol and number of involved medications. These routine admissions are costly, disruptive, and isolating to patients. Here, we describe our experience transitioning from inpatient to outpatient ambulatory EPOCH-based chemotherapy in a safety-net hospital, associated cost savings, and patient perceptions. Guidelines for chemotherapy administration and educational materials were developed by a multidisciplinary team of physicians, nurses, and pharmacists. Data were collected via chart review and costs via the finance department. Patient satisfaction with chemotherapy at home compared with hospitalization was measured on a Likert-type scale via direct-to-patient survey. From January 30, 2017, through January 30, 2018, 87 cycles of EPOCH-based chemotherapy were administered to 23 patients. Sixty-one ambulatory cycles (70%) were administered to 18 patients. Of 26 cycles administered in the hospital, 18 (69%) were the first cycle of treatment. Rates of inappropriate prophylactic antimicrobial prescription and laboratory testing were lower in the outpatient setting. Eight of nine patients surveyed preferred home chemotherapy to inpatient chemotherapy. Per-cycle drug costs were 57.6% lower in outpatients as a result of differences in the acquisition cost in the outpatient setting. In total, the transition to ambulatory EPOCH-based chemotherapy yielded 1-year savings of $502,030 and an estimated 336 days of avoided hospital confinement. Multiday ambulatory EPOCH-based regimens were successfully and safely administered in our safety-net hospital. Outpatient therapy was associated with significant savings through avoided hospitalizations and reductions in drug acquisition cost and improved patient satisfaction.

Decreasing daily blood work in hospitals: What works and what doesn't.

Recurrent, inappropriate laboratory testing is a costly and wasteful use of healthcare resources. Recognizing this problem, the American Board of Internal Medicine, Canadian Society of Internal Medicine, and the Canadian Association of Pathologist all supported the Choosing Wisely campaign to reduce laboratory investigations in patients who demonstrate clinical and laboratory stability. In this narrative, we review studies looking at a variety of approaches to reduce excessive testing including education, audit and feedback, computerized physician order entry system changes, and forcing functions. Each type of intervention has its own unique advantages and disadvantages, varying in complexity, disruptiveness, effectiveness, and sustainability. Before implementing any quality improvement project, it is important to analyze the local context to identify the root causes for the practice behavior and aim to use the minimal amount of intervention to achieve the desired result. Change is often incremental and will seldom occur with a single intervention or Plan-Do-Study-Act cycle. Garnering the support of opinion leaders and a quality improvement team will help make the process and intervention a success.

What the Doctor Ordered: Improving the Use and Value of Laboratory Testing

About 70 percent of medical decisions are based on the results of laboratory tests (Forsman 1996). If testing amounts to inappropriate over-utilization, it could lead to further unnecessary testing, inaccurate diagnosis and potentially inappropriate treatments that could be accompanied by adverse and unnecessary side-effects. A test may also be inappropriately underutilized – it should be ordered, but isn’t – which leads to delayed diagnosis and treatment and potential worsening of the patient’s condition. The importance of laboratory testing in diagnosis, in addition to its significant cost, makes it a primary target for quality improvement. Reducing inappropriate laboratory testing would have the dual benefits of making the health system as a whole more efficient and improving patient outcomes and experience. This Commentary investigates the use and cost of laboratory testing in Canada and finds variation across the country. To decrease the amount of unnecessary laboratory testing and the associated downstream medical costs, strategies must balance effectiveness with maintaining doctor and patient autonomy in choosing treatments. We propose a number of options for policymakers to reduce inappropriate laboratory testing: adjusting physician compensation to align incentives with improving appropriateness; utilization management via practice variation and feedback information; reforming requisition orders and care paths to more closely adhere to clinical guidelines; and development of provincial formularies for diagnostic testing.

Estimated costs of 51 commonly ordered laboratory tests in Canada

IntroductionTest cost display has been shown to reduce inappropriate laboratory test ordering practices in the United States. Unfortunately, such a system is limited in the Canadian publically funded healthcare environment. Many Canadian physicians inaccurately estimate the cost of laboratory tests, which may contribute to mis-utilization. Here, we provide an estimated cost of over 50 commonly ordered laboratory tests in Canada as an educational tool for physicians. MethodsTest volume data was collected from Calgary Laboratory Services' Laboratory Information System in order to determine which laboratory and diagnostic tests are most commonly ordered in Calgary and its surrounding area. Reference median cost (RMC) of fifty one commonly ordered test was calculated by determining the price list of all-inclusive indirect costs from six different clinical laboratories across Canada. ResultsOf the 51 laboratory tests included, the minimum RMC was $5 CAD (eg: albumin, calcium, urea), and the maximum RMC was $300 (surgical pathology report). ConclusionsA caveat to the provided list of test costs is that it is only an estimate and may differ from what each individual clinical laboratories charges to third parties or for research purposes. However, this list can serve as an educational tool and raise awareness for Canadian physicians on the relative costs of laboratory tests.

Electronic Laboratory Medicine ordering with evidence-based Order sets in primary care (ELMO study): protocol for a cluster randomised trial

BackgroundLaboratory testing is an important clinical act with a valuable role in screening, diagnosis, management and monitoring of diseases or therapies. However, inappropriate laboratory test ordering is frequent, burdening health care spending and negatively influencing quality of care. Inappropriate tests may also result in false-positive results and potentially cause excessive downstream activities. Clinical decision support systems (CDSSs) have shown promising results to influence the test-ordering behaviour of physicians and to improve appropriateness. Order sets, a form of CDSS where a limited set of evidence-based tests are proposed for a series of indications, integrated in a computerised physician order entry (CPOE) have been shown to be effective in reducing the volume of ordered laboratory tests but convincing evidence that they influence appropriateness is lacking. The aim of this study is to evaluate the effect of order sets on the quality and quantity of laboratory test orders by physicians. We also aim to evaluate the effect of order sets on diagnostic error and explore the effect on downstream or cascade activities.MethodsWe will conduct a cluster randomised controlled trial in Belgian primary care practices. The study is powered to measure two outcomes. We will primarily measure the influence of our CDSS on the appropriateness of laboratory test ordering. Additionally, we will also measure the influence on diagnostic error. We will also explore the effects of our intervention on cascade activities due to altered results of inappropriate tests.DiscussionWe have designed a study that should be able to demonstrate whether the CDSS aimed at diagnostic testing is not only able to influence appropriateness but also safe with respect to diagnostic error. These findings will influence a lager, nationwide implementation of this CDSS.Trial registrationClinicalTrials.gov, NCT02950142.

Clustered interventions to reduce inappropriate duplicate laboratory tests in an Irish tertiary hospital

BackgroundThere is increasing emphasis on understanding the rate, and avoidable costs, of inappropriate laboratory testing in hospitals, especially associated with duplication of tests following transfer of patients from one hospital to another. While studies of inappropriate testing have been reported previously, there are no published data relevant to Ireland. AimsTo determine the baseline rate of inappropriate testing for a subset of clinical parameters, specifically, full blood counts (FBC), biochemistry profiles (Bio) and coagulation (Coag) screens for geriatric patients transferring to and from University Hospital Limerick (UHL). Prospective pilot-scale implementation of five clustered interventions, and assessment of their effect. MethodsBaseline testing levels were determined between October 2013 and January 2014. A patient survey was conducted to evaluate patient awareness of the blood tests they underwent. Five interventions were trialed sequentially each month between January and May 2014. These included: educational poster, intern training, presentations and communication to consultants; automated prompt in the Lab Information Technology system; highlighting of patient survey results to medical staff; inclusion of laboratory test details on patient transfer document; patient booklet promoting empowerment. Impact was assessed by determining rates of inappropriate laboratory testing monthly, and associated actual cost reductions were calculated. ResultsApproximately two-thirds of geriatric inpatients were unaware of why they underwent blood tests. Baseline numbers of inappropriate duplicate FBCs, Bio profiles and Coag tests were 758, 749 and 268 respectively for patients transferring to and from UHL. Following the interventions, these numbers dropped to 85, 84 and 0, respectively. ConclusionThe interventions resulted in sustained reduction in rates of inappropriate testing by May 2014. Extrapolated cost reductions exceed two million Euro annually. The most effective intervention involved staff education.

Estimating the environmental impact of inappropriate laboratory testing

In a recent letter commenting a previous article published in the Journal of Laboratory and Precision Medicine (1), Joseph Watine has outlined an intriguing and almost overlooked consequence of inappropriate laboratory testing, i.e., the potential impact of redundant or unnecessary tests on environmental protection (2). Notwithstanding this concept is theoretically straightforward, Watine failed to provide significant data in support of this statement, which hence remains hypothetical in essence.

Rates of inappropriate laboratory test utilization in Ontario

BackgroundMedical laboratory tests ordered redundantly represent one of the targets for reducing diagnostic testing without negatively, and possibly positively, affecting patient care. We study a clearly defined category of excessive laboratory utilization for nine analytes where inappropriate diagnostic testing is defined in terms of the time interval between tests; that is, ordering a test too soon following the previous order of the same test. MethodsPopulation data from the near universal public Ontario Health Insurance Plan for the years 2006–2010 are employed where the tests are fulfilled by community medical laboratories. The analytes selected for consideration are thyroid stimulating hormone, hemoglobin A1c, lipid profile, serum protein electrophoresis, immunofixation, quantitative immunoglobulins, Vitamin D, Vitamin B12, and folate. ResultsFor the nine analytes studied, the percentage of inappropriate tests ranged from 6% to 20%. Large proportions of these inappropriate tests were completed >2weeks prior to the minimum threshold to reorder defined by practice guidelines and/or were repeated excessively within a year. Between 60% and 85% of the time, the ordering physician of an inappropriate test was the same physician who ordered the previous test. Specialists were more likely than primary care physicians to order repeat tests too soon. ConclusionsA sizeable proportion of testing for these analytes was inappropriate according to practice guidelines. It is recommended that systems for preventing unnecessary repeat testing are investigated by the funding agencies and that reducing inappropriate testing be considered as a design element for electronic medical records and related information technology systems.

The Effects of Computerized Clinical Decision Support Systems on Laboratory Test Ordering: A Systematic Review.

- Inappropriate laboratory test ordering has been shown to be as high as 30%. This can have an important impact on quality of care and costs because of downstream consequences such as additional diagnostics, repeat testing, imaging, prescriptions, surgeries, or hospital stays. - To evaluate the effect of computerized clinical decision support systems on appropriateness of laboratory test ordering. - We used MEDLINE, Embase, CINAHL, MEDLINE In-Process and Other Non-Indexed Citations, Clinicaltrials.gov, Cochrane Library, and Inspec through December 2015. Investigators independently screened articles to identify randomized trials that assessed a computerized clinical decision support system aimed at improving laboratory test ordering by providing patient-specific information, delivered in the form of an on-screen management option, reminder, or suggestion through a computerized physician order entry using a rule-based or algorithm-based system relying on an evidence-based knowledge resource. Investigators extracted data from 30 papers about study design, various study characteristics, study setting, various intervention characteristics, involvement of the software developers in the evaluation of the computerized clinical decision support system, outcome types, and various outcome characteristics. - Because of heterogeneity of systems and settings, pooled estimates of effect could not be made. Data showed that computerized clinical decision support systems had little or no effect on clinical outcomes but some effect on compliance. Computerized clinical decision support systems targeted at laboratory test ordering for multiple conditions appear to be more effective than those targeted at a single condition.

Evaluation of thyroid test utilization through analysis of population-level data.

Inappropriate laboratory test utilization can result in unnecessary patient testing and increased healthcare costs. While several thyroid function tests are available, thyroid-stimulating hormone (TSH) is recommended as the first-line test for investigating and monitoring thyroid dysfunction. We evaluate thyroid test utilization in Northern Alberta in terms of testing patterns, frequencies, and reflex cutpoints. This retrospective study analyzed thyroid test requests from January to December 2014. Each request was designated as appropriate or potentially inappropriate as per clinical practice guidelines and Choosing Wisely recommendations, and the frequencies of each testing pattern were calculated. Sub-analysis was performed to categorize testing patterns based on physician specialty. The number of test requests per patient was determined to assess the appropriateness of testing frequency. Receiver operating characteristic (ROC) curves were generated to define optimal TSH cutpoints for automatic reflex to FT4 testing. Of 752,217 test requests, approximately 10% were potentially inappropriate in terms of testing patterns. Free thyroxine (FT4) and free triiodothyronine (FT3) requested with TSH accounted for 59% of all potentially inappropriate test requests, and 49% of requests from endocrinologists (ENDO) were potentially inappropriate, occurring most frequently among those with less experience. Excessive testing frequencies were observed in 869 patients, accounting for 9382 test requests. Adjustment of our TSH reflex cutpoint would significantly increase specificity for identifying a low FT4 without compromising sensitivity. This study suggests that questionable testing patterns, excessive testing frequencies, and suboptimal reflexive testing cutpoints contribute to inappropriate thyroid test utilization.

Failed Attempts to Reduce Inappropriate Laboratory Utilization in an Emergency Department Setting in Cyprus: Lessons Learned

BackgroundLaboratory test ordering is a significant part of the diagnosis definition and disease treatment monitoring process. Inappropriate laboratory test ordering wastes scarce resources, places unnecessary burden on the health care delivery system, and exposes patients to unnecessary discomfort. Inappropriate ordering is caused by many factors, such as lack of guidelines, defensive medicine, thoughtless ordering, and lack of awareness of costs incurred to the system. ObjectivesThe purpose of this study is to assess two successive measures, which were introduced in a Cyprus emergency department (ED) for the purpose of synergistically reducing inappropriate laboratory ordering: the introduction of a copayment fee to reduce nonemergent visits, and the development of a Web-based protocol defining the tests emergency physicians could order. MethodsAn autoregressive integrated moving average model for interrupted time series analysis was constructed. Data include number and type of tests ordered, along with number of visits for a period of 4 years from an ED in Cyprus. ResultsCopayment fee and introduction of a revised Web-based protocol for a test ordering form did not reduce the number of ordered tests in the ED unit. Copayment fee alone resulted in a statistically significant reduction in ED visits. ConclusionsThe implementation of two consecutive measures resulted in an increase of ordered tests per patient. Laboratory ordering is a multidimensional process that is primarily supplier induced, therefore, all underlying possible causes must be scrutinized by health authorities. These include lack of guidelines, defensive medicine and thoughtless prescribing. To attain significant gains, an integrated approach must be implemented.

Effectiveness of a computerized alert system based on re-testing intervals for limiting the inappropriateness of laboratory test requests

ObjectivesThere is consolidated evidence that the burden of inappropriate laboratory test requests is very high, up to 70%. We describe here the function of a computerized alert system linked to the order entry, designed to limit the number of potentially inappropriate laboratory test requests. Design and methodsA computerized alert system based on re-testing intervals and entailing the generation of pop-up alerts when preset criteria of appropriateness for 15 laboratory tests were violated was implemented in two clinical wards of the University Hospital of Parma. The effectiveness of the system for limiting potentially inappropriate tests was monitored for 6months. ResultsOverall, 765/3539 (22%) test requests violated the preset criteria of appropriateness and generated the appearance of electronic alert. After alert appearance, 591 requests were annulled (17% of total tests requested and 77% of tests alerted, respectively). The total number of test requests violating the preset criteria of inappropriateness constantly decreased over time (26% in the first three months of implementation versus 17% in the following period; p<0.001). The total financial saving of test withdrawn was 3387 Euros (12.8% of the total test cost) throughout the study period. ConclusionsThe results of this study suggest that a computerized alert system may be effective to limit the inappropriateness of laboratory test requests, generating significant economic saving and educating physicians to a more efficient use of laboratory resources.

Decreasing Inappropriate Laboratory Test Utilization

Laboratory directors, hospital administrators, managed care plans, insurance companies, and governments continue to grapple with the competing demands of controlling health care costs, maintaining or improving quality of care, and addressing demands for increased access to newer expensive technologies. Although annual expenditures for laboratory tests are a relatively small part of total health care costs, clinical laboratory testing has not been spared from cost containment efforts. Controlling laboratory costs can be divided into two categories: good business practices and management systems that are part of stewardship of resources, along with systems designed to control laboratory utilization. Much has been written about the latter, but our understanding of how to do this without adversely affecting patient safety or quality of care is incomplete. Moreover, although a number of approaches to controlling laboratory utilization have been used, it is not known which approach is the most effective or how to integrate these approaches with other systems designed to control laboratory costs. Perhaps the most common approach to control expenditures on laboratory services is simply reducing reimbursement rates. This approach can be effective in the short run but has several fundamental flaws. The first of these is that there is an irreducible minimum cost to perform any test, so laboratories can only reduce costs before they start losing money each time they perform the test. Many laboratories already operate on all too thin margins, with little or no room to cut costs further. Moreover, once reimbursement rates fall below the cost of performing a test, it is not sustainable for laboratories to lose even more money each time reimbursement rates fall. It has been argued that this approach can work if laboratories use positive margins from some tests to subsidize tests with negative margins, but this is specious reasoning in an era when …

Translation editor M.L. Sveshchinskiy. The landscape of inappropriate laboratory testing: a 15-year meta-analysis

Translation editor M.L. Sveshchinskiy. The landscape of inappropriate laboratory testing: a 15-year meta-analysis