How Many Lab Tests Do Patients Really Need?

Published by Irving Nachamkin, DrPH, MPH, D(ABMM), FAAM, FIDSA, on September 29, 2015

Nearly one year ago, I was contacted by Jen Myers, MD, Director of Quality and Safety Education, and faculty leader for the hospital housestaff and advanced practitioner quality council (HAP Council) about a new quality initiative being developed by the HAP Council. To my surprise, the council had chosen to work on reducing unnecessary common laboratory test ordering and to see if I was interested in the project. After catching my breath, I didn’t need any more information other than to “sign me on.”

The idea that the hospital housestaff were taking the initiative to address a common problem in all hospitals, particularly teaching hospitals, was exciting and gave me hope that, finally, we could tackle the common problem of ordering daily labs without any clinical indication.

There has been a lot of press around this topic in the past year. Only a few weeks ago, an article by Gina Kolata in the New York Times on determining hospital costs mentioned this very topic, and that research has shown 20-50% of hospital lab tests were completely unnecessary and ordered by residents without any clinical indications. According to the article, orders plummeted when the University of Utah hospital required residents to justify all lab orders, saving the hospital hundreds of thousands of dollars per year.

The laboratory is frequently asked to figure out a way to control lab test utilization but in my view, the way to control test ordering starts with the provider. If providers can’t learn to order tests only when clinically necessary, we can only do so much in the laboratory after the blood samples have been obtained. It is obvious to all that reducing unnecessary lab tests would improve patient satisfaction (fewer needle sticks), reduce nosocomial anemia, reduce adverse effects from false positive tests, less hospital waste and reduced health care costs.

Beginning last year, the HAP Council (led by Mina Sedrak, Justin Ziemba, and Dana Murray) performed a survey of residents at HUP about lab test ordering and, to no one’s surprise, 70% of the respondents acknowledged that they frequently ordered unnecessary lab tests and more than one time per week.

Over the course of many months, the HAP council leadership team along with members of the lab team (Dan Danoski, Debbie Mincarelli, and Irv Nachamkin) developed a strategy for the reducing unnecessary lab tests campaign, including displaying test charges (medicare allowable charge), an educational and marketing campaign, and implement improvements to the SCM ordering system that currently enables tests to be too easily ordered in advance.

Two lab tests, Complete Blood Count (CBC) and Basic Metabolic Panel (BMP), were targeted for the project to reduce the number of CBC and BMP orders housewide. The strategy for displaying test charges and education/marketing was started in Feb/March of 2015 (SCM improvements not yet activated) and we are already seeing a significant change in test ordering patterns with an average monthly reduction of ~2000 tests. To put this into perspective, this reduction is equivalent to approximately 220 units of whole blood saved (using 4 cc/tube drawn for each test).

The reductions shown above are statistically significant and, if sustainable, will have a huge impact for patients as well as the institution. Reducing unnecessary lab tests cannot be just a campaign which has a start and end date, but needs to be part of the routine thought process for every patient by every provider of care. The HAP council has taken on a tremendous patient care issue and should be commended for their effort. Persistence with the message (see below) is key to the long-term success for this project.

Irving Nachamkin, DrPH, MPH, D(ABMM), FAAM, FIDSA, is the Director of the William Pepper Laboratory and the Division of Laboratory Medicine at Penn Medicine.

Disclaimer: The views and opinions expressed in this blog column are those of the authors or other attributed individuals and do not necessarily represent the official position of the Department, Penn Medicine, or the University of Pennsylvania. Health information is provided for educational purposes and should not be used as a source of medical advice or diagnosis.