College of Population Health (Dr. Kaminski) and Sidney Kimmel Medical College (Ms. Venkat), Thomas Jefferson University, Philadelphia, PA mitchell.kaminski@jefferson.edu
The authors reported no potential conflict of interest relevant to this article.
Following these guidelines to order fewer tests can improve health care quality and patient experience, while reducing wasteful costs.
› Follow US Preventive Services Task Force and professional society recommendations for laboratory testing, including choice and frequency of tests. A
› Consider the pretest probability of your patient having a disease, and order the most sensitive and specific test to diagnose a new condition. Employ a 2-step approach with a second laboratory test when the first is outside the reference range. B
› Refrain from ordering routine preoperative testing for patients undergoing low-risk surgeries; these data do not improve postoperative outcomes, can lead to costly testing cascades, and may delay necessary surgical care for patients. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence C Consensus, usual practice, opinion, disease-oriented evidence, case series
References
CASE
A 35-year-old man arrives for an annual wellness visit with no specific complaints and no significant personal or family history. His normal exam includes a blood pressure of 110/74 mm Hg and a body mass index (BMI) of 23.6. You order “routine labs” for prevention, which include a comprehensive metabolic panel (CMP), fasting lipid profile, and thyroid-stimulating hormone (TSH) and 25(OH) vitamin D tests. Are you practicing value-based laboratory testing?
The answer to this question appears in the Case discussion at the end of the article.
Value-based care, including care provided through laboratory testing, can achieve the Institute for Healthcare Improvement’s Triple Aim of improving population health, improving the patient experience of care (including quality and satisfaction), and reducing cost: Value = (Quality x Patient experience) / Cost.1
As quality and patient experience rise and cost falls, the value of care increases. Unnecessary lab testing, however, can negatively impact this equation:
Error introduced by unnecessary testing can adversely affect quality.
Patients experience inconvenience and sometimes cascades of testing, in addition to financial responsibility, from unnecessary testing.
Low-value testing also contributes to work burden and provider burnout by requiring additional review and follow-up.
Rising health care costs are approaching 18% of the US gross domestic product, driven in large part by a wasteful and inefficient care delivery system.2 One review of “waste domains” identified by the Institute of Medicine estimates that approximately one-quarter of health care costs represent waste, including overtreatment, breakdowns of care coordination, and pricing that fails to correlate to the level of care received.3 High-volume, low-cost testing contributes more to total cost than low-volume, high-cost tests.4
Provider and system factors that contribute to ongoing waste
A lack of awareness of waste and how to reduce it contribute to the problem, as does an underappreciation of the harmful effects caused by incidental abnormal results.
Provider intoleranceof diagnostic uncertainty often leads to ordering even more tests.
