Inappropriate Laboratory Testing Found Throughout Medicine

Laboratory testing is the single highest-volume medical activity and drives clinical decision-making across medicine with over five billion tests performed each year in the USA.

The overall landscape of inappropriate testing, which is thought to be dominated by repeat testing, is unclear. Systematic differences in initial versus repeat testing, measurement criteria, and other factors would suggest new priorities for improving laboratory testing.

Scientists at the Harvard Medical School (Boston, MA, USA) and colleagues from Beth Israel Deaconess Medical Center (BIDMC; Boston MA, USA) performed a multi-database systematic review on published studies from 1997–2012. For measures of overutilization, they determined whether the inappropriateness criteria were objective or subjective; restrictive, permissive, or both; and whether they involved initial testing, repeat testing, or both. Test volume, low, medium, or high was also determined.

From these measurements, they set about estimating the overall prevalence of inappropriate testing, including overuse, tests that are ordered but not indicated, and underuse tests that are indicated but not ordered. They also distinguished between inappropriate initial testing, during a clinician's first evaluation of a patient or in response to new signs or symptoms, and inappropriate repeat testing, which occurs when the same tests are repeated, often multiple times, during a patient's hospitalization.

The authors found that not only was there a 30% overall rate of test overuse, there was a similar rate of underuse. On average, the available evidence suggests that underutilization is more prevalent than overutilization, 44.8% versus 20.6%. Ramy Arnaout, MD, DPhil, the senior author, said, “It's not ordering more tests or fewer tests that we should be aiming for, it's ordering the right tests, however few or many that is. Remember, laboratory tests are inexpensive. Ordering one more test or one less test isn't going to ‘bend the curve,’ even if we do it across the board. It's everything that happens next: the downstream visits, the surgeries, the hospital stays that matters to patients and to the economy and should matter to us.”

William Taylor, MD, a clinician in BIDMC's Division of General Medicine and Primary Care, said, “Because laboratory tests play such a crucial and ubiquitous role in medicine, efforts to identify opportunities for improvement in the selection of tests have the potential to contribute greatly to the care patients receive. By drawing attention to this important topic, the authors are setting the stage for further work to help more patients benefit from proper test selection, while protecting patients from the potential harm and wasted resources induced by unnecessary tests.” The study was published on November 15, 2013, in the journal Public Library of Science ONE.

Related Links:
Harvard Medical School
Beth Israel Deaconess Medical Center