Background: As health systems focus on providing high–value, cost–conscious care, efforts to optimize laboratory testing are increasing. In order to improve safe and effective utilization of the laboratory, it is informative to understand the prevalence of overuse and its contributing factors.
Methods: The Value Improves Quality (VIQ) curriculum was implemented at our institution in 2014 to provide Internal Medicine residents with a practical understanding of high–value care. Rotating groups of housestaff engage in projects addressing high–value care topics every 2 weeks. We selected the subset of projects which addressed lab utilization for further study; specifically, these projects examined use of folic acid level, ammonia level, CK-MB, TSH, Hepatitis C antibody, Digoxin level, and CBC testing. At the end of each rotation, residents complete a summary document that describes their findings, proposed interventions, and any barriers identified. We reviewed the 11 proposals that specifically addressed lab utilization and compiled a list of barriers identified. We then extracted common themes to elucidate the major drivers of overuse.
Results: When our current practice was compared with evidence-based and/or consensus-based indications for specific tests, we identified significant overutilization. Extrapolated annually, we identified 335,600 tests, at least 100,000 phlebotomies, 500 liters of blood, and $7,460,800 in direct costs that were potentially avoidable (Figure 1). Common themes identified as drivers of overuse were: lack of awareness of test indication, lack of awareness of test cost, inappropriate test repetition (e.g repeating a Hepatitis C antibody test after an initial positive result), repeating a test sooner than clinically indicated (e.g. several TSH tests in a single hospital admission), repeating a test when the results of the initial test are still pending, and ordering tests to be repeated daily for an unlimited duration.
Conclusions: Significant overutilization of laboratory testing was documented at our institution. Because our analyses were at times limited to the Medicine service and were focused on a limited number of specific tests, the results likely underestimate the magnitude of the problem. Interventions designed to improve appropriate laboratory utilization which address the drivers above, may improve outcomes for patients while reducing healthcare costs. Designing EMR systems with provider education around test indications, costs, and repetition should be a starting point.