Medicine by the Numbers

August 13, 2009

numbers

Elizabeth Gaines MD

Faculty Peer Reviewed

$275.50: The cost of routine morning labs at Bellevue in 2008.

Every morning, I sit down with my sign-out and scrawl “N, S, L” in red ink under each of my patients name. This becomes my to-do list, so that each day I remember to write a Note, up-date the Sign-out, and order morning Labs for each of my patients. As objective as I think I am, everyday I order morning labs that I probably don’t need. However, early in my internship, I learned that it is better to have too much information, than not enough. So, six days (sometimes seven) a week, my patients get a CBC and BMP, and most also get LFTs and a coagulation panel too. I can always justify to myself why I order a particular lab (trending potassium, following a white count, patient is on coumadin), but is it really necessary? How often do I treat a lab result and not the patient? And more importantly, how much does it all actually cost?

Several studies have identified the overuse of daily lab testing and how certain interventions can effectively reduce tests ordered. A study by Miyakis et al. examined the effects of disclosing lab test costs on the frequency at which healthcare providers ordered these tests. 24,482 laboratory tests were ordered before the intervention (mean 2.96 tests/patient/day). Among those, roughly 70% were not considered to have contributed towards management of patients (mean avoidable 2.01 tests/patient/day). After costs of tests were disclosed, the avoidable tests/patient/day were significantly decreased (mean 1.58, p = 0.002), but containment of unnecessary ordering of tests gradually waned during the semester after the intervention. (1) A study by Kumwilaisak et al. examined how the implementation of formal guidelines effected how laboratory tests were ordered. 1,117 patients were enrolled. After the institution of the guidelines, the number of laboratory tests decreased by 37% (from 64,305 to 40,877). Furthermore, this result was still present at 1 year. (3)

Unfortunately, over ordering daily labs is just the tip of the iceberg when if comes to the overuse of healthcare. As reimbursement rates have declined in recent years, most doctors have adapted by increasing the quantity of services. Increases in labs tests, imaging studies, and consultations with specialists have dramatically increased over the past few decades. This is in part due to lower reimbursements from Medicare and Medicaid. It is also in part due to the commercialization of medicine. Thanks largely to the internet, patients are more educated and are making more demands from their physicians. Patients come in asking for tests that they heard about on the Today Show or that they read about on WebMD but that may not be medically indicated. If one physician says no, it is not difficult for them to go down the road and find someone who will say yes.

Unfortunately, more is not translating into better. In 2007, according to the Commonwealth Fund, the United States ranked 45th in life expectancy, behind Bosnia and Jordan; near last, compared with other developed countries, in infant mortality; and in last place, among major industrialized countries in health-care quality, access and efficiency. Clearly, the problem extends far beyond the over-ordering of daily inpatient labs. However, it is important that we realize that in just ordering tests for the sake of ordering tests, we are contributing to a very large and very expensive problem, to the tune of billions of dollars. Daily morning labs may only be a small drop in this very large bucket, but we can each do our part to prevent this big problem from getting even bigger.

Peer Reviewed by Kelly Crotty MD, NYU Division of General Internal Medicine

Spiros Miyakis , Georgios Karamanof , Michalis Liontos , Theodore D Mountokalakis. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgraduate Medical Journal 2006;82:823-829

J Kwok and B Jones. Unnecessary repeat requesting of tests: an audit in a government hospital immunology laboratory Journal of Clinical Pathology 2005;58:457-462

Kumwilaisak, Kanya, Noto, Alberto, Schmidt, Ulrich, MD, PhD, Beck, Clare, Crimi, Claudia, Lewandrowski, Kent, Bigatello, Luca Effect of laboratory testing guidelines on the utilization of tests and order entries in a surgical intensive care unit Critical Care Medicine. 36(11):2993-2999, November 2008

Jauhar S. Many Doctors, Many Tests, No Rhyme or Reason. The New York Times. March 11, 2008.

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