According to a report prepared by the Institute of Medicine, approximately 30% of U.S. healthcare is duplicative or unnecessary. Inappropriate or over-utilized medical tests account for $250 to $300 billion in U.S. medical expenses each year. Inappropriate testing not only compromises the quality of care but, in some cases, may pose risk or harm to patients by leading to more testing and unnecessary procedures or medication.
Pathologists and laboratory professionals play a critical leadership role in promoting and managing the delivery and use of healthcare resources. They can also play a key role in initiating conversations about appropriate test use with clinicians.
The American Society for Clinical Pathology (ASCP), which represents more than 100,000 pathologists and medical laboratory scientists worldwide, is one of 37 medical societies participating in the American Board of Internal Medicine’s Choosing Wisely campaign for test utilization and is the only one representing both pathologists and laboratory professionals. Choosing Wisely is about doing the right thing for patients and avoiding harmful care. ASCP is a major proponent of patient-centered care and evidence-based medicine.
To determine their initial Choosing Wisely recommendations, an ASCP review panel examined hundreds of options based on both the practice of pathology and evidence available through an extensive review of the literature. The laboratory tests targeted in our recommendations were selected because they are tests that are performed frequently; there is evidence that the test either offers no benefit or is potentially harmful; use of the test is costly and it does not provide higher-quality care; and eliminating it or changing to another test is within the control of the clinician. The recommendations:
- Do not perform population-based screening for 25-OH-Vitamin D deficiency.
- Do not perform low-risk human papillomavirus (HPV) testing.
- Avoid routine preoperative testing for low-risk surgeries without a clinical indication.
- Only order methylated septin (SEPT9) on patients for whom conventional diagnostics are not possible.
- Do not use bleeding time tests to guide patient care.
This list is not exhaustive. In fact, a number of other tests/procedures were also identified and considered for inclusion. But the recommendations, if instituted, would result in higher quality care, lower costs, and more effective use of our medical laboratory resources and personnel.
Clearly, diagnostic medicine is a key interest for all medical societies, as many other organizations participating in the Choosing Wisely program also included laboratory tests among their recommendations.
These recommendations are just the start of a multi-pronged strategy to start more conversations between patients and doctors so patients can be more informed about their health and make wiser decisions. One example of this is ASCP’s collaboration with the California Society of Pathologists (CSP) in a year-long grassroots initiative to reduce inappropriate or over-utilized lab testing and improve the quality and safety of medicine in California.
As part of this outreach, ASCP and CSP recently hosted a symposium to assist California pathologists in effectively implementing ASCP’s Choosing Wisely best practices; impacting positive clinical outcomes and cost reduction; and overcoming communication, organizational, and systems barriers to do so. The symposium, funded by a grant from the Robert Wood Johnson Foundation, featured distinguished presenters including George D. Lundberg, MD, FASCP, former editor of JAMA and MedScape, who emphasized that pathologists should make every laboratory test maximally useful.
Dr. Lundberg also stressed that this includes organizing laboratory services based upon turnaround time as well as test names; that those who work in labs should be thinking about and researching patient outcomes stemming from laboratory test use; and that all stakeholders should consider whether tests that have little or no effect on outcome should continue to be offered.
Another longtime proponent of reducing unnecessary tests and improving patient care, Gary W. Procop, MD, MS, FASCP, led the Cleveland Clinic’s highly successful review process of duplicative testing last year. The initiative has become a model for health systems across the country.
The first step to implementing a successful duplicative test reduction initiative is awareness, according to Dr. Procop, Chair of Molecular Pathology at the Clinic, who shared his perspectives on how laboratories can lead their organizations in promoting appropriate test utilization at ASCP’s 2013 Annual Meeting.
As part of the Cleveland Clinic’s initiative, pathologists and laboratory professionals engaged the medical leadership in their institutions—hospital administrators, the chief medical and surgical operations officers, and department chairs—as important allies for the system-wide implementation of test utilization initiatives. Implementing best practices for test utilization is a team effort.
Healthcare institutions seeking to reduce unnecessary testing should encourage open lines of communication between pathologists and laboratory professionals—who perform and interpret the tests—and the clinicians who prescribe them. Clinicians prescribe a lot of tests, yet some of these tests may duplicate those ordered by another doctor and others may be unhelpful for patient care. Pathologists and laboratory professionals are experts in this arena and can advise clinicians which tests are and are not appropriate.
