Unnecessary testing wastes money and can lead to further testing. Why does it occur?

Almost 60% of medical personnel surveyed at a large academic medical center believed that hospitalized patients should have daily laboratory testing.

Of 1580 attending physicians, fellows, residents, physician assistants, nurse practitioners, and nurses sent surveys, 837 (53%) responded; 393 (47%) were RNs, and 80% of those nurses felt that daily laboratory testing should be done on all patients.

Nurses strongly felt that patient safety and protection against malpractice litigation were enhanced by daily laboratory testing.

Of note is that more than half of those who returned completed surveys said they thought attendings would be uncomfortable with less testing, and 37% said they ordered unnecessary tests to satisfy attendings. However, the category of respondents who least felt daily tests were needed was attending physicians at 28%, and 84% of attending physicians said they would be comfortable if their patients had fewer laboratory tests.

Unnecessary lab testing on their units was observed by 60% of respondents, but only 37% said they had requested unnecessary testing themselves. Perhaps the unnecessary tests had been ordered by people who did not respond to the survey or the tests were ordering themselves.

The authors of the JAMA Internal Medicine study, done at Memorial Sloan Kettering Cancer Center in New York, concluded that although nurses did not order laboratory testing themselves, they might have some effect on the frequency of lab tests being done.

Another recent survey published in Hospital Medicine asked internal medicine and general surgery residents at the Hospital of the University of Pennsylvania why they ordered unnecessary tests as defined by the authors.

Of the 116 respondents, 105 (90.5%) said they ordered daily labs out of habit because that’s the way they were trained. Other frequent responses were that tests were ordered because residents weren’t aware of the costs (86.2%), discomfort with diagnostic uncertainty (82.8%), and as was the case in the previous paper, concern that the attending would ask for the lab results (75.9%).

Solutions offered by the residents surveyed included making the residents aware of the  costs, improving faculty role modeling [in other words, educating the attending physicians], computerized reminders/decision support, and educating the staff.

An October 2017 review of the literature on this subject offered a lengthy algorithm for eliminating unnecessary and repetitive testing—including education, auditing orders, giving feedback to staff, and allowing the electronic medical record to prohibit or limit repeat orders.

Those ideas all seem reasonable, but here’s how we dealt with this issue when I was an intern in 1971.

Our ward service consisted of several rooms with 9 or 10 patients in each room. We did not have a phlebotomy team. One of our many duties was drawing morning bloodwork.

Although we became adept at drawing blood, we had to do the work ourselves at 5:30 a.m. We thought long and hard about every test we ordered.

We asked ourselves, “Do we really need another CBC?” Often the answer was “No.”

 

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last 8 years, he has been blogging at SkepticalScalpel.blogspot.comand tweeting as @SkepticScalpel. His blog has had more than 3,000,000 page views, and he has over 18,000 followers on Twitter.