Laboratory Test requesting Appropriateness and Patient Safety

María Salinas, Maite Lopez-Garrígos, Enrique Rodriguez-Borja, Álvaro Blasco, Arturo Carratalá

• Publisher: De Gruyter
• Year: 2016
• eBook ISBN: 9783110391480
• Edition: 1
• Topic: Medicine
• Subtopic: Biochemistry in Medicine

The global medical process is a chain of different medical multidisciplinary procedures. The success in global Patient Safety will depend on the Safety of the consecutive medical processes that intervene in this complex system. Laboratory data is an essential part of health care, indeed it is used in 70% of clinical decisions. Inappropriate laboratory test over requesting is extremely frequent. The prevalence of under requesting has been less studied. The consequences of under requesting are clear, we are missing a diagnosis. Inappropriate over requesting can result not only in a problem of cost but also in a problem regarding patient safety. Additionally, another important consequence of inappropriate tests over requesting is that such amount of unnecessary tests has probably contributed to a significant increase in the volume of those over the last years. In all, there is general consensus that the inadequacy of test requesting must be corrected through strategies and monitored over time through indicators to assure the optimal laboratory contribution to clinical decision-making and patient safety.

María Salinas

1Introduction: clinical laboratory contribution to patient safety

The global medical process is a chain of different medical multidisciplinary procedures. Success of global patient safety will depend on the safety of consecutive medical processes that intervene in this complex system.

Laboratory data are an essential part of healthcare. Indeed, it is used in 70% of clinical decisions [1]. However, as a global medical process, clinical laboratory is also a multiphase procedure, called “brain-to-brain loop” or “total testing process” (TTP) [2]. It begins when the ordering physician figures out the appropriate tests to be requested, according to relevant medical history and physical examination, and ends when he thinks, again, how to interpret the test results.

The first step is crucial. Inappropriate laboratory test requesting is extremely frequent. Although over-requesting is widely studied, the prevalence of under-requesting has been less considered. What they have in common is that both can produce devastating damage to the patient. Proper laboratory utilization contributes to patient safety. The consequences of under-requesting are clear – we are missing a diagnosis. Nevertheless, inappropriate over-requesting does not only result in excessive laboratory expenditures. It also has other adverse effects. The consequences of false-positive results due to over-requesting will not only generate additional costs from the unnecessary diagnostic procedures, patient referees, and treatments, but also patient anxiety. In addition, inappropriate over-requesting may have contributed to the considerable increase in volume of laboratory tests over the last years. This overload causes the laboratory to be commoditized, making it very difficult to pay necessary attention to appropriately requested tests and deliver meaningful clinical laboratory information instead of simply laboratory data [3]. In fact, there is a real danger for the laboratory to become a data-dispensing machine instead of a modern organization issuing personalized, individualized information. Finally, unnecessary laboratory test results can hide or mask clinically important laboratory information – test results that are necessary to clinical decision making [4].

In all, there is general consensus that the inadequacy of test requesting must be corrected through strategies and monitored over time through indicators to assure the optimal laboratory contribution to clinical decision making and patient safety.

The action of getting an appropriate test request refers to applying everything that is right and appropriate, taking into account its own peculiar characteristics.

Each laboratory test is a diagnostic tool by itself. It has some unique features. Furthermore, its behavior changes in every setting, according to the different contexts. In fact, it has different uses and characteristics, when used as a diagnostic, monitoring, or prevention tool, and even in each disease, with its inherent individualities such as sensitivity and specificity. Moreover, a test may show very different results, depending on the cutoff point decided as suitable for dichotomizing the population into healthy or sick, or even depending on disease prevalence. Hence, the intervention of laboratory professionals, with their expertise in laboratory tests and their participation, in this critical step of the TTP is crucial.

Smellie defined “inappropriate test” as a test that “could reasonably be avoided at no significant detriment to a patient’s care” [5: p. 586] and adaptation, modulation, or demand management when using a health resource to maximize their utility [6].

When talking of appropriating laboratory test demand, it is important to differentiate the term “restricting demand”, which is associated with strategies that lead to a lower test demand and that consequently has an important economic connotation, from the term “modulation or management”, which is used to ensure that proper request is done.

Traditionally, the term “inappropriate request” refers to test over-requesting [7]. However, currently, it is also considered as inadequate requesting due to under-requesting [8, 9]. In this context, getting a proper demand does not only refer to a decrease in unnecessary over-demand, but also to an increase in requests for appropriate tests. The correction of test over-request will decrease laboratory expenditures. However, when establishing strategies to solve test under-request, we are also increasing laboratory expenditures, but it is when greater savings can be achieved, which should always to be checked through a continuous monitoring of the strategy through process indicators, but especially through patient outcome results.

Consequently, an appropriate test request is not always synonymous with savings in the laboratory. In this context, the use of outcome indicators that are mainly related to improvement of patient diagnosis or quality of life or merely cost savings to assess the benefit to the patient or the overall healthcare system is crucial.

References

[1]Forsman R.W. (1996) Why is the laboratory an afterthought for managed care organizations? Clin. Chem. 42:813–6.

[2]Lundberg G.D. (1981) Acting on significant laboratory results. JAMA. 245:1762–3.

[3]Salinas M., López-Garrigós M., Uris J. (2011) Towards laboratory knowledge, not data, in 70% of clinical decision-making. What “knowledge management” can add to clinical practice? Clin. Chem. Lab. Med. 49:1389–90.

[4]Plebani M. (2013) Harmonization in laboratory medicine: the complete picture. Clin. Chem. Lab. Med. 51:741–51.

[5]Smellie W.S. (2003) Appropriateness of test use in pathology: a new era or reinventing the wheel? Ann. Clin. Biochem. 40:585–92.

[6]Janssens P.M., Wasser G. (2013) Managing laboratory test ordering through test frequency filtering. Clin. Chem. Lab. Med. 51:1207–15.

[7]Hauser R.G., Shirts B.H. (2014) Do we now know what inappropriate laboratory utilization is? An expanded systematic review of laboratory clinical audits. Am. J. Clin. Pathol. 141:774–83.

[8]Alonso-Cerezo M.C., Martin J.S., Garcia Montes M.A., de la Iglesia V.M. (2009) Appropriate utilization of clinical laboratory tests. Clin. Chem. Lab. Med. 47:1461–5.

[9]Zhi M., Ding E.L., Theisen-Toupal J., Whelan J., Arnaout R. (2013) The landscape of inappropriate laboratory testing: a 15-year meta-analysis. PloS. One 8:e78962.

Maite López-Garrigós

2Inappropriateness in laboratory test requesting in the literature

The objective of this chapter is not to produce an exhaustive review of the literature because excellent reviews [narrative [1–7] and systematic [8–10]] already exist on the matter. The main objective is to show the increasing interest in the literature for the appropriate use of laboratory tests. Proof of this interest is the growing number of results that are obtained when a search is carried out through PubMed using the keywords “appropriateness” and “clinical laboratory” (Fig. 2.1).

Reduction in healthcare budgets has led to pressure to reduce healthcare costs. Laboratories are one of the main targets for cost containment [11]. The number of diagnostic tests ordered is growing, and many of these tests seem to be unnecessary according to established, evidence-based guidelines. The number of unnecessary tests in the clinical laboratory ranges from 5% to 95% of the total number of laboratory tests [8]. On more than one occasion, the terms “inappropriateness” and “overutilization” are used synonymously; however, the available evidence suggests that underutilization is more frequent than overutilization (44.8% versus 20.6%, respectively). This result was obtained despite there being only one-fifth the number of studies on underutilization as on overutilization in this review [9]. The same fact is also observed in another previous review [8]. This imbalance in representation could be due to great importance being given to the overutilization of laboratory tests historically.

Fig. 2.1: Number of results per year in PubMed using “appropriateness” and “clinical laboratory” as a keywords. Source: Medline; August 2014

The volume of laboratory testing would not be a concern if increased growth were coupled with effective laboratory utilization and improved patient outcomes. Observations indicate that increased testing does not correlate positively with improved care, which is the real problem. Appropriateness is a complex concept, and managing it requires an understanding of which different factors are relevant.

2.1Laboratory process-test request

The total testing process (TTP) is based on the “brain-to-brain loop” concept described by Lundberg [12, 13] (Fig. 2.2).

As shown in Fig. 2.2, this process begins with the clinical question in the mind of the doctor and ends with the interpretation of the result and the decision making by the same doctor. Connecting these two actions, we found six steps: collection...

Table of contents

• Cover
• Title Page
• Copyright
• Preface
• Table of contents
• 1 Introduction: clinical laboratory contribution to patient safety
• 2 Inappropriateness in laboratory test requesting in the literature
• 3 Causes and negative effects of inappropriateness in laboratory test requesting
• 4 Strategies to correct inappropriateness in laboratory test requesting
• 5 Practical pathway to design, establish, and monitor over time test requesting appropriateness strategies: indicators to detect the inappropriateness and to monitor after interventions
• 6 Potential of computer physician order entry (CPOE) to improve patient safety related to laboratory test requesting