Ordering Laboratory tests and Procedures: The Art, Science, Economics, and Politics Of The Process

For years, I have found it fascinating that if two patients with virtually identical clinical circumstances go to two different physicians who have similar medical training, the patient management plans often differ considerably.  For example, let’s say that both patients are 14 year old females with histories of fatigue and weight gain over the previous 6 months.  Let’s also say that both physicians obtain excellent medical histories and perform equally excellent physical examinations and find no specific clues to the reason for the patients’ signs and symptoms.  Both physicians then consider the likely possibilities and formulate plans.  At this point, the physicians take somewhat different approaches.  The first physician, Dr. Jones  decides to order a few basic laboratory tests such as a blood count, urinalysis, and, perhaps, a thyroid profile (maybe a free T4 and TSH), planning to see the patient back for follow-up in 3-4 weeks.  The second physician, Dr. Smith,  also decides to order some laboratory tests; perhaps the same tests that the first physician ordered but in addition,  a fasting lipid profile, a pregnancy test, a metabolic panel (various tests of blood chemistries, liver function, etc), HbA1c (a test for diabetes mellitus), Serum insulin (to evaluated the patient for insulin resistance and, perhaps the metabolic syndrome, a 24-h urine for free cortisol (to rule out Cushing’s disease), an EKG and chest X-ray (to look for heart disease), and a nutrition consult.  The physician also plans to see the patient back in 3-4 weeks.  So, how is it that Dr. Jones orders a few basic studies,  while Dr. Smith orders many more tests (as well as a consultation).  Certainly, the costs for the visits differ significantly, by about $500-$1000.  Which physician is right?  Are they both right?

Do Physicians Order Unnecessary Laboratory Tests and Procedures?

There are endless data, especially in the past few years, to show that as a group, physicians order far too many laboratory tests and procedures.  The recent interest in this phenomenon is to a great extent related to efforts to bring some measure of control to U.S. health care costs.  For example, a recent report in the New York Times  addressed the question of laboratory tests and procedures, focusing on a report by 9 major medical specialty groups in which 45 tests and procedures that have no proven benefit to patients were  listed.   The newspaper article was entitled “Endless screenings don’t bring everlasting health,” and was written by Lisa Schwartz and Steven Woloshin.  There has also been a measure of pressure brought to the question of whether physicians who own a stake in a laboratory, order more tests (performed in the physician-owned laboratory) than those who have no financial interest in ordering the test other than, perhaps, a charge for interpreting the test result (see “Doctor’s stake in a lab affects biopsy rate, ” written by Mitchell, JM., in Health Affairs, April 2012).  To me, the most interesting data are those from a study carried out a few years ago in which the investigators studied whether physicians ordered fewer tests when the prices of the test were listed on the order form.  As it turned out, when the prices were listed, doctors actually ordered about 20% fewer tests.  Clearly they didn’t “need” those tests, but just wanted them.  That’s the good news.  The bad news is that after a year, when the prices were taken off the ordering form, the docs, reverted to their original ordering behavior.  Recent studies have found very similar results.  For example,  hospitalists at the Johns Hopkins Hospital in Baltimore studied how often common but expensive laboratory tests were ordered with or without the cost of the test listed (“Knowing costs affects lab test ordering“).  They found that over a 6-month period November 2009-May 2010, there was an average decrease of about $16,000 billing per test when costs were displayed on the order form compared with a 6-month period 1 year earlier.  This was just for one hospital.  The investigators, led by Dr. Leonard Feldman, concluded that much of the reason for the excessive test ordering was simply a lack of awareness of how much tests cost.  The investigators acknowledged that they did not have any data to show that patients’ outcomes were not affected adversely by stingy testing.   So, the excessive ordering is not always related to to either personal financial benefit or other factors such as medico-legal concerns.  What is it due to?  Beats me, but I think it is to a great extent a “reflex” action and one of convenience- if I order everything I might need right now, I will know what’s what sooner. That’s just my theory.  It might be mostly a question of personality- those docs who require immediate gratification vs. those who can tolerate waiting for answers?  We can gain some insights from a recent study entitled, “Why do physicians order unnecessary preoperative tests? A qualitative study,” written by SR Brown and J Brown (Family Medicine 2011;43:338-43).  the investigators interviewed 23 physicians and nurse administrators and found that the main reasons for ordering unnecessary tests were as follows: practice tradition, belief that physicians wanted the tests performed, concern about medicolegal issues, concern about possible surgical delays, and lack of awareness of evidence and guidelines.

How Should Physicians Order Laboratory Test and Procedures?

I do not believe most medical students and resident physicians are taught the “art” of ordering laboratory studies and procedures.  That gap in training is to some extent, related to the fact that many of the patients seen by students and resident physicians have either acute illnesses where time is of the essence or are patients for which reliable follow-up is quite uncertain.  So, it’s sort of “catch while catch can.”  In the real world, physicians are generally not in such a rush and they would do well to stage their testing unless the situation is urgent.  Why order every test you might need at the first encounter when starting with a few simple basic tests would suffice?  Sometimes, I hear that the blitz is performed because it causes less inconvenience for the patient- they won’t need to come back for a test that is needed based on the initial basic testing.  In my opinion, that argument is nonsense.  It certainly makes no economic sense.  If one is worried about the possible need for another venipuncture, extra blood can be drawn initially and stored, to be assayed as needed.  Laboratories do it all they time.  That’s what freezers are for.

Another side of the question of what to order, is the importance of explaining to the patient exactly what tests were ordered and why.  Many physicians just do not take the time to explain this to their patients.  Maybe, sometime the docs just don’t know exactly why they ordered what they ordered?

Finally, there is the question of letting the patient know what the tests showed and what it all means.  I am astonished how many physicians have no organized way to communicate test results with their patients.  It is really shameful.  Have any of them ever heard of e-mail or even the U.S. postal service?  In my view, if a physician takes the time and trouble (for the physician and patient) to order a laboratory test or procedure, the least the doc can do is get back to the patient with the test result and interpretation/plan in timely fashion.  Some physicians are super at this task and some are horrible.

The Future

It will be interesting to see how much pressure is put on physicians various “expert panels,” insurers, and governmental agencies (e.g., Medicare, Medicaid) to cut back on ordering tests?  It is already happening, particularly for various screening studies.  I do worry that some of our patients will suffer because of ill-advised recommendations based on epidemiological data (the kind that look at how many people we need to screen for this or that disease to save 1 life or to detect 1 cancer.  Good medical care is not always about maximum cost effectiveness.  But, there is no question that we as physicians could do better in the way we order laboratory tests and how we use the results to guide our therapies.

 

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