Evidence-Based Guidelines to Reduce Excessive Laboratory Testing

As healthcare expenditures continue to increase, there is a growing substantial interest in promoting high-value care initiatives.

With the excessive amount of daily laboratory testing of hospitalized patients being a prevalent clinical issue, JAMA Internal Medicine published an evidence-based implementation blueprint to guide the appropriate amount of routine laboratory testing.

“Although laboratory expenditure often represents less than 5% of most hospital budgets, the impact is far-reaching given that laboratory tests influence nearly 60% to 70% of all medical decisions,” wrote the authors.

In addition to the cost, phlebotomy overuse causes patient discomfort and can lead to hospital-acquired anemia, which results in additional testing, prolonged hospitalizations, unnecessary transfusions, and increased mortality for patients with cardiopulmonary diseases.

In a previous study of 17,676 patients, researchers found that approximately 20% of hospitalized patients developed “moderate to severe hospital-acquired anemia.” A single-center observational study discovered a direct correlation between the volume of phlebotomy and the decrease in hemoglobin levels. However, implementing guidelines on how to prevent this is challenging because there are many contributing factors to laboratory test overuse, such as insufficient knowledge of laboratory costs, fear of litigation, and differing levels of healthcare professionals’ training.

Hospitals that have attempted a reduction of routine daily laboratory tests have focused on 3 strategies: education, audit and feedback on provider ordering practices, and electronic health record (EHR)-enabled restrictive ordering. The most successful interventions were the ones that implemented a combination of these strategies.

Analyzing past intervention strategies, the authors of this study created an algorithm as a guide to reducing the excessive use of routine daily laboratory testing. However, the algorithm must be paired with the willingness to change within an institution for it to be effective, the authors wrote. Utilizing the 3 commonly used strategies, the authors came up with the following:

1. Designing and implementing hospital-wide educational initiatives. This includes targeting a multidisciplinary audience across all departments and services, including healthcare professionals at all levels, having professional leaders in each department lead or be involved in educational events, and encouraging daily discussion on rounds to specify the clinical rationale for laboratory testing.
2. Audit and provide feedback to ordering clinicians. This includes providing ordering clinicians with real-time data on their personal ordering patterns with an institutional benchmark, providing anonymized and specialty-specific comparison data at routine interval, and encouraging high utilizers to develop a personalized, educative approach to reduce unnecessary ordering practices.
3. Leveraging the EHR to adopt a restrictive ordering strategy. This includes restricting the ability to order repetitive daily laboratory tests, creating alerts that display prior normal or stable results for the test being ordered, and encouraging clinicians to engage in reflective ordering patterns based on clinical indication review, which will increase targeted testing rather than decrease laboratory testing overall.

“This intervention can catalyze a commitment to improve high-value practices across the whole enterprise, which ultimately will result in improved safety, satisfaction, and cost-effectiveness for all stakeholders,” concluded the authors.