Low value tests are exhausting resources

Lab testing is the single highest volume medical activity. While many of these tests provide diagnostic insights important to patient care, not all tests are needed. Low-value lab tests unnecessarily consume health care resources and lead to false positives, unnecessary follow-ups and potential harm for patients.

An estimated 16-56 percent of lab tests offer no clinical value and decreasing unnecessary laboratory tests in hospitals could save as much as $82 million annually — money that could be redirected to more clinically meaningful care.

Choosing Wisely Canada is inviting hospitals across Canada to join Using Labs Wisely, a concerted effort to curb low-value testing so available lab resources could be put to better use. (Your hospital’s participation can also count towards the quality improvement requirements in CPSO’s Partnership with Hospitals program).

There are many drivers of low-value lab testing, Dr. Janet Simons, a medical biochemist and internist at Vancouver’s Providence Health Care, told a virtual audience at the annual Choosing Wisely Canada national meeting. It can be the result of individual decisions on the frontlines; but more often than not, it is the product of antiquated systems and organizational practices that repeatedly nudge people toward ordering more than what is necessary.

“A significant proportion of the tests ordered are not clinically valuable or add anything to the patient’s diagnosis or management,” said Dr. Simons. “But they are being ordered as part of a larger panel or as part of routine clinical practice, and are not being led by evidence or patient need.”

The laboratory team has minimal influence on the number of tests ordered and collections/tubes required, and staffing shortages have affected the ability of lab teams to respond to materials shortages, said Dr. Simons. Clinical teams, she said, have a large impact, but often little understanding of how their ordering practices affect the lab and the use of laboratory resources.

Uncovering and modifying these habits and processes takes time, the involvement of multiple stakeholders, and a commitment to continuous quality improvement, she said. Having a national lab stewardship community will make a measurable impact on reducing low-value testing across the country, said Dr. Simons.

The first tests to be targeted are what Dr. Simons calls, the “low hanging fruit” of this effort — the tests that research has determined are often ordered in a setting where they have little clinical utility and reducing their use will pose minimal clinical risk. The tests targeted for reduction are: Urea (compared to Cr); Folate (compared to typical CBC findings); CK-MB (compared to cardiac troponins); PTT (compared to PT/INR); and AST (compared to ALT).

Using Labs Wisely was partially inspired by a quality improvement project undertaken by St. Michael’s Hospital in Toronto. The hospital documented high rates of repetitive routine blood testing and confirmed an association with worsening anemia. A goal was set to reduce repetitive routine blood tests across the hospital by 15 percent. The change strategy involved increasing awareness of local repetitive routine blood test rates, educating clinicians around the harms of repetitive routine blood tests, and revising order sets to remove unnecessary tests and open-ended routine blood test orders.

Prior to the intervention, the average volume of blood collected for routine blood tests per patient-day-admitted was 7.27, 9.03 and 12.07 mL/inpatient-day on the General Internal Medicine, Hematology/Oncology, and Cardiovascular/Vascular Surgery services, respectively. Following an education and awareness effort, these rates decreased to 6.10, 8.19 and 11.43 mL/inpatient-day, respectively. After order set changes were introduced, the rates decreased further to 5.30, 6.98 and 10.00mL/inpatient-day, representing total decreases of 27 percent, 23 percent and 17 percent, respectively, from the baseline period. No significant change in balance measures (length of stay and proportion of tests sent stat) was observed.

Dr. Simons implemented a similar change at St Paul’s Hospital in Vancouver, where orders for ‘daily’ lab work would automatically expire after three days and would need to be actively re-ordered to continue. That site saw a reduction of 15 percent in the number of patients getting blood work done each morning on the acute Internal Medicine wards.

Hospitals of various sizes and levels of experience with implementing lab stewardship projects are welcome to join Using Labs Wisely. Choosing Wisely Canada is currently in the process of recruiting hospitals and will launch the program nationally in September.

Participating hospitals will:

1. Implement Change

• Identify local improvement priorities and develop annual quality improvement plans.
• Implement interventions to reduce lab utilization and measure the change.

2. Share Data

• Submit aggregated utilization data on a defined set of tests.
• Receive comparative reports on your hospital’s performance compared to peers in the program.
• Contribute to the creation of a national reporting system for appropriate lab utilization in Canada.

3. Learn with Others

• Participate in interactive learning sessions with hospitals from across Canada.
• Gain access to tools, coaching and mentoring opportunities.
• Network with like-minded clinicians, lab experts, researchers and administrators

Perks to Participating

• Receive national recognition as a member of the Using Labs Wisely consortium.
• Earn valuable credits towards becoming a Choosing Wisely Canada Hospital.
• Make these efforts count twice by applying them towards licensure and accreditation requirements:
  • Royal College of Physicians and Surgeons of Canada
  • For Ontario Hospitals: CPSO’S Partnership for Hospitals