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Quality of Care

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Many costly lab tests performed in the hospital are unnecessary

A substantial proportion of laboratory tests that are ordered in hospitals are unnecessary. Not only is excessive test ordering costly, but it also results in more false-positive results, which may lead to further unnecessary treatment and increased costs. Two recent studies supported by the Agency for Health Care Policy and Research (HS08297) and led by David W. Bates, M.D., M.Sc., of Brigham and Women's Hospital, examined inappropriate hospital testing. The first study uncovered a high proportion of inappropriate digoxin level monitoring tests. The second study found that computerized reminders for physicians entering a test order helped reduce redundant laboratory tests.

Casas, F., Tanasijevic, M.J., Ma'luf, N., and others (1999, February). "Evaluating the appropriateness of digoxin level monitoring." Archives of Internal Medicine 159, pp. 363-368.

Laboratory measurement of serum digoxin levels in patients with atrial fibrillation (a type of irregular heart beat) or heart failure can be useful in high-risk patients receiving digoxin therapy for a variety of reasons, including evaluating patient compliance with the therapeutic regimen and verifying toxicity of the therapy. However, in this study, unjustified once-a-day digoxin monitoring tests among hospital patients was common. Overall, 84 percent of inpatient digoxin level tests had no appropriate indication. Of these, 76 percent were serial tests drawn less than 10 days apart, 9.5 percent were done on patients not receiving digoxin, 8.5 percent were done after initiation of digoxin therapy before a pharmacological steady state had been achieved, 3 percent were done after adjustment of digoxin dosage before steady state had been reached, and 3 percent were done to follow levels in the toxic range that were measured before the level could be expected to decrease to the therapeutic range. Furthermore, 48 percent of the digoxin levels measured in outpatients had no appropriate indication. Of the inappropriate tests, 76 percent were due to early routine monitoring, 13 percent were performed on high-risk patients, 2 percent were performed on patients with worsening congestive heart failure or atrial fibrillation, 2 percent were performed after changing the digoxin regimen but before steady state had been reached, and 8 percent were due to other causes.

Bates, D.W., Kuperman, G.J., Rittenberg, E., and others (1999, February). "A randomized trial of a computer-based intervention to reduce utilization of redundant laboratory tests." American Journal of Medicine 106, pp. 144-150.

This study found a total of 939 apparently redundant hospital laboratory tests among over 77,000 study tests that were ordered over a 4-month period at one hospital. Physicians of study patients (n = 5,700) who ordered tests on the computer terminal received computerized reminders if a test was redundant (that is, had been performed recently or was pending); physicians of control patients (n = 5,886 patients) received no such reminders. Sixty-nine percent of tests were canceled when a reminder was given. Of the 137 overrides (the doctor ordered the test despite the reminder), 41 percent appeared to be justified based on review of patient charts. However, the estimated annual savings in laboratory charges resulting from computer reminders was only $35,000, for several reasons. Most important were that only 44 percent of redundant tests performed had computer orders, only half of the computer orders were screened for redundancy, and almost one-third of the reminders were overridden. Thus, while reminders about orders for apparently redundant laboratory tests were effective when delivered, these other factors limited the overall effect.


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