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Choosing Lab Tests Wisely

Many different medical specialties are beginning to speak openly about the problem of overutilization of medical resources including laboratory tests. As I have previously discussed in blogs posted on November 17, 2013 and March 23, 2014, the American Board of Internal Medicine Foundation has started the Choosing Wisely Campaign in which each medical society has been asked to publish a list of at least 5 practices that physicians and patients should question. A total of 47 medical specialties have participated.

Recently, I reviewed all of the Choosing Wisely entries to determine which laboratory tests and transfusion practices were deemed as providing low value. Below is a complete summary of my findings organized by medical specialty.

American Academy of Allergy, Asthma & Immunology (AAAAI)

• Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.
• Don’t routinely do diagnostic testing in patients with chronic urticaria
• Don’t perform food IgE testing without a history consistent with potential IgE-mediated food allergy.

American Association of Blood Banks (AABB)

• Don’t perform serial blood counts on clinically stable patients.
• Don’t transfuse more units of blood than absolutely necessary
• Don’t routinely use blood products to reverse warfarin
• Don’t transfuse O negative blood except to O negative patients and in emergencies for women of child bearing potential with unknown blood group.

American Association of Clinical Endocrinologists (AACE)

• Don’t routinely measure 1,25-dihydroxyvitamin D unless the patient has hypercalcemia or decreased kidney function.
• Don’t order a total or free T3 level when assessing levothyroxine (T4) dose in hypothyroid patients.

American Academy of Dermatology (AAD

• Don’t perform sentinel lymph node biopsy or other diagnostic tests for the evaluation of early, thin melanoma because they do not improve survival.
• Don’t use skin prick tests or blood tests such as the radioallergosorbent test (RAST) for the routine evaluation of eczema.

American Academy of Family Physicians (AAFP

• Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.
• Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.
• Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
• Don’t screen women younger than 30 years of age for cervical cancer with HPV testing, alone or in combination with cytology
• Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam.

American Academy of Ophthalmology

• Don’t perform preoperative medical tests for eye surgery unless there are specific medical indications.

American Academy of Pediatrics (AAP)

• Don’t perform screening panels for food allergies without previous consideration of medical history.
• Avoid the use of surveillance cultures for the screening and treatment of asymptomatic bacteruria.

American Association for the Study of Liver Diseases (AASLD)

• Don’t repeat hepatitis C viral load testing outside of antiviral therapy.
• Don’t routinely transfuse fresh frozen plasma and platelets prior to abdominal paracentesis or endoscopic variceal band ligation.

American College of Medical Genetics and Genomics (ACMG)

• Don’t order a duplicate genetic test for an inherited condition unless there is uncertainty about the validity of the existing test result.
• Don’t order APOE genetic testing as a predictive test for Alzheimer disease.
• Don’t order HFE genetic testing for a patient without iron overload or a family history of HFE-associated hereditary hemochromatosis
• Don’t order MTHFR genetic testing for the risk assessment of hereditary thrombophilia.

American College of Obstetricians and Gynecologists

• Don’t perform routine annual cervical cytology screening (Pap tests) in women 30–65 years of age.
• Don’t screen for ovarian cancer in asymptomatic women at average risk.

American College of Medical Toxicology (ACMT)

• Don’t order heavy metal screening tests to assess non-specific symptoms in the absence of excessive exposure to metals.
• Don’t order tests to evaluate for or diagnose “idiopathic environmental intolerances,” “electromagnetic hypersensitivity” or “mold toxicosis.”
• Don’t perform hair or nail testing for “metal poisoning” screening in patients with nonspecific symptoms.

American College of Physicians (ACP)

• In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.

American College of Preventive Medicine (ACPM)

• Don’t routinely perform PSA-based screening for prostate cancer.
• Don’t perform screening for cervical cancer in low-risk women aged 65 years or older and in women who have had a total hysterectomy for benign disease.

American College of Rheumatology (ACR)

• Don’t test ANA sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.
• Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings
• Don’t order autoantibody panels unless positive antinuclear antibodies (ANA) and evidence of rheumatic disease.

ACR Pediatric Rheumatology

• Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings.
• Don’t perform methotrexate toxicity labs more often than every 12 weeks on stable doses.
• Don’t repeat a confirmed positive ANA in patients with established JIA or systemic lupus erythematosus (SLE).

American College of Surgeons (ACS)

• Don’t perform axillary lymph node dissection for clinical stages I and II breast cancer with clinically negative lymph nodes without attempting sentinel node biopsy
• Avoid colorectal cancer screening tests on asymptomatic patients with a life expectancy of less than 10 years and no family or personal history of colorectal neoplasia.

American Geriatrics Society (AGS)

• Don’t recommend screening for breast, colorectal, prostate or lung cancer without considering life expectancy and the risks of testing, overdiagnosis and overtreatment.

Society for Post -Acute and Long-Term Care Medicine

• Don’t obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract.
• Don’t recommend screening for breast, colorectal or prostate cancer if life expectancy is estimated to be less than 10 years
• Don’t obtain a C. difficile toxin test to confirm “cure” if symptoms have resolved.

American Society of Anesthesiologists (ASA)

• Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery – specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.
• Don’t administer packed red blood cells (PRBCs) in a young healthy patient without ongoing blood loss and hemoglobin of ? 6 g/dL unless symptomatic or hemodynamically unstable.

American Society of Clinical Oncology (ASCO)

• Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.
• Don’t perform PSA testing for prostate cancer screening in men with no symptoms of the disease when they are expected to live less than 10 years.
• Don’t use a targeted therapy intended for use against a specific genetic aberration unless a patient’s tumor cells have a specific biomarker that predicts an effective response to the targeted therapy.

American Society for Clinical Pathology (ASCP)

• Don’t perform population based screening for 25-OH-Vitamin D deficiency.
• Don’t perform low risk HPV testing
• Avoid routine preoperative testing for low risk surgeries without a clinical indication.
• Don’t use bleeding time test to guide patient care.
• Don’t order an erythrocyte sedimentation rate (ESR) to look for inflammation in patients with undiagnosed conditions. Order a C-reactive protein (CRP) to detect acute phase inflammation.
• Don’t test for myoglobin or CK-MB in the diagnosis of acute myocardial infarction (AMI). Instead, use troponin I or T.
• Don’t order multiple tests in the initial evaluation of a patient with suspected non-neoplastic thyroid disease. Order thyroid-stimulating hormone (TSH), and if abnormal, follow up with additional evaluation or treatment depending in the findings.

American Society of Hematology (ASH)

• Don’t transfuse more than the minimum number of red blood cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable, non-cardiac in-patients).
• Don’t test for thrombophilia in adult patients with venous thromboembolism (VTE) occurring in the setting of major transient risk factors (surgery, trauma or prolonged immobility
• Don’t administer plasma or prothrombin complex concentrates for non-emergent reversal of vitamin K antagonists (i.e. outside of the setting of major bleeding, intracranial hemorrhage or anticipated emergent surgery).
• Don’t routinely transfuse patients with sickle cell disease (SCD) for chronic anemia or uncomplicated pain crisis without an appropriate clinical indication
• Don’t test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability of HIT.

American Society of Nephrology (ASN)

• Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms.

American Urological Association (AUA)

• Offer PSA screening for detecting prostate cancer only after engaging in shared decision making.
• Don’t diagnose microhematuria solely on the results of a urine dipstick (macroscopic urinalysis).

Critical Care Societies Collaborative

• Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions. (ABG, chemistry, blood counts)
• Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 g/dL.

Endocrine Society

• Don’t routinely measure 1,25-dihydroxyvitamin D unless the patient has hypercalcemia or decreased kidney function
• Don’t order a total or free T3 level when assessing levothyroxine (T4) dose in hypothyroid patients.

HIV Medicine Association

• Avoid unnecessary CD4 tests.
• Don’t order complex lymphocyte panels when ordering CD4 counts.
• Don’t routinely order testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency for patients who are not predisposed due to race/ethnicity.
• Don’t routinely test for CMV IgG in HIV-infected patients who have a high likelihood of being infected with CMV.

Infectious Diseases Society of America’s (IDSA)

• Avoid testing for a Clostridium difficile infection in the absence of diarrhea.

Society of General Internal Medicine (SGIM)

• Don’t perform routine general health checks for asymptomatic adults
• Don’t perform routine pre-operative testing before low-risk surgical procedures.
• Don’t recommend cancer screening in adults with life expectancy of less than 10 years.

Society of Gynecologic Oncology (SGO

• Don’t screen low risk women with CA-125 or ultrasound for ovarian cancer
• Don’t perform Pap tests for surveillance of women with a history of endometrial cancer.

Society for Healthcare epidemiology of America

• Don’t perform urinalysis, urine culture, blood culture or C. difficile testing unless patients have signs or symptoms of infection. Tests can be falsely positive leading to overdiagnosis and overtreatment.

Society of Hospital Medicine (SHM)

• Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.
• Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure or stroke

Society for maternal fetal medicine

• Don’t do an inherited thrombophilia evaluation for women with histories of pregnancy loss, intrauterine growth restriction (IUGR), preeclampsia and abruption.
• Don’t offer noninvasive prenatal testing (NIPT) to low-risk patients or make irreversible decisions based on the results of this screening test
• Don’t perform antenatal testing on women with the diagnosis of gestational diabetes who are well controlled by diet alone and without other indications for testing
• Don’t order serum aneuploidy screening after cfDNA aneuploidy screening has already been performed.
• Don’t perform maternal serologic studies for cytomegalovirus and toxoplasma as part of routine prenatal laboratory studies.

Society for Vascular Medicine (SVM)

• Don’t do work up for clotting disorder (order hypercoagulable testing) for patients who develop first episode of deep vein thrombosis (DVT) in the setting of a known cause.

If these guidelines were widely adopted by physicians, health care could realize a significant reduction in unnecessary laboratory testing and inappropriate transfusions.