Overutilization is Being Publically Discussed
Many different medical specialties are beginning to speak openly about the problem of overutilization of medical resources including laboratory tests. The American Board of Internal Medicine Foundation has started the Choosing Wisely Campaign. Each society has been asked to publish a list of 5 thinks that physicians and patients should question.
The American College of Physicians has started its own partnership with Consumer Reports, which is called the High Value, Cost Conscious Care Initiative. Its goal is to help patients understand the benefits, harms and costs of tests and treatments of common disorders. The Archives of Internal Medicine has started including a section called “Less is More” in April 2010.
Recently, I reviewed the lists of laboratory tests that are considered to be low value by the American College of Physicians specialties. They included:
- Measuring brain natriuretic peptide in the initial evaluation of patients with typical findings of heart failure.
- Chemistry panels or UA for screening of asymptomatic, healthy adults
- Annual lipid screening for patients not receiving lipid-lowering drug or diet therapy in the absence of reasons for changing lipid profiles.
- In asymptomatic women with previously treated breast cancer, performing follow-up complete blood counts, blood chemistry studies, tumor marker studies, chest radiography, or imaging studies other than appropriate breast imaging.
- Screening low-risk individuals for hepatitis B virus infection.
- Pap tests on patients <21 years or in women post-hysterectomy for benign disease
- Screening for cervical cancer in low-risk women age 65 years or older and in women who have had a total hysterectomy (uterus and cervix) for benign disease.
- Screening for colorectal cancer in adults older than 75 years or in adults with a life expectancy of less than 10 years.
- Screening for prostate cancer in men older than 75 years or with a life expectancy of less than 10 years.
- Using CA-125 antigen levels to screen women for ovarian cancer in the absence of increased risk.
- Ordering routine preoperative laboratory tests, including complete blood count, liver chemistry tests, and metabolic profiles, in otherwise healthy patients undergoing elective surgery.
- Performing preoperative coagulation studies in patients without risk factors or predisposing conditions for bleeding and with a negative history of abnormal bleeding.
- Performing serologic testing for suspected early Lyme disease.
- Performing serologic testing for Lyme disease in patients with chronic nonspecific symptoms and no clinical evidence of disseminated Lyme disease.
- Performing imaging studies, rather than a high-sensitivity D-dimer measurement, as the initial diagnostic test in patients with low pretest probability of venous thromboembolism.
- Measuring D-dimer rather than performing appropriate diagnostic imaging (extremity ultrasonography, CT angiography, or ventilation–perfusion scintigraphy), in patients with intermediate or high probability of venous thromboembolism.
- Performing an antinuclear antibody test in patients with nonspecific symptoms, such as fatigue and myalgia, or in patients with fibromyalgia.
In the next blog we will begin to explore strategies that pathologists and clinical laboratories can undertake to encourage appropriate testing and reduce unnecessary testing.
