Erroneous laboratory results

Elias Peter pheski69 at GMAIL.COM
Sat May 28 11:38:39 UTC 2016


My primary concern was not the cost statistic, as that is relatively easy to obtain and verify. My concern was (and remains) the claim that 70% of clinical decision making is dependent on laboratory testing.

The study you provided is interesting but I don’t think it answers this question. It is limited to oncologists and cardiologists, so it is not a representative sample and cannot be generalized to medical care as a whole. And it is an interview, asking clinicians, in effect, how often did the lab testing they arranged have an impact on decision making. One would expect this to generate a high number, as it would be unlikely that a large percentage of narrow-scope specialists who practice in relatively laboratory intensive fields would respond to an interview question by saying that most of the lab they do has no impact on care.

Peter Elias


> On 2016.05.28, at 3:30 AM, Mario Plebani <mario.plebani at unipd.it> wrote:
> 
> Dear Elias
>  
> while I agree with most of your sentences, I have to disagree with the story of the 70% claim. There is a recently published paper (attached) confirming that in oncology and cardiology (in the US and Germany) about 65% of clinical decisions are based on laboratory tests and that the costs compared with the total spending for healthcare is about 2.4% in the US and lower (1.6%) in Germany.
> There is an overestimation of laboratory costs and an underappreciation of the value of the laboratory information if tests are appropriately requested and interpreted. This is a matter of quality and patient safety, for sure. And this is particularly true in an era of "omics" and personalised medicine if we really would like to have early diagnoses, identification of risk factors and not a reactive medicine.
> We are working to improve the appropriate utilization of the laboratory information and to reduce diagnostic errors.
> Regards
> Mario Plebani, MD
>  
> Da: Elias Peter [mailto:pheski69 at GMAIL.COM] 
> Inviato: venerdě 27 maggio 2016 23.43
> A: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Oggetto: Re: [IMPROVEDX] Erroneous laboratory results
> 
> Regarding the relative roles of history, exam and extra testing, context matters. A lot.
> 
> For the majority of patients in a primary care office presenting with a new issue, a properly done history and exam coupled with the diagnostic device between our ears and allowed to work for sufficient time will provide the diagnosis in an overwhelming majority of cases. (Based both on 40 years personal experience and a fair amount of literature.) 
> 
> Further testing (lab, radiology, following the natural history by seeing the patient back and repeating the initial process after a suitable wait) are very useful to:
> 
> Confirm a suspected diagnosis, especially important if the diagnosis is going to lead to treatment that could do harm if the diagnosis is wrong.
> Evaluate the extent of the diagnosis (anemia with a hemoglobin of 6 and MCV of 68 is different from anemia with a hemoglobin of 9 and a normal MCV).
> Differentiate among several possible diagnoses that could explain the presentation.
> Investigate why a treatment based on a diagnosis has not had the expected result.
> Reassure the patient or clinician.
> Satisfy an external process (“What do you mean you started the patient on a BP medicine for newly diagnosed hypertension without checking an LDL and calcium?”)
> 
> In primary care, however, additional testing at the initial visit often reflects less admirable triggers:
> 
> No clue what’s going on. Let’s go fishing. (How many red herrings can we catch along with the target fish?)
> Too little time to do a good history and exam.
> Too little training to do a good history and exam.
> Too little experience to trust one’s history and exam.
> The reasonable possibility that there is a time-sensitive and life threatening issue that will only be identified by further testing. (Feared far more often than justified.)
> 
> That’s in primary care and with a known patient presenting with a new problem.  If I am on call for my local hospital and the ED calls me to evaluate/admit a patient I do not know with severe abdominal pain. that is a totally different story. If I am treating a patient with a medicine that affects potassium or renal function or can depress platelet production or Vitamin K metabolism, laboratory studies can be essential and skipping them is like driving with one’s eyes closed. 
> 
> With regard to the claim that 70% of medical decisions are based on laboratory studies which represent 5% of costs, I believe that is an example of a ‘zombie’ statistic that has been refuted but refuses to die. A couple years ago in preparation for a talk, I tried to find the origin. I think it comes from this paper by Forsman in 1996 (http://www.clinchem.org/content/42/5/813.full.pdf <http://www.clinchem.org/content/42/5/813.full.pdf>) where it is stated but not referenced beyond saying that at Mayo they knew that 5% of their costs at Mayo (which are arguably not broadly representative) were lab related and that 70% of ‘critical decisions’ (admissions, discharges, drug therapy) were ‘leveraged by’ lab results.  If someone has newer documentation about this, I would love to hear.
> 
> One of the problems, and this is what I understood Jason Maude to be referencing, is that laboratory testing -= because it is concrete and easy to measure/monitor - is talked and written about, used as a metric, specified in recipes far more often than the cognitive processes which should occur prior to obtaining the laboratory study, in order to be able to use the laboratory study result.
> 
> Just my take. YMMV.
> 
> Peter Elias, MD
> 
> 
> 
>> On 2016.05.27, at 2:14 PM, Knapp, Lucy <LKnapp at PEACEHEALTHLABS.ORG <mailto:LKnapp at PEACEHEALTHLABS.ORG>> wrote:
>> 
>> As a medical technologist with close to 40 years’ experience I am so offended by this poorly educated comment I don’t even know how to respond. I do agree that history and physical are extremely important, but objective data and the ability to correctly use the data – both in ordering tests and interpreting results is just as important. Recent studies (sorry, I can’t quote a source, but I’m sure anyone with laboratory experience will agree) have shown as much as 70% of medical decisions are based on diagnostic testing and at the same time the cost of that testing is 3% of the total medical costs in the US.
>>  
>> Personal experience – History and physical diagnosed a painful uterine “fibroid’ in 2012. I had a hysterectomy using morcellation; no danger of cancer, obviously. Pathology testing of the removed tissue showed Leiomyosarcoma – unstageable because of the morcellation, but undoubtedly spread by morcellation. I’m currently trying to deal with recurrence. Additional pathology testing for estrogen receptors has provided me an additional “gun” in the fight.
>>  
>> Please – don’t dismiss what you don’t understand.
>>  
>> Lucy
>>  
>> Lucy Knapp, MT(ASCP)   |  Technical Specialist, Chemistry  |  Laboratory
>> PeaceHealth <http://www.peacehealth.org/>  |  400 NE Mother Joseph Place  |  Vancouver, WA 98664
>> office 360-514-2732  |  fax 360-514-1646
>> 
>>  
>> From: Jason Maude [mailto:jason.maude at ISABELHEALTHCARE.COM <mailto:jason.maude at ISABELHEALTHCARE.COM>] 
>> Sent: Friday, May 27, 2016 2:55 AM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> Subject: Re: [IMPROVEDX] Erroneous laboratory results
>> This message originated outside of PeaceHealth's email system and contains web links. Use caution when clicking on links. VERIFY THE SENDER before opening attachments, clicking links or providing information.
>> How is it the profession has ended up placing such reliance on an aspect which is shown to contribute so little and cost so much? 
>>  
>> This study backs up the old adage that 80% of the diagnosis is given by the history and physical with relatively little contributed by tests
>> http://archinte.jamanetwork.com/article.aspx?articleid=1106285 <https://mail2.peacehealth.org/enduser/classify_url.html?url=SRKJG9+bKBsCsym7kQNOcDkS6NcPUsik/R0n2BFbRkRPfGwyYd2lLfnMCg+upqON3/dK89OabI4jSAPKTwURVA==>
>>  
>> To paraphrase Churchill, never in an industry has so much been shown to contribute so little for so much expense!
>>  
>> Regards
>> Jason Maude
>>  
>>  
>> From: Tom Benzoni <benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>>
>> Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Tom Benzoni <benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>>
>> Date: Wednesday, 25 May 2016 17:08
>> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
>> Subject: Re: [IMPROVEDX] Erroneous laboratory results
>>  
>> I'm a "thin" lab tester and 90% of what I order I don't need.
>> My junior confreres order easily double my volume.
>> Same outcomes narrowly defined; fully defined, worse outcomes.
>> (I don't order d-dimer on patients without at least moderate likelihood PEs or DVT. My junior guys do so routinely and so do many more CTA and U/S. We have the same rate of final diagnoses. But I (likely) have fewer renal failures (we don't see followup) and fewer bankruptcies.
>> 
>> Take, for example, ABGs. They are rarely needed; the same data is available venously and from already done tests (BMP/MGA/SMA7), pulse ox and EtCO2, yet I see 40% of our ICU tests are ABG.
>> CBC with diff when most folks can't interpret the diff but don't know they can't. CBC without diff when you only need the Hgb.
>> EKG in my shop is an excellent predictor that you do NOT have ACS.
>> All LPs go to IR.
>> 
>> I could go on.
>> 
>> So overtesting is huge.
>>  
>> tom benzoni
>>  
>> On Wed, May 25, 2016 at 10:20 AM, Cameron Powell <cameron at physiciancognition.com <mailto:cameron at physiciancognition.com>> wrote:
>>> Perhaps some of you have already seen this study on under- and over-testing.
>>>  
>>> “First we found that the rate of overuse, meaning [medical laboratory] tests that we performed that shouldn’t have been performed, average around 20%. That means out of every 10 tests ordered about two tests on average should not have been ordered.
>>> 
>>> “Even more surprising was the rate of underuse [of medical laboratory tests]. This is the rate of tests that should have been ordered in a given time but weren’t ordered. That rate was over 40%. So, for every three tests performed, an additional two tests should have been ordered.”   
>>> 
>>> http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0078962 <https://mail2.peacehealth.org/enduser/classify_url.html?url=BxZ18kZyS6/KbPy/1ujgfTFrANiURXwk9lu0BcA37sQiueOJlTGHIQYgv3MPwM/VOughlTjYANbZQFZKLC1gNg1hOHMtXP+U9p3xGL+KxP0=> 
>>> 
>>>  
>>> We’ve taken a run at solving suboptimal testing strategies and it’s going very well. We’ll keep you posted on our progress.
>>>  
>>> Cameron
>>>  
>>>  
>>> 
>>> Teaching Mode is Here! (Android <https://mail2.peacehealth.org/enduser/classify_url.html?url=imGsfm3ZNesqbP1TCmWOGASQo7k4WxSSgHzcyCv3fKrrXbqRp0dPI35H4ZTlUWueZrBN45CXLydjYw7283X2CXPd451/aS/cjQxRlQ1TzAs=> | IOS <https://itunes.apple.com/us/app/xebra-pro/id1051676634>),
>>>  
>>>  
>>> Cameron Powell  |  CEO, Physician Cognition, Inc.
>>>   ———————————————————————
>>>   (:  503 502 5030 <tel:503%20502%205030> 
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>>>> On May 20, 2016, at 12:40 PM, DR WILLIAM CORCORAN <williamcorcoran at SBCGLOBAL.NET <mailto:williamcorcoran at sbcglobal.net>> wrote:
>>>>  
>>>> What do you think of the YouTube video and the comments posted?
>>>>  
>>>> WSJ journalist John Carreyrou shares year-long Theranos investigation & breaks latest, stunning news <https://mail2.peacehealth.org/enduser/classify_url.html?url=PXYTP0DfAoGKNy2qWUaxDadPXd0hfftNChM33MkbHcI=>
>>>>  <https://mail2.peacehealth.org/enduser/classify_url.html?url=PXYTP0DfAoGKNy2qWUaxDadPXd0hfftNChM33MkbHcI=>	
>>>> WSJ journalist John Carreyrou shares year-long Theranos ... <https://mail2.peacehealth.org/enduser/classify_url.html?url=PXYTP0DfAoGKNy2qWUaxDadPXd0hfftNChM33MkbHcI=>
>>>> View on youtu.be <https://mail2.peacehealth.org/enduser/classify_url.html?url=PXYTP0DfAoGKNy2qWUaxDadPXd0hfftNChM33MkbHcI=>	
>>>> Preview by Yahoo
>>>>  
>>>> Take care,
>>>>  
>>>> Bill Corcoran
>>>> 
>>>>  
>>>> William  R. Corcoran, Ph.D., P.E.
>>>> 21 Broadleaf Circle
>>>> Windsor, CT 06095-1634
>>>> 860-285-8779 <tel:860-285-8779>
>>>> William.R.Corcoran at 1959.USNA.com <mailto:William.R.Corcoran at 1959.usna.com>
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>>>> 
>>>>  
>>>> On Friday, May 20, 2016 11:10 AM, Dwight Oxley <dwight.oxley at GMAIL.COM <mailto:dwight.oxley at gmail.com>> wrote:
>>>>>  
>>>>> The link below details how a large number of erroneous results were reported from a commercial medical laboratory. This report is just the latest in the Wall Street Journal’s coverage of the Theranos Co. Lab results account for more than 50% of the information in a medical record, thus the impact of these is enormous.
>>>>>  
>>>>> Dwight Oxley
>>>>>  
>>>>>  
>>>>> http://on.wsj.com/1TpKiL3 <https://mail2.peacehealth.org/enduser/classify_url.html?url=iTdf6NEttgW/V5B52qqWhkdYtwG9sKVjV9kGwBzHuhU=>
>>>>>  
>>>>> 
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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