White paper on inappropriate laboratory testing

Tom Benzoni benzonit at GMAIL.COM
Thu Feb 21 18:25:29 UTC 2019


I know we're supposed to ridicule House of God; that opinion comes from
those not in the field.

"If you don't take a temperature, you can't find a fever."
Don't order labs if you have no place/diagnosis wherein to put the results.

I'd love to have an "indications" box on the lab tests I order; it should
be required for radiographs, too, instead of the autocomplete box we get.
I was taught to call the radiologist and ask what sort of study to order
for this clinical question.
For reimbursement, I'd also like "This is ordered at patient request; bill
the patient directly."

Start with an instructional screen: Enter your presumed diagnosis.
Mouse-over a test; display sensitivity-specificity of this test for this
diagnosis. Order if you want. Study the outcomes. This could be
forward-tabulated as a study.

Tom



On Thursday, February 21, 2019, Mark Gusack <gusackm at comcast.net> wrote:

> Or worse:
>
>
>
> Gusack’s law of clinical lab tests part I: “If a test is not indicated,
> the ordering clinician will interpret it incorrectly!”
>
> Gusack’s law of clinical lab tests part II: “If a test is not indicated
> and the patient is harmed, the ordering clinician will blame the lab!”
>
>
>
> Hi Rana.  I retired from the VA in mid 2017 and now do consulting work.
> Sorry we couldn’t get things going on a laboratory compendium.  That would
> have gone a long way in establishing standards in the VA for test ordering.
>
>
>
> Mark
>
>
>
> Mark Gusack, M.D.
>
> President
>
> MANX Enterprises, Ltd.
>
> 304 521-1980
>
> www.manxenterprises.com
>
>
>
> *From:* Samuel, Rana <0000001850eada0c-dmarc-
> request at LIST.IMPROVEDIAGNOSIS.ORG>
> *Sent:* Thursday, February 21, 2019 9:02 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] White paper on inappropriate laboratory testing
>
>
>
> There is definitely a selection bias in my experience (since I only get
> calls from physicians asking “What do I do now?” when they have an
> unexpected abnormal test result, and my answer usually is a polite version
> of– “Why did you order the test if you don’t know what to do with the
> result?”) so my tongue-in-cheek response to Jason’s comment is:
>
>
>
> Murphy’s law of the universe: “If something can go wrong, it will!”
>
> Samuel’s law of clinical lab tests:  “If a test was not indicated, the
> result will be abnormal!”
>
>
>
> Ai! Yi! Yi! Yi!
>
>
>
> Rana
>
>
>
> *Rana Samuel, MD, FCAP*
>
> *Chief, Pathology and Laboratory Medicine Service (PALMS, 113)*
>
> *Medical Review Officer, Federal Drug Free Workplace Program (DFWP)*
>
> VA western New York Healthcare System (VAWNYHS)
>
> 3495 Bailey Avenue, Buffalo, NY 14215
> <https://maps.google.com/?q=3495+Bailey+Avenue,+Buffalo,+NY+14215&entry=gmail&source=g>
>
>
>
> *Lead pathologist* – VISN 2
>
> *Regional Commissioner*, Region 2, National Enforcement Office
>
>
>
> Ph:    716-862-8701
>
> Fax:  716-862-7824
>
> Rana.samuel at va.gov
>
>
>
>
>
> *From:* Jason Maude [mailto:jason.maude at ISABELHEALTHCARE.COM
> <jason.maude at ISABELHEALTHCARE.COM>]
> *Sent:* Thursday, February 21, 2019 7:58 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* [EXTERNAL] Re: [IMPROVEDX] White paper on inappropriate
> laboratory testing
>
>
>
> This is a great study. I was amazed that the rate of abnormal test results
> for the Calgary physicians was just 9% and even lower than my long held
> wild guesstimate!
>
>
>
> If clinicians had to record what they suspected *before* ordering a test
> wouldn’t that both stimulate thinking at a good moment and significantly
> improve appropriateness of ordering?
>
>
>
> Dare I suggest, but could the level of abnormal test results also be
> another good proxy measure for diagnosis (along with presence of a DDx)?
>
>
>
> Regards
>
> Jason
>
>
>
> Jason Maude
>
> Founder and CEO Isabel Healthcare
> Tel: +44 1428 644886
> Tel: +1 703 879 1890
> www.isabelhealthcare.com
>
>
>
>
>
> *From: *Mark Gusack <gusackm at COMCAST.NET>
> *Reply-To: *Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.
> IMPROVEDIAGNOSIS.ORG>, "gusackm at COMCAST.NET" <gusackm at COMCAST.NET>
> *Date: *Monday, 18 February 2019 at 22:56
> *To: *"IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.
> IMPROVEDIAGNOSIS.ORG>
> *Subject: *Re: [IMPROVEDX] White paper on inappropriate laboratory testing
>
>
>
> Good Evening Mark:
>
>
>
> The C.D. Howe Institute report on laboratory testing is, in my opinion,
> one of the best I’ve seen.  I’ve done a number of similar studies at a
> variety of healthcare institutions over the past 35 years and have always
> found what is very well illustrated on page 14 of the report.  That plot
> shows that a small number of physicians greatly overutilize the laboratory
> along with a moderate number of physicians who moderately over utilize the
> laboratory.  I’ve had the opportunity to reign this sort of behavior in and
> have discovered to my chagrin that the highest utilizers are often the most
> well connected politically or financially to the institution making it very
> difficult to modify their behavior.
>
>
>
> However…on two occasions I was also well connected politically.  In both
> cases the worst offenders were forced to change their behavior.
>
>
>
> In one case, a small rural hospital had lost over 600 thousand dollars in
> the prior year and was nearing bankruptcy.  The medical director was a
> close friend and fully supported my offer to look at the laboratory
> ordering trends for each physician.  The result?  Just one physician – a
> family practitioner – was costing the hospital over 200 thousand dollars in
> unnecessary testing and blood utilization.  This was eliminated but only
> after a very vocal ‘argument’ during a medical executive meeting.  After
> getting I convinced the ED physician to change behavior another 150
> thousand dollars were saved.  That is over half the hospital deficit.  Two
> doctors.  Just two…
>
>
>
> In the other case, as a resident, I was tasked with finding out why over a
> million dollars in laboratory tests were being ordered every year by just
> one ward.  As surgical ward?!  I discovered that a former physician had set
> up a very expensive laboratory testing panel as part of a clinical
> investigation slated for eventual publication.  It required the hiring of
> at least five additional technologists, the installation of additional
> laboratory equipment, and all the rest of the expenses of doing the tests.
> He left the hospital six years earlier less than one year into the study.
> No one had bothered to continue the study nor had anyone had the presence
> of mind to cancel the study testing protocol.
>
>
>
> I reported my findings to my department director and he told me to go back
> to the ward and remove the standing testing orders (this was in the good
> old days before eHR’s).  It turned that out earlier efforts to do this by
> prior pathologists had failed.  None had been willing to stand up to the
> ward personnel.  And I found out why.  There was massive blowback with
> accusations that I was trying to harm the patients.  Soon after, I found
> myself in front of the hospital CEO with two physicians and three nurses
> from the ward all yelling at me simultaneously.  Thankfully, the CEO had
> the presence of mind to realize my position was the correct one.  He
> severely chastise my opponents and ordered them to stop.  Who knows how
> long the hemorrhaging would have gone on if this hadn’t happened.
>
>
>
> I have dozens of other similar experiences where I was not successful in
> reigning in unnecessary and even dangerous laboratory testing due to a
> variety of political, prejudicial, and financial reasons.  If one adds in
> unnecessary radiologic and surgical procedures done each year in the U.S.
> you have an enormous amount of valuable resources being wasted when they
> could be used to pay for the implementation of better diagnostic methods
> and to cover more people with high quality healthcare.
>
>
>
> Mark Gusack, M.D.
>
> President
>
> MANX Enterprises, Ltd.
>
> 304 521-1980
>
> www.manxenterprises.com
>
>
>
> *From:* Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG>
> *Sent:* Monday, February 18, 2019 1:48 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* [IMPROVEDX] White paper on inappropriate laboratory testing
>
>
>
> FYI…..
>
>
>
> Attached is an authoritative report just issued from the Howe Institute on
> inappropriate lab testing in Canada.
>
>
>
> The report estimates the magnitude of inappropriate over- and
> under-utilization, and provides advice on how to improve more appropriate
> test ordering going forward.
>
>
>
>
>
> Mark L Graber MD FACP
>
> Chief Medical Officer; Founder and President Emeritus, SIDM
>
> Professor Emeritus, Stony Brook University, NY
>
> [image: cid:image002.jpg at 01D4C7B3.74ED2900]
>
>
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>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
> ------------------------------
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>
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>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
> ------------------------------
>
>
>
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>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
> ------------------------------
>
>
>
> To unsubscribe from IMPROVEDX: click the following link:
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>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
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> LIST.IMPROVEDIAGNOSIS.ORG
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
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-- 
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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