White paper on inappropriate laboratory testing

Bertrand H. Vipond Bertrand.H.Vipond at KP.ORG
Thu Feb 21 22:25:06 UTC 2019


“a normal patient is one who has not yet had a CT scan”

From: Tom Benzoni <benzonit at GMAIL.COM>
Sent: Thursday, February 21, 2019 10:25 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] White paper on inappropriate laboratory testing


Caution: This email came from outside Kaiser Permanente. Do not open attachments or click on links if you do not recognize the sender.

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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<mailto: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<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.manxenterprises.com&d=DwMFaQ&c=ZMR5nv7DeMA_5yIzV7zEdkSfOjTGya0xwGqp1JcaTq0&r=YXAKagORvM3QHE8HlbKK5LvoafwQgRBw2-gSOaJ2JAc&m=ymhDQjw7nt2nfO-atU7-nm9Wes2SIYnmPL0fAsuY7G8&s=mlrJgmshQMvo2Nu1QTWZKlU1zq6DRnm4_5v7e4jLYsY&e=>

From: Samuel, Rana <0000001850eada0c-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000001850eada0c-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
Sent: Thursday, February 21, 2019 9:02 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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://urldefense.proofpoint.com/v2/url?u=https-3A__maps.google.com_-3Fq-3D3495-2BBailey-2BAvenue-2C-2BBuffalo-2C-2BNY-2B14215-26entry-3Dgmail-26source-3Dg&d=DwMFaQ&c=ZMR5nv7DeMA_5yIzV7zEdkSfOjTGya0xwGqp1JcaTq0&r=YXAKagORvM3QHE8HlbKK5LvoafwQgRBw2-gSOaJ2JAc&m=ymhDQjw7nt2nfO-atU7-nm9Wes2SIYnmPL0fAsuY7G8&s=GVerpxSphrteUhYeXmK1yJueZ8fApnZgyGofDnwi1ig&e=>

Lead pathologist – VISN 2
Regional Commissioner, Region 2, National Enforcement Office

Ph:    716-862-8701
Fax:  716-862-7824
Rana.samuel at va.gov<mailto:Rana.samuel at va.gov>


From: Jason Maude [mailto:jason.maude at ISABELHEALTHCARE.COM]
Sent: Thursday, February 21, 2019 7:58 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.isabelhealthcare.com_&d=DwMFaQ&c=ZMR5nv7DeMA_5yIzV7zEdkSfOjTGya0xwGqp1JcaTq0&r=YXAKagORvM3QHE8HlbKK5LvoafwQgRBw2-gSOaJ2JAc&m=ymhDQjw7nt2nfO-atU7-nm9Wes2SIYnmPL0fAsuY7G8&s=p2xrB5NABl1hX7bXfZLeEhmWnOlT2OIT90MAIZ2syeM&e=>


From: Mark Gusack <gusackm at COMCAST.NET<mailto:gusackm at COMCAST.NET>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, "gusackm at COMCAST.NET<mailto:gusackm at COMCAST.NET>" <gusackm at COMCAST.NET<mailto:gusackm at COMCAST.NET>>
Date: Monday, 18 February 2019 at 22:56
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] 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<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.manxenterprises.com&d=DwMFaQ&c=ZMR5nv7DeMA_5yIzV7zEdkSfOjTGya0xwGqp1JcaTq0&r=YXAKagORvM3QHE8HlbKK5LvoafwQgRBw2-gSOaJ2JAc&m=ymhDQjw7nt2nfO-atU7-nm9Wes2SIYnmPL0fAsuY7G8&s=mlrJgmshQMvo2Nu1QTWZKlU1zq6DRnm4_5v7e4jLYsY&e=>

From: Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG<mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG>>
Sent: Monday, February 18, 2019 1:48 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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
[cid:image002.jpg at 01D4C7B3.74ED2900]

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