Improving laboratory test ordering practices in military medical centers.

Increasing national health care costs have created additional pressures to reduce expenses related to medical testing and procedures while maintaining high quality of care in the screening, diagnosis, monitoring, and treatment of patients. The recent announcement of extensive governmental spending cuts necessitates the reevaluation of current medical practices and the identification of less expensive alternatives without compromising care. Of interest, laboratory-based diagnostics are reported to influence up to 70% of medical decisions; however, costs associated with these services account for only 2.3% of health care spending in the United States. This disparity may present clinicians with considerable opportunity to use inexpensive clinical laboratory tests to support cost-effective strategies in the provision of health care. In the evaluation of potential laboratory-based alternatives, laboratory professionals and health care providers share the responsibility in determining best ordering practices to optimize appropriate and conservative test use while maintaining superior standard of care. Appropriate patient care has been defined by numerous organizations, to include the Institute of Medicine, RAND Corporation, and the College of American Pathologists. Among these, as defined by the College of American Pathologists, appropriate care is understood as “the extent to which a procedure, treatment, test or service is effective, clearly indicated, not-excessive and adequate in quantity where best suited to a patient’s need.” In the context of laboratory tests, inappropriate use may include misuse such as ordering for purposes other than standard of care, overuse such as habitual ordering practices not directed by clinical guidelines or continued assessment of patient status, and/or underuse such as foregoing testing indicated by high pretest probability for standard of care. Although misuse, overuse, and underuse have varying severities of clinical consequence, publications directed to control and guide appropriate laboratory testing are observed by the authors to focus on overuse and misuse scenarios (e.g., Refs. and 4 among others). Inappropriate or excessive test ordering and use can be confounded by numerous factors, such as knowledge gaps, lack of available or effective consultation services, fear of malpractice or causing patient harm, or specific patient demand. A 2008 report prepared for the Centers for Disease Control and Prevention cited two major reasons for physician knowledge gaps associated with laboratory test utilization: (1) rapid proliferation of available tests and (2) lack of formal education in laboratory testing. These gaps are exacerbated by increasing daily demands with rapidly expanding practice expectations; many providers have little time to stay current with literature, new methods, and current clinical guidelines. Successful programs guiding appropriate laboratory testing have implemented multifaceted approaches that include provider education, information technology solutions, general consultation, and review and approval criteria-based laboratory testing (e.g., Ref.). Traditionally, and perhaps as expected, such programs gravitate to regulating access to the most expensive and/or esoteric diagnostic evaluations, including many molecular and genetic tests. While lack of regulation can lead to misuse, overuse, and significant unnecessary costs, directed changes in available test options and profile contents in conjunction with health care provider education and facility-wide coordination of ordering guidelines can lead to significant decreases in test usage without compromising care. Recently, one facility demonstrated that a simple and direct strategy could be used to mitigate reference testing costs, implementing a policy requiring prior written justification for externally referenced tests. This policy resulted in a 50% reduction in reference testing, proportional cost savings, and minimal perceived impact on patient care. However, information regarding the direct effect of this program on quality of patient care was limited outside of the observation that little negative feedback was received from health care professionals. The establishment of laboratory testing control measures is particularly important in the rapidly growing realm *Department of Pathology, Madigan Army Medical Center, 9040 Fitzsimmons Drive, Tacoma, WA 98431. †Tripler Army Medical Center, 1 Garrett White Road, Honolulu, HI 96859. doi: 10.7205/MILMED-D-13-00168