Influence of educational, audit and feedback, system based, and incentive and penalty interventions to reduce laboratory test utilization: a systematic review

Abstract

Laboratory and radiographic tests are often ordered unnecessarily. This excess testing has financial costs and is a burden on patients. We performed a systematic review to determine the effectiveness interventions to reduce test utilization by physicians. The MEDLINE and EMBASE databases were searched for the years 1946 through to September 2013 for English articles that had themes of test utilization and cost containment or optimization. Bibliographies of included papers were scanned to identify other potentially relevant studies. Our search resulted in 3236 articles of which 109 met the inclusion criteria of having an intervention aimed at reducing test utilization with results that could be expressed as a percent reduction in test use relative to the comparator. Each intervention was categorized into one or more non-exclusive category of education, audit and feedback, system based, or incentive or penalty. A rating of study quality was also performed. The percent reductions in test use ranged from a 99.7% reduction to a 27.7% increase in test use. Each category of intervention was effective in reducing test utilization. Heterogeneity between interventions, poor study quality, and limited time horizons makes generalizations difficult and calls into question the validity of results. Very few studies measure any patient safety or quality of care outcomes affected by reduced test use. There are numerous studies that use low investment strategies to reduce test utilization with one time changes in the ordering system. These low investment strategies are the most promising for achievable and durable reductions in inappropriate test use.

Costs and stewardship of laboratory tests in the Capital Health District

“…Previous research has shown cost savings among clinicians exposed to diagnostic pricing data compared to control groups, [11][12][13][14] and in all clinical cases studied with data available, this did not affect patient outcomes or satisfaction. 13 However, the availability of outcome data remains quite limited overall.…”

“…Unfortunately, there is very limited research in this regard. 11 Nonetheless, in the opinion of the author, the potential short-term benefits of these data still make this research worthwhile.…”

“…13 However, the availability of outcome data remains quite limited overall. 11 Interestingly, in three of six clinical and simulated studies involving pricing education, the observed cost savings did not necessarily arise from reduced testing overall, but rather from substitutions. 13 Physicians have also shown enthusiasm for learning more about the costs of their orders.…”

Overriding Concerns: The Role of Electronic Medical Record–Based Best Practice Alerts in Reducing Unnecessary Laboratory Testing

“…Multiple investigators have studied strategies to reduce unnecessary testing that include provider education, audit and feedback, incentives or penalties, and system-based interventions such as electronic order entry and clinical decision support systems (2 ). These interventions have met with varying success, with reported changes in use ranging from a 98% reduction to a 28% increase in testing (2 ).…”

“…These interventions have met with varying success, with reported changes in use ranging from a 98% reduction to a 28% increase in testing (2 ). Techniques that use multimodality strategies to reduce laboratory overutilization seem to be most effective (3 ).…”