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

Abstract

In an era of rising healthcare costs and increasing emphasis on value-based healthcare spending, laboratory testing that is unnecessary, redundant, or otherwise wasteful is of increasing concern. Such testing may occur for myriad reasons including diagnostic uncertainty, defensive medicine, patient reassurance, or knowledge gaps regarding best practices. Whereas some studies have found the incidence of inappropriate laboratory testing to be as high as 95% (1 ), the true impact of laboratory overtesting is not known and likely varies between institutions and practice settings. The costs-both direct and indirect-of these unwarranted tests are subsequently passed on to the patient, third-party payer, or hospital depending on the reimbursement model.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 ). Techniques that use multimodality strategies to reduce laboratory overutilization seem to be most effective (3 ). With the widespread adoption of the electronic health record (EHR) 2 in recent years, computerized provider order entry (CPOE) systems have emerged as attractive targets for intervention, with the potential for interrupting unwarranted services before implementation. However, studies have shown mixed outcomes and cost savings with this approach (4 -6 ).Cardiac troponin testing has drawn particular scrutiny for potential overuse because of the high proportion of hospitalized patients in whom this test is performed, as well as the frequent ordering of serial tests. In a recent study by Makam and Nguyen (7 ), cardiac biomarkers were measured in 16.9% of all emergency department visits in the US over a 2-year period, despite the absence of acute coronary syndrome (ACS) symptoms in nearly one-third of those tested. Although cardiac troponins are recognized for their sensitivity and specificity in detecting myocardial injury, they are not specific for ACS (8 ). Thus, the advantage of a high negative predictive value in ruling out myocardial infarction (MI) is offset by a high clinical false-positive rate due to non-ACS troponin increases, a balance that is heavily influenced by the pretest probability of ACS in the tested population (7-9 ). The implications of unnecessary cardiac troponin testing therefore include not only the cost of the assay itself, but also the costs (financial and otherwise) of downstream cardiac testing and patient care to follow up on any falsepositive results (7 ). Already a source of major concern and frustration for practicing cardiologists, the "troponin consult" for non-ACS troponin increases is likely to become even more common with increasing adoption of high-sensitivity troponin assays (9 ).In this context, we read with great interest t...

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