Skip to main content
SpringerLink
Log in

Laboratory Utilization

  • Chapter
  • First Online:
Utilization Management in the Clinical Laboratory and Other Ancillary Services

  • 892 Accesses

Abstract

Diagnostic testing is important in medical treatment but can contribute greatly to treatment charges. The five categories for rational testing are: screening, homeostatic, case finding, diagnostic, and monitoring. Unnecessary testing is common and due to multiple complex factors such as inexperience, ignorance, prior training, pressure from colleagues and patients, and fear of litigation. The consequences of abundant testing include the expenses, anxiety, pain, and phlebotomy. Strategies which have been shown to be effective in decreasing excessive lab utilization include education, peer review and audit, and administrative order changes. Multimodal strategies are most effective and should be performed with leadership support. Ultimately, the goal of reducing unnecessary laboratory utilization aligns with the goal of improving quality and value of care and also in training clinicians to engage in thoughtful, conscientious investigation.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 119.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Martin AR, Wolf MA, Thibodeau LA, Dzau V, Braunwald E. A trial of two strategies to modify the test-ordering behavior of medical residents. N Engl J Med. 1980;303(23):1330–6.

    Article  CAS  PubMed  Google Scholar 

  2. Gortmaker SL, Bickford AF, Mathewson HO, Dumbaugh K, Tirrell PC. A successful experiment to reduce unnecessary laboratory use in a community hospital. Med Care. 1988;26(6):631–42.

    Article  CAS  PubMed  Google Scholar 

  3. Eisenberg JM. An educational program to modify laboratory use by house staff. J Med Educ. 1977;52(7):578–81.

    CAS  PubMed  Google Scholar 

  4. Miyakis S, Karamanof G, Liontos M, Mountokalakis TD. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J. 2006;82(974):823–9.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Weinberger SE. Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155(6):386–8.

    Article  PubMed  Google Scholar 

  6. Robinson A. Rationale for cost-effective laboratory medicine. Clin Microbiol Rev. 1994;7(2):185–99.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Tierney WM, Miller ME, McDonald CJ. The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests. N Engl J Med. 1990;322(21):1499–504.

    Article  CAS  PubMed  Google Scholar 

  8. Ezzie ME, Aberegg SK, O’Brien Jr JM. Laboratory testing in the intensive care unit. Crit Care Clin. 2007;23(3):435–65.

    Article  CAS  PubMed  Google Scholar 

  9. Griner PF, Liptzin B. Use of the laboratory in a teaching hospital. Implications for patient care, education, and hospital costs. Ann Intern Med. 1971;75(2):157–63.

    Article  CAS  PubMed  Google Scholar 

  10. Grossman RM. A review of physician cost-containment strategies for laboratory testing. Med Care. 1983;21(8):783–802.

    Article  CAS  PubMed  Google Scholar 

  11. Daniels M, Schroeder SA. Variation among physicians in use of laboratory tests. II. Relation to clinical productivity and outcomes of care. Med Care. 1977;15(6):482–7.

    Article  CAS  PubMed  Google Scholar 

  12. Schroeder SA, Kenders K, Cooper JK, Piemme TE. Use of laboratory tests and pharmaceuticals. Variation among physicians and effect of cost audit on subsequent use. JAMA. 1973;225(8):969–73.

    Article  CAS  PubMed  Google Scholar 

  13. Sood R, Sood A, Ghosh AK. Non-evidence-based variables affecting physicians’ test-ordering tendencies: a systematic review. Neth J Med. 2007;65(5):167–77.

    CAS  PubMed  Google Scholar 

  14. Epstein AM, McNeil BJ. Physician characteristics and organizational factors influencing use of ambulatory tests. Med Decis Making. 1985;5(4):401–15.

    Article  CAS  PubMed  Google Scholar 

  15. Epstein AM, McNeil BJ. Relationship of beliefs and behavior in test ordering. Am J Med. 1986;80(5):865–70.

    Article  CAS  PubMed  Google Scholar 

  16. Williams SV, Eisenberg JM. A controlled trial to decrease the unnecessary use of diagnostic tests. J Gen Intern Med. 1986;1(1):8–13.

    Article  CAS  PubMed  Google Scholar 

  17. Berwick DM, Coltin KL. Feedback reduces test use in a health maintenance organization. JAMA. 1986;255(11):1450–4.

    Article  CAS  PubMed  Google Scholar 

  18. Schroeder SA, Schliftman A, Piemme TE. Variation among physicians in use of laboratory tests: relation to quality of care. Med Care. 1974;12(8):709–13.

    Article  CAS  PubMed  Google Scholar 

  19. Garland A, Shaman Z, Baron J, Connors Jr AF. Physician-attributable differences in intensive care unit costs: a single-center study. Am J Respir Crit Care Med. 2006;174(11):1206–10.

    Article  PubMed  Google Scholar 

  20. Parker VL, Ritchie JE, Drake TM, Hookham J, Balasubramanian SP. A randomised assessment of trainee doctors’ understanding and interpretation of diagnostic test results. World J Surg. 2016;40(1):21–8.

    Article  CAS  PubMed  Google Scholar 

  21. Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care. 2006;22(7):480–4.

    Article  PubMed  Google Scholar 

  22. Tasse JL, Janzen ML, Ahmed NA, Chung RS. Screening laboratory and radiology panels for trauma patients have low utility and are not cost effective. J Trauma. 2008;65(5):1114–6.

    Article  PubMed  Google Scholar 

  23. Tortella BJ, Lavery RF, Rekant M. Utility of routine admission serum chemistry panels in adult trauma patients. Acad Emerg Med. 1995;2(3):190–4.

    Article  CAS  PubMed  Google Scholar 

  24. Fenton SJ, Peterson DN, Connors RC, Hansen KW, Metzger RR, Scaife ER. A standard pediatric trauma laboratory panel: a plea for a minimalist approach. J Trauma. 2009;66(3):703–6.

    Article  PubMed  Google Scholar 

  25. Namias N, McKenney MG, Martin LC. Utility of admission chemistry and coagulation profiles in trauma patients: a reappraisal of traditional practice. J Trauma. 1996;41(1):21–5.

    Article  CAS  PubMed  Google Scholar 

  26. Keller MS, Coln CE, Trimble JA, Green MC, Weber TR. The utility of routine trauma laboratories in pediatric trauma resuscitations. Am J Surg. 2004;188(6):671–8.

    Article  PubMed  Google Scholar 

  27. Chu UB, Clevenger FW, Imami ER, Lampard SD, Frykberg ER, Tepas 3rd JJ. The impact of selective laboratory evaluation on utilization of laboratory resources and patient care in a level-I trauma center. Am J Surg. 1996;172(5):558–62. Discussion 62–3.

    Article  CAS  PubMed  Google Scholar 

  28. Jacobs IA, Kelly K, Valenziano C, Chevinsky AH, Pawar J, Jones C. Cost savings associated with changes in routine laboratory tests ordered for victims of trauma. Am Surg. 2000;66(6):579–84.

    CAS  PubMed  Google Scholar 

  29. Bates DW, Boyle DL, Rittenberg E, Kuperman GJ, Ma’Luf N, Menkin V, et al. What proportion of common diagnostic tests appear redundant? Am J Med. 1998;104(4):361–8.

    Article  CAS  PubMed  Google Scholar 

  30. Bounameaux H, Cirafici P, de Moerloose P, Schneider PA, Slosman D, Reber G, et al. Measurement of D-dimer in plasma as diagnostic aid in suspected pulmonary embolism. Lancet. 1991;337(8735):196–200.

    Article  CAS  PubMed  Google Scholar 

  31. Crowther MA, Cook DJ, Griffith LE, Meade M, Hanna S, Rabbat C, et al. Neither baseline tests of molecular hypercoagulability nor D-dimer levels predict deep venous thrombosis in critically ill medical-surgical patients. Intensive Care Med. 2005;31(1):48–55.

    Article  CAS  PubMed  Google Scholar 

  32. Solomon DH, Hashimoto H, Daltroy L, Liang MH. Techniques to improve physicians’ use of diagnostic tests: a new conceptual framework. JAMA. 1998;280(23):2020–7.

    Article  CAS  PubMed  Google Scholar 

  33. Kim JY, Dzik WH, Dighe AS, Lewandrowski KB. Utilization management in a large urban academic medical center: a 10-year experience. Am J Clin Pathol. 2011;135(1):108–18.

    Article  PubMed  Google Scholar 

  34. Miller RA, Waitman LR, Chen S, Rosenbloom ST. The anatomy of decision support during inpatient care provider order entry (CPOE): empirical observations from a decade of CPOE experience at Vanderbilt. J Biomed Inform. 2005;38(6):469–85.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Prat G, Lefevre M, Nowak E, Tonnelier JM, Renault A, L’Her E, et al. Impact of clinical guidelines to improve appropriateness of laboratory tests and chest radiographs. Intensive Care Med. 2009;35(6):1047–53.

    Article  PubMed  Google Scholar 

  36. Marx WH, DeMaintenon NL, Mooney KF, Mascia ML, Medicis J, Franklin PD, et al. Cost reduction and outcome improvement in the intensive care unit. J Trauma. 1999;46(4):625–9. Discussion 9–30.

    Article  CAS  PubMed  Google Scholar 

  37. Schubart JR, Fowler CE, Donowitz GR, Connors Jr AF. Algorithm-based decision rules to safely reduce laboratory test ordering. Stud Health Technol Inform. 2001;84(Pt 1):523–7.

    CAS  PubMed  Google Scholar 

  38. Bates DW, Kuperman GJ, Rittenberg E, Teich JM, Fiskio J, Ma’luf N, et al. A randomized trial of a computer-based intervention to reduce utilization of redundant laboratory tests. Am J Med. 1999;106(2):144–50.

    Article  CAS  PubMed  Google Scholar 

  39. Chen J, Majercik S, Bledsoe J, Connor K, Morris B, Gardner S, et al. The prevalence and impact of defensive medicine in the radiographic workup of the trauma patient: a pilot study. Am J Surg. 2015;210(3):462–7.

    Article  PubMed  Google Scholar 

  40. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493–9.

    Article  PubMed  Google Scholar 

  41. Greene HL, Goldberg RJ, Beattie H, Russo AR, Ellison RC, Dalen JE. Physician attitudes toward cost containment. The missing piece of the puzzle. Arch Intern Med. 1989;149(9):1966–8.

    Article  CAS  PubMed  Google Scholar 

  42. Post J, Reed D, Halvorsen AJ, Huddleston J, McDonald F. Teaching high-value, cost-conscious care: improving residents’ knowledge and attitudes. Am J Med. 2013;126(9):838–42.

    Article  PubMed  Google Scholar 

  43. Zimmerman JE, Seneff MG, Sun X, Wagner DP, Knaus WA. Evaluating laboratory usage in the intensive care unit: patient and institutional characteristics that influence frequency of blood sampling. Crit Care Med. 1997;25(5):737–48.

    Article  CAS  PubMed  Google Scholar 

  44. Griner PF, Glaser RJ. Sounding boards. Misuse of laboratory tests and diagnostic procedures. N Engl J Med. 1982;307(21):1336–9.

    Article  CAS  PubMed  Google Scholar 

  45. Stammen LA, Stalmeijer RE, Paternotte E, Oudkerk Pool A, Driessen EW, Scheele F, et al. Training physicians to provide high-value. Cost-conscious care: a systematic review. JAMA. 2015;314(22):2384–400.

    Article  CAS  PubMed  Google Scholar 

  46. Winkelman JW. Less utilization of the clinical laboratory produces disproportionately small true cost reductions. Hum Pathol. 1984;15(6):499–501.

    Article  CAS  PubMed  Google Scholar 

  47. Axt-Adam P, van der Wouden JC, van der Does E. Influencing behavior of physicians ordering laboratory tests: a literature study. Med Care. 1993;31(9):784–94.

    Article  CAS  PubMed  Google Scholar 

  48. Rang M. The Ulysses syndrome. Can Med Assoc J. 1972;106(2):122–3.

    CAS  PubMed  PubMed Central  Google Scholar 

  49. Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, et al. Anemia and blood transfusion in critically ill patients. JAMA. 2002;288(12):1499–507.

    Article  PubMed  Google Scholar 

  50. Shaffer C. Diagnostic blood loss in mechanically ventilated patients. Heart Lung. 2007;36(3):217–22.

    Article  PubMed  Google Scholar 

  51. Smoller BR, Kruskall MS. Phlebotomy for diagnostic laboratory tests in adults. Pattern of use and effect on transfusion requirements. N Engl J Med. 1986;314(19):1233–5.

    Article  CAS  PubMed  Google Scholar 

  52. Kumwilaisak K, Noto A, Schmidt UH, Beck CI, Crimi C, Lewandrowski K, et al. Effect of laboratory testing guidelines on the utilization of tests and order entries in a surgical intensive care unit. Crit Care Med. 2008;36(11):2993–9.

    Article  PubMed  Google Scholar 

  53. Chant C, Wilson G, Friedrich JO. Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study. Crit Care. 2006;10(5):R140.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Smith WR. Evidence for the effectiveness of techniques to change physician behavior. Chest. 2000;118(2 Suppl):8S–17.

    Article  CAS  PubMed  Google Scholar 

  55. Kassirer JP. Our stubborn quest for diagnostic certainty. A cause of excessive testing. N Engl J Med. 1989;320(22):1489–91.

    Article  CAS  PubMed  Google Scholar 

  56. Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med. 1993;329(17):1271–3.

    Article  CAS  PubMed  Google Scholar 

  57. Eisenberg JM, Williams SV. Cost containment and changing physicians’ practice behavior. Can the fox learn to guard the chicken coop? JAMA. 1981;246(19):2195–201.

    Article  CAS  PubMed  Google Scholar 

  58. Allan GM, Lexchin J. Physician awareness of diagnostic and nondrug therapeutic costs: a systematic review. Int J Technol Assess Health Care. 2008;24(2):158–65.

    Article  PubMed  Google Scholar 

  59. Feldman LS, Shihab HM, Thiemann D, Yeh HC, Ardolino M, Mandell S, et al. Impact of providing fee data on laboratory test ordering: a controlled clinical trial. JAMA Intern Med. 2013;173(10):903–8.

    Article  PubMed  Google Scholar 

  60. Bates DW, Kuperman GJ, Jha A, Teich JM, Orav EJ, Ma’luf N, et al. Does the computerized display of charges affect inpatient ancillary test utilization? Arch Intern Med. 1997;157(21):2501–8.

    Article  CAS  PubMed  Google Scholar 

  61. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995;274(9):700–5.

    Article  CAS  PubMed  Google Scholar 

  62. Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39(8 Suppl 2):II2–45.

    CAS  PubMed  Google Scholar 

  63. Bunting PS, Van Walraven C. Effect of a controlled feedback intervention on laboratory test ordering by community physicians. Clin Chem. 2004;50(2):321–6.

    Article  CAS  PubMed  Google Scholar 

  64. Kroenke K, Hanley JF, Copley JB, Matthews JI, Davis CE, Foulks CJ, et al. Improving house staff ordering of three common laboratory tests. Reductions in test ordering need not result in underutilization. Med Care. 1987;25(10):928–35.

    Article  CAS  PubMed  Google Scholar 

  65. Bareford D, Hayling A. Inappropriate use of laboratory services: long term combined approach to modify request patterns. BMJ. 1990;301(6764):1305–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. Yeh DD, Naraghi L, Larentzakis A, Nielsen N, Dzik W, Bittner EA, et al. Peer-to-peer physician feedback improves adherence to blood transfusion guidelines in the surgical intensive care unit. J Trauma Acute Care Surg. 2015;79(1):65–70.

    Article  PubMed  Google Scholar 

  67. Winkens RA, Pop P, Grol RP, Kester AD, Knottnerus JA. Effect of feedback on test ordering behaviour of general practitioners. BMJ. 1992;304(6834):1093–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  68. Winkens RA, Pop P, Bugter-Maessen AM, Grol RP, Kester AD, Beusmans GH, et al. Randomised controlled trial of routine individual feedback to improve rationality and reduce numbers of test requests. Lancet. 1995;345(8948):498–502.

    Article  CAS  PubMed  Google Scholar 

  69. Lundberg GD. Changing physician behavior in ordering diagnostic tests. JAMA. 1998;280(23):2036.

    Article  CAS  PubMed  Google Scholar 

  70. May TA, Clancy M, Critchfield J, Ebeling F, Enriquez A, Gallagher C, et al. Reducing unnecessary inpatient laboratory testing in a teaching hospital. Am J Clin Pathol. 2006;126(2):200–6.

    Article  PubMed  Google Scholar 

  71. Thaler RH, Sunstein CR. Nudge: improving decisions about health, wealth, and happiness. New York, NY: Penguin; 2009. Rev. and expanded ed.

    Google Scholar 

  72. Hindmarsh JT, Lyon AW. Strategies to promote rational clinical chemistry test utilization. Clin Biochem. 1996;29(4):291–9.

    Article  CAS  PubMed  Google Scholar 

  73. Emerson JF, Emerson SS. The impact of requisition design on laboratory utilization. Am J Clin Pathol. 2001;116(6):879–84.

    Article  CAS  PubMed  Google Scholar 

  74. Groopman DS, Powers RD. Effect of “standard order” deletion on emergency department coagulation profile use. Ann Emerg Med. 1992;21(5):524–7.

    Article  CAS  PubMed  Google Scholar 

  75. Mozes B, Lubin D, Modan B, Ben-Bassat I, Gitel SN, Halkin H. Evaluation of an intervention aimed at reducing inappropriate use of preoperative blood coagulation tests. Arch Intern Med. 1989;149(8):1836–8.

    Article  CAS  PubMed  Google Scholar 

  76. Attali M, Barel Y, Somin M, Beilinson N, Shankman M, Ackerman A, et al. A cost-effective method for reducing the volume of laboratory tests in a university-associated teaching hospital. Mt Sinai J Med. 2006;73(5):787–94.

    PubMed  Google Scholar 

  77. Neilson EG, Johnson KB, Rosenbloom ST, Dupont WD, Talbert D, Giuse DA, et al. The impact of peer management on test-ordering behavior. Ann Intern Med. 2004;141(3):196–204.

    Article  PubMed  Google Scholar 

  78. Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, et al. Implementation of the Ottawa ankle rules. JAMA. 1994;271(11):827–32.

    Article  CAS  PubMed  Google Scholar 

  79. Haut ER, Lau BD, Kraenzlin FS, Hobson DB, Kraus PS, Carolan HT, et al. Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma. Arch Surg. 2012;147(10):901–7.

    Article  PubMed  Google Scholar 

  80. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343(2):94–9.

    Article  CAS  PubMed  Google Scholar 

  81. Stuart PJ, Crooks S, Porton M. An interventional program for diagnostic testing in the emergency department. Med J Aust. 2002;177(3):131–4.

    PubMed  Google Scholar 

  82. Barie PS, Hydo LJ. Lessons learned: durability and progress of a program for ancillary cost reduction in surgical critical care. J Trauma. 1997;43(4):590–4. Discussion 4–6.

    Article  CAS  PubMed  Google Scholar 

  83. Fowkes FG, Hall R, Jones JH, Scanlon MF, Elder GH, Hobbs DR, et al. Trial of strategy for reducing the use of laboratory tests. Br Med J (Clin Res Ed). 1986;292(6524):883–5.

    Article  CAS  Google Scholar 

  84. Barie PS, Hydo LJ. Learning to not know: results of a program for ancillary cost reduction in surgical critical care. J Trauma. 1996;41(4):714–20.

    Article  CAS  PubMed  Google Scholar 

  85. Buntinx F, Winkens R, Grol R, Knottnerus JA. Influencing diagnostic and preventive performance in ambulatory care by feedback and reminders. A review. Fam Pract. 1993;10(2):219–28.

    Article  CAS  PubMed  Google Scholar 

  86. Spiegel JS, Shapiro MF, Berman B, Greenfield S. Changing physician test ordering in a university hospital. An intervention of physician participation, explicit criteria, and feedback. Arch Intern Med. 1989;149(3):549–53.

    Article  CAS  PubMed  Google Scholar 

  87. Merkeley HL, Hemmett J, Cessford TA, Amiri N, Geller GS, Baradaran N, et al. Multipronged strategy to reduce routine-priority blood testing in intensive care unit patients. J Crit Care. 2015;1(1):212–6.

    Google Scholar 

  88. Han SJ, Saigal R, Rolston JD, Cheng JS, Lau CY, Mistry RI, et al. Targeted reduction in neurosurgical laboratory utilization: resident-led effort at a single academic institution. J Neurosurg. 2014;120(1):173–7.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Trauma Emergency Surgery Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge St. #810, Boston, MA, 02114, USA

    Daniel Dante Yeh

Authors
  1. Daniel Dante Yeh
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Daniel Dante Yeh .

Editor information

Editors and Affiliations

  1. Division of Laboratory Medicine Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA

    Kent Lewandrowski

  2. Pathology Service Core Laboratories, Massachusetts General Hospital, Boston, Massachusetts, USA

    Patrick M. Sluss

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Yeh, D.D. (2017). Laboratory Utilization. In: Lewandrowski, K., Sluss, P. (eds) Utilization Management in the Clinical Laboratory and Other Ancillary Services. Springer, Cham. https://doi.org/10.1007/978-3-319-34199-6_18

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-34199-6_18

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-34197-2

  • Online ISBN: 978-3-319-34199-6

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation