A judicious approach to ordering lab tests
Following these guidelines to order fewer tests can improve health care quality and patient experience, while reducing wasteful costs.
PRACTICE RECOMMENDATIONS
› Follow US Preventive Services Task Force and professional society recommendations for laboratory testing, including choice and frequency of tests. A
› Consider the pretest probability of your patient having a disease, and order the most sensitive and specific test to diagnose a new condition. Employ a 2-step approach with a second laboratory test when the first is outside the reference range. B
› Refrain from ordering routine preoperative testing for patients undergoing low-risk surgeries; these data do not improve postoperative outcomes, can lead to costly testing cascades, and may delay necessary surgical care for patients. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
The American Society of Anesthesiologists (ASA) Physical Status Classification System, which has been in use for more than 60 years, considers the patient’s physical status (ASA grades I-VI),24 and when paired with surgery grades of minor, intermediate, and major/complex, can help assess preoperative risk and guide preoperative testing (TABLE).24-26
Preoperative medical testing did not reduce the risk of medical adverse events during or after cataract surgery when compared with selective or no testing.27 Unnecessary preoperative testing can lead to a nonproductive cascade of additional investigations. In a 2018 study of Medicare beneficiaries, unnecessary routine preoperative testing and testing sequelae for cataract surgery was calculated to cost Medicare up to $45.4 million annually.28
CASE
You would not be practicing value-based laboratory testing, according to the USPSTF, if you ordered a CMP, fasting lipid profile, and TSH and 25(OH) vitamin D tests for this healthy 35-year-old man whose family history, blood pressure, and BMI do not put him at elevated risk. Universal lipid screening (Grade Ba) is recommended for all adults ages 40 to 75. Thyroid screening tests and measurement of 25(OH) vitamin D level (I statementsa) are not recommended. The USPSTF has not evaluated chemistry panels for screening.
The USPSTF would recommend the following actions for this patient:
- Screen for HIV (ages 15 to 65 years; and younger or older if patient is at risk). (A recommendationa,29)
- Screen for hepatitis C virus (in those ages 18 to 79). (B recommendation30)
The following USPSTF recommendations might have come into play if this patient had certain risk factors, or if the patient had been a woman:
- Screen for diabetes if the patient is overweight or obese (B recommendation).
- Screen for hepatitis B in adults at risk (B recommendation).
- Screen for gonorrhea and chlamydia in women at risk (B recommendation). Such screening has an “I”statement for screening men at risk.
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