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
As noted, costs of laboratory testing vary widely, depending upon what tests are ordered, what type of insurance the patient has, and which tests the patient’s insurance covers. Who performs the testing also factors into the cost. Payers negotiate reduced fees for commercial lab testing, but potential out-of-pocket costs to patients are much higher.
For our healthy 35-year-old man, the cost of the initially proposed testing (CMP, lipid panel, TSH, and 25[OH] vitamin D level) ranges from a negotiated payer cost of $85 to potential patient out-of-pocket cost of more than $400.6
Insurance would cover the USPSTF-recommended testing (HIV and hepatitis C screening tests), which might incur only a patient co-pay, and cost the system about $65.
The USPSTF home page, found at www.uspreventiveservicestaskforce.org/uspstf/ includes recommendations that can be sorted for your patients. A web and mobile device application is also available through the website.
a USPSTF grade definitions:
A: There is high certainty that the net benefit is substantial. Offer service.
B: There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial. Offer service.
C: There is at least moderate certainty that the net benefit is small. Offer service selectively.
D: There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Don’t offer service.
I: Current evidence is insufficient to assess the balance of benefits and harms of the service.
CORRESPONDENCE
Mitchell Kaminski, MD, MBA, 901 Walnut Street, 10th Floor, Jefferson College of Population Health, Philadelphia, PA 19107; mitchell.kaminski@jefferson.edu
