Impact of Clinical Specialty on Attitudes Regarding Overuse of Inpatient Laboratory Testing
Routine laboratory testing is common among hospitalized patients, with associated harm. Attitudes toward testing and drivers across clinical specialties have not been described. We performed a cross-sectional study and anonymously surveyed inpatient clinicians (nurses, advanced practice providers, and physicians) at a tertiary cancer center regarding attitudes toward unnecessary laboratory testing and its drivers across clinical specialties. A total of 837 providers completed surveys (response rate 53%). Most respondents agreed with daily testing of hospitalized patients and that daily labs generally enhance safety, and those from pediatric and surgical specialties generally valued testing less than others. Participants most commonly identified habit and institutional culture as important drivers of unnecessary testing. There were differences in other drivers across specialties, with pediatric clinicians identifying family pressure more commonly and fear of litigation less commonly compared to others. Future interventions to reduce unnecessary inpatient laboratory testing should acknowledge different attitudes based on specialty and tailor interventions accordingly.
© 2018 Society of Hospital Medicine
Routine laboratory testing in hospitalized patients is common, with a high prevalence of unnecessary tests that do not contribute to patient management.1 Excessive laboratory testing of hospitalized patients can contribute to anemia2 and may cause patient discomfort, additional unnecessary testing resulting from false positive results, and higher out-of-pocket patient costs. Excessive testing can impact hospital budgets both directly (though direct costs are often low) and indirectly through costly downstream services and prolonged hospital stay.3 As part of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely initiative, several professional societies have recommended against routine laboratory testing of hospitalized adult patients.4
Excessive inpatient laboratory testing has been documented mostly among adult internal medicine (IM) patients with studies of drivers of unnecessary testing and efforts to reduce it conducted in IM settings.5, 6 Attitudes toward other issues related to testing overuse differ by specialty7 and are likely to similarly vary with regard to unnecessary laboratory testing. Understanding differences in attitudes by clinical specialty is critical for framing tailored approaches to reducing inappropriate care.
We performed a cross-sectional survey of a diverse group of hospital clinicians to describe attitudes and beliefs regarding laboratory testing and its overuse across clinical specialties (eg, medical, surgical, and pediatric). We hypothesized that attitudes toward the need for testing would differ across specialties.
METHODS
Survey Development and Administration
The study was conducted at Memorial Sloan Kettering Cancer Center, a tertiary academic cancer hospital in New York City. The 12-item survey was adopted from a previously administered but not formally validated survey (Online-only Appendix).5,8 The survey was pilot tested with 4 physicians, 3 NPs, 2 PAs, and 3 RNs and edited for content and clarity. All staff providers including NPs, PAs, RNs, and resident, fellow, and attending MDs working in the hospital during the 2-week survey period (November 2-15, 2015) were eligible to participate and were emailed a link to the survey. The email invitation was resent 3 times during the survey period. Participants who completed the survey received a coupon for a free coffee. The study was reviewed by the Institutional Review Board and exempted from ongoing oversight.
Measures
Demographic items included clinical specialty, provider type, and gender (Online-only Appendix). The remaining survey questions included the following categories:
1. Attitudes toward laboratory testing were evaluated by 3 items about accepted norms for lab testing and 2 items about fears (Table 2). Responses to these items used a 4-point Likert scale (strongly agree to strongly disagree).
2. Drivers contributing to unnecessary testing were evaluated by presenting a list of possible contributing factors (Table 2). Responses to these items used a 3-point Likert scale (contributes a lot, contributes a little, or does not contribute).
Analysis
We used univariate statistics to describe demographics and survey responses. We used the chi-square statistic to evaluate differences in attitudes and drivers by clinical specialty. We dichotomized responses regarding attitudes toward lab testing (“strongly agree” and “somewhat agree” vs. “somewhat disagree” and “strongly disagree.”) and beliefs regarding contributing drivers (“contributes a lot” vs all others). We grouped clinical specialty into medical/med-oncology, surgical, pediatric, and other (gynecological, critical care, and other).
