As a nation, our healthcare system is transitioning to a service mode, where there is more emphasis on value. The economic task for medical laboratories of the future is to think about how they can diagnose patients efficiently, providing the maximum benefit for the lowest cost.
As our system transitions to accountable care organizations, capitated payments and other payment methods, labs will be incentivized to conserve their resources, rather than spend them. The Choosing Wisely campaign, an initiative of the American Board of Internal Medicine, can be an important tool that helps these labs position themselves for the future.
The goal of the campaign is to spark conversations between physicians and patients regarding which medical services are most appropriate and truly necessary based on an individual patient’s needs. The Choosing Wisely campaign developed recommendations to educate clinicians and patients on target services, including diagnostic tests, that are performed frequently, offer little or no benefit or may be potentially harmful and are costly while failing to contribute to higher quality care. These recommendations, rooted in evidence, target not only overused tests, but also misused services with the end goal of the campaign being to reduce harm and increase efficiency.
Over 70 Societies Take Up the Cause
Since 2012, more than 70 special medical societies, including the American Society for Clinical Pathology (ASCP), have joined the Choosing Wisely campaign. To date, more than 330 tests and procedures to question have been released as part of the campaign, and the specialty societies are now undertaking considerable efforts to share the recommendations with their collective memberships.
In 2013, ASCP released its first list of recommendations for five laboratory tests that are commonly ordered, but not always appropriate in pathology and laboratory medicine as part of the Choosing Wisely campaign. The Society conducted symposiums in several cities across the United States to disseminate information about test utilization best practices to pathologists and other members of the medical community.
In February 2015, the Society issued a second list of five targeted, evidence-based recommendations that expands the original list. ASCP’s new Choosing Wisely recommendations include:
– Don’t order an erythrocyte sedimentation rate (ESR) to look for inflammation in patients with undiagnosed conditions. Order a C-reactive protein (CRP) to detect acute phase inflammation.
– Don’t test vitamin K levels unless the patient has an abnormal international normalized ratio (INR) and does not respond to vitamin K therapy.
– Don’t prescribe testosterone therapy unless there is laboratory evidence of testosterone deficiency.
– Don’t test for myoglobin or CK-MB in the diagnosis of acute myocardial infarction (AMI). Instead, use troponin I or T.
– Don’t order multiple tests in the initial evaluation of a patient with suspected non-neoplastic thyroid disease. Order thyroid-stimulating hormone (TSH) and, if abnormal, follow-up with additional evaluation or treatment depending on the findings.
Many Tests Outdated
The 10 tests that ASCP has recommended should be evaluated for appropriate use are easily identified. There are many more diagnostic tests used that may be outdated or are no longer appropriate. Pathologists and medical laboratory professionals, as the major providers of diagnostic testing, have an unprecedented opportunity to provide leadership and guidance to clinicians to select the most appropriate tests.
For example, studies show that many clinicians don’t understand molecular testing.1 Over the past decade, the explosion of molecular testing has vastly expanded the number of assays available to clinicians. A 2013 study of 200 internists revealed that, while 65 percent of respondents reported they had counseled a patient on a genetic issue and 44 percent had ordered a genetic test during the six months prior, 74 percent said their knowledge of genetics was “somewhat poor” or “very poor.”1, 2