Lab testing overload: a comprehensive analysis of overutilization in hospital-based settings

Abstract

Overuse of laboratory tests has been a growing problem in the inpatient hospital setting for years, which adds to the rising cost of care. Various factors come into play, such as clinical routines, lack of cost transparency, and the convenience of electronic health record–based ordering. The financial ramifications of the overuse are significant, as lab costs drive most medical decisions. Eliminating unnecessary testing with clinical decision support and best practices is associated with marked cost savings, improved outcomes, and decreased patient distress. The excessive use of laboratory tests highly affects patients, resulting in hospital-induced anemia, low patient satisfaction, and poor outcomes. Tackling lab overuse requires a multifaceted approach that includes education, technology, and policy changes. In the era of precision healthcare, optimizing test utilization can reduce costs, decrease waste, and improve patient care.

Over the years, low-value care has been challenging to address due to the excessive overuse of tests and procedures in an inpatient setting. Diagnostic tests, imaging, and procedures are essential to a patient’s workup for reaching a diagnosis and guiding further management (Figure 1). One out of every five inpatient laboratory examinations ordered are unnecessary since they do not progress patient treatment.¹ Over 4 billion laboratory tests are conducted annually in the United States, according to estimates, costing $65 billion.² Within the first week of being in the hospital, patients receive 5.7 laboratory requests on average, and up to 85% of patients need additional testing.³ Frequent laboratory testing of hospitalized patients can exacerbate anemia, lead to discomfort, promote futile testing brought on by falsely positive results, and increase personal costs for the patient.⁴ Through expensive subsequent treatments and extended hospital stays, excessive testing can have a harmful direct and indirect impact on hospital expenditures.⁵

Figure 1.

Comprehensive overview of laboratory test overutilization in inpatient settings.

Despite the fact that laboratory costs typically account for <5% of hospital budgets, they have a significant impact because about 60% to 70% of all medical decisions are influenced by laboratory results.⁶ According to a study by Sedrak et al, the majority of residents attributed the overuse of lab testing in part to clinical routines, a lack of cost transparency, and the ease with which repeat lab tests can be ordered in the electronic health record.⁷ It has been demonstrated that low-cost, frequent tests are used extensively and represent a larger portion of overall healthcare costs than expensive tests.⁸ The Choosing Wisely campaign was formed to address the issue of overuse causing diagnostic errors, increased healthcare spending, and resource use. Hospitals were committed to reducing the amount of lab testing ordered, following specific guidelines and recommendations, implemented by the program.⁹ The implementation of clinical decision support systems (CDSS) that promote best practice laboratory testing results in cost reductions, according to other research articles.¹⁰ Provider education, price displays, warnings against unnecessary testing, hints on progress notes, and separating test panels with numerous components were some of the previous approaches used to address this issue.^11,12 Methods including analyzing the average number of tests ordered per patient, ordering habits, and feedback surveys used before and after intervention can be applied to resolve the issue.¹³ Healthcare providers and organizations need to continue to explore alternatives to minimize non–value-added care while maintaining quality as value-based healthcare systems continue to develop. This review article provides an overview of laboratory test overutilization in inpatient settings, noting ways to promote cost-effectiveness, patient outcomes, and patient satisfaction.

SPECIALTY-BASED LAB TESTING

All provider types have been identified as having requested inefficient tests, indicating that greater effort is needed to optimize acceptable utilization.¹⁰

The benefit of testing was usually viewed less favorably by doctors who cared for pediatric patients, and internal medicine clinicians were the most likely to support daily testing and claim that it improves patient safety and reduces the risk of malpractice lawsuits.¹⁴ The vast majority of doctors concurred that daily testing generally improves safety (55%), hospitalized patients should receive daily labs (59%), and patients should be tested on the day of discharge (52%). Fewer pediatric and surgical physicians agreed that regular lab testing would improve patient safety (46% and 47%, respectively) and should be done (56% and 47%, respectively) (Table 1).¹⁵

Table 1.

Studies on the prevalence, physician perceptions, and appropriateness of diagnostic tests related to specialty-based lab testing overuse

Research study	Core metrics	Additional insights
Physician views on testing15	55% believed daily testing improved safety 59% supported daily lab testing for hospitalized patients	Majority consensus among healthcare professionals
Physician agreement15	46% pediatric physicians endorsed regular lab testing for safety 47% surgical physicians favored regular lab testing	Variations in perspectives within specialties
Inappropriate diagnostic testing16	Review included 357,171 patients from 63 studies (15 countries) Inappropriateness rates ranged from 0.2% to 100%	Significant variability in diagnostic test appropriateness worldwide
Cardiovascular testing17	21% unnecessary clinical chemistry tests for cardiovascular patients (June-Dec)	Potential for resource optimization
Cancer care focus18	Only 29% of studies addressed active cancer treatment	Mainly focused on early stage breast cancer and low- to intermediate-risk prostate cancer

O’Sullivan et al, in their systematic review and metaanalysis, included 357,171 patients from 63 studies in 15 countries, measuring the inappropriateness of diagnostic tests ordered for adult patients in primary care. The review identified 62 measures of overuse of diagnostic tests in primary care, where the overall rate of inappropriate diagnostic test ordering varied substantially, ranging from 0.2% to 100% (Table 1).¹⁶ The clinical chemistry laboratory, which conducts a variety of diagnostic tests to identify and track cardiovascular illnesses, is one area where resources might be spent excessively. In a cross-sectional study, cardiovascular patients underwent numerous clinical chemistry tests, with 21% of the facility-ordered tests being deemed unnecessary, emphasizing the need to address factors such as fear, malpractice, and patient pressure to reduce overuse (Table 1).¹⁷

One study discovered that just 29% of studies on the overuse of cancer care addressed services during active treatment, with the majority of studies focusing on imaging early stage breast cancer and low- to intermediate-risk prostate cancer (Table 1).¹⁸ A multifaceted strategy is needed to address the overuse of lab testing in these professions, including the creation of standards unique to each specialty, continued training for healthcare professionals, and more patient involvement. With prudent ordering of lab tests, both patient care and healthcare cost effectiveness are improved.

PATIENT SATISFACTION AND OUTCOME

Patient satisfaction and outcome is based on efficient treatments in hospital-based settings. Overutilization has led patients to face adverse effects, such as repetitive blood draws and incorrect diagnoses. Blood is drawn in the early morning, which leads to fragmented patient sleep, delirium, and low patient satisfaction rates.¹⁹ Hospital-acquired anemia occurs due to iatrogenic blood loss from repeated labs and is associated with increased mortality. If patients feel their providers perform too many tests without considering their concerns, it can lead to a loss of trust and miscommunication. A 2-month educational intervention was assessed where internal medicine providers were educated through flyers and email reminders to order daily blood tests only when necessary, and the study measured the change in daily blood test orders per patient per day. The result was a reduction in blood draw procedures by 9%, resulting in decreased patient distress, phlebotomist workload, and cost.²⁰ Reduced lab testing lowers blood transfusion needs, improves patient outcomes, and can save $150,000 annually.²⁰ Patient exposure to direct harms, like radiation exposure, as well as potential poor outcomes, incidental results, and overdiagnosis are all consequences of overusing testing, providing tests with no obvious value, or testing when the potential risks outweigh the potential benefits.¹⁶ Repeated testing may make patients feel worried about their health and question the quality of care being provided, causing stress and anxiety. Implementing strategies such as electronic medical record (EMR) changes can reduce unnecessary laboratory testing, which not only saves costs but can also contribute to improved patient satisfaction by minimizing unnecessary needle sticks and tests.²¹ Healthcare professionals need to include patients during decision-making, as their preferences should be taken into consideration.

In a review of various articles on the causes and effects of lab overutilization, patient concerns and satisfaction were the least recognized. Many of these studies did not include great detail on how patients were affected and what they thought about the tests’ effect on their value of care. Healthcare outcomes can be optimized, and patient satisfaction could rise, by controlling overuse through patient-centered techniques and improved communication.

OVERALL IMPACT

Ordering the correct test, at an appropriate time, for the right purpose can lower costs, eliminate waste, and enhance patient quality, results, and satisfaction in this era of precision healthcare.¹⁰ A systematic review by Müskens et al found that the prevalence of diagnostic testing overuse ranged from 0.09% to 97.5% across healthcare settings, with a median prevalence of 11.0% for assessments done in different healthcare places, 2.0% for the general patient population, and 30.7% for overall services provided by the health care center.²² When interventions were applied in different categories—audit and feedback, price transparency, patient education, EMR modification, and policy variations—the EMR and policy changes had the most effective results.²¹ However, EMR changes were less used among physicians who had strict limitations and pop up alerts, while strategies like cost display and education were more effective in combination with other methods, making it unclear how well they work on an individual basis.²¹ In addition, there is a suspicion that a decline in routine laboratory monitoring could be linked to an undiscovered deterioration in the patient’s clinical status.²³ In previous research studies applying similar interventions, several potential detrimental effects were investigated, but no associations were shown.²⁴

According to another analysis, preoperative testing and imaging are the most commonly performed yet low-value diagnostic techniques for nonspecific low back pain.²⁵ Physicians and hospital administrators who work with policies and regulations need to operate with a sense of urgency and assist with devising effective initiatives to combat low-value diagnostic overtesting.²⁶ Many physicians emphasize the importance of patient safety, the possibility of diagnosing occult diseases, and concerns about malpractice, while 60% of physicians mentioned the risks of false-positive and false-negative tests leading to potential harm and resource overuse in patients.²⁷

The model for improvement and the Donabedian framework were applied to identify the problem, assess the initial situation, and make targeted improvements in a general internal medicine unit. The quality improvement initiative, which included education and process changes, resulted in an 18.9% reduction in the total number of core lab tests ordered and an 18.2% decrease in the proportion of patients receiving daily repeated lab tests.²⁸ The convenience of ordering automated daily labs through admission order sets can be decreased, encouraging and enabling doctors to make clinical decisions specific to each patient’s condition and avoid relying on automated orders for routine testing.²⁹ Residents advocated for educational initiatives, whereas specialists highlighted technical solutions such as lockouts.³⁰

Overall, these studies emphasize the prevalent issue of excessive lab testing in healthcare settings, demonstrating differences in incidence across different situations. While some interventions, such as EMR modifications and policy changes, have shown efficacy in reducing overuse, the scarcity of comprehensive research highlights the need for novel approaches to address this persistent issue and ensure the prudent use of diagnostic tests. Precision medicine requires the wise use of diagnostics in hospital-based settings. The disparate rates of overuse highlight the importance of targeted interventions, and EMR modifications hold considerable promise in tackling this problem. Drivers behind the rapidly accelerating momentum for tackling potential low-value testing include patient safety concerns, false-positives or false-negatives, and communication gaps with profound downstream impacts. Root cause analysis, facilitated by improvement models like plan-do-study-act, provides a path to quality, cost savings, and stakeholder buy-in to curb the overutilization of diagnostic tests.

FUTURE PERSPECTIVES

Addressing inpatient laboratory test overutilization is essential for improving healthcare value, thus requiring cost containment, better patient outcomes, and increased patient satisfaction. Several techniques can be applied toward resolving the issue.

• Education. Physicians should be educated on laboratory testing use, which includes clinical indications and adverse effects affected by the excessive use of such tests. Providers should constantly be aware of making informed decisions through continuous training and awareness programs.

• Technology and CDSS. CDSS can be incorporated through integration within the EMR. This allows it to guide healthcare providers automatically in real time and recommend appropriate test orders based on clinical data. For example, CDSS may advise on alternatives to costly tests so that physicians remember to factor in such options in their diagnosis.

• Policy change. Unnecessary testing in hospitals and other healthcare institutions can be discouraged by setting appropriate policies. Such measures should focus on restricting some tests for which there are protocols, requiring doctors to specify a clinical reason for orders, and providing administrative consequences against unnecessary examinations.

• Data-driven strategies. The pattern of test orders can be uncovered through regular data analysis and surveillance. Such information allows an organization to focus its effort on areas that will yield positive results. Specifically, analysis can help pinpoint the departments or specialties with the highest rates of overutilization for targeted interventions.

• Patient-centered care. Incorporating patients into the decision-making process for their tests may reduce unnecessary lab orders. Informing patients about why specific tests are necessary, possible risks, and financial implications can lead to shared decision-making consistent with particular preferences and reduce unnecessary discomfort.

Using a combination of education, technology, policy change, data-driven strategies, and patient-centered care, healthcare systems can address this challenge successfully. Collaborative and interdisciplinary teams are needed, from managing healthcare providers to administrators to policymakers. The EMR can be used to monitor laboratory use. The ultimate aim is to create a healthcare landscape where lab orders are performed judiciously so that every test adds measurable value to patient care, resulting in better health outcomes, and is aligned with the principles of cost-effective and patient-centered healthcare delivery.

CONCLUSION

The ongoing problem of inpatient hospital laboratory test overuse requires urgent and multifaceted action. The financial implications are staggering: laboratory tests, although usually just a small fraction of hospital budgets, exert an outsize influence over medical decisions, especially since frequent, low-cost tests can add up to such a large part of overall healthcare expenses. To fully address this issue, several critical tactics must be explored. Education is essential to empower healthcare providers with the knowledge to make informed decisions about laboratory test ordering. Providers need to comprehend the clinical indications for tests, the potential harm from overuse, and the cost to healthcare systems. Additionally, CDSS can provide decision support, giving providers real-time suggestions on test orders and reducing overutilization. Organizational policy changes are also critical, including interventions such as cost reduction, clinical decision support that alerts unwarranted testing, and optimization of EMR to decrease frictionless test ordering without medical necessity. Coordination among multidisciplinary healthcare teams, including residents, attendings, and nurses, is vital in developing and executing effective interventions. Real-time data analysis and surveillance can identify test ordering patterns so organizations can focus improvement efforts where they work best. Furthermore, integrating patient-centered care and incorporating patient perspectives in decision-making can help align testing to individual preferences, reducing unnecessary discomfort and enhancing satisfaction.

CONFLICTS OF INTEREST

The authors report no funding or conflicts of interest.