Testing is an important part of medicine across all specialties and settings. As a result, the volume of testing is enormous, with an estimated 4-5 billion tests performed in the United States each year.1 Unnecessary laboratory testing and diagnostic imaging is believed to be common. Studies looking at testing of patients have found 40%-60% of tests to be unnecessary.1, 2, 3 Unnecessary tests can cause patient discomfort, patient harm, and increase health care costs. Unnecessary tests can also lead to false positive results, which often lead to other tests, a phenomenon known as a diagnostic cascade.4 To evaluate the extent of unnecessary testing and physician awareness of this problem, we conducted a chart review and questionnaire for resident physicians at two academic medical centers.
Methods
Study Design
We conducted a retrospective review of electronic medical records from a convenience sample of patients admitted to medicine services at two hospitals (a tertiary care medical center and a Department of Veterans Affairs hospital). Participants were eligible if they were admitted to an Internal Medicine service from the Emergency Department. Data abstraction included all laboratory testing and imaging testing performed within the first 24 hours of medical care. Physician reviewers determined if each test or procedure was necessary based on a chart review. Necessity of test or procedure was defined with a 4-point scale (1 = absolutely unnecessary, 2 = somewhat unnecessary, 3 = somewhat necessary, 4 = absolutely necessary) by the reviewing physician, similar to past chart reviews for preventability of adverse events.5 Necessity was determined based upon most appropriate clinical guidelines or UpToDate, an evidence-based, physician-authored clinical decision support resource.6, 7 Reviewers also reported if each identified test resulted in a change in management and if any other tests or procedures resulted because of the test. If changes in management were identified, the reviewer reported what these were. Finally, we recorded if any harms or benefits occurred as a result of tests or procedures.8
In addition to chart review, a paper questionnaire was administered in person to a convenience sample of frontline providers caring for these patients. The questionnaire was completed by providers within the first 24 hours of the patient’s hospitalization. Completion of the questionnaire was voluntary, and no provider-identifiable information was transferred to the database. The questionnaire contained a list of 10 common laboratory and 11 common imaging tests, as well as an open-ended section for other tests. Participants were asked to report all medical tests ordered within the first 24 hours of care for the patients without opening the patient’s chart for this information. Participants were also asked to grade the necessity of each test using the same 4-point scale as the chart reviews, and to report if the test led to a change in management. This study was approved by the institutional review board at each institution and a waiver of informed consent was granted for this study.
Statistical Methods
Chart review and questionnaire results were compiled and the frequency of each test type ordered, abnormal findings, changes in management, and other tests/procedure information were analyzed for all patients. Necessity scores were averaged for chart reviews and for physician questionnaires. Statistics were compiled using Microsoft Excel (Microsoft Corporation, Redmond, WA) and calculated using SAS version 9.4 (SAS Institute Inc., Cary, NC). Data entered in the database were deidentified.
Results
Chart reviews and physician questionnaires were conducted from January 1, 2017 to June 16, 2017. During the study period 177 charts were reviewed. Additionally, 49 frontline provider questionnaires were collected on patients, which amounted to 28% (49 of 177) of chart reviews.
Chart Reviews
The 177 patients reviewed had a mean age of 68.5 years; 92% were male and 63% identified as black or African American. Overall, patients had a mean of 9.2 tests ordered within the first 24 hours of medical care. Of these, 31.5% (2.9/9.2) of tests were determined by review to be unnecessary (either a 1 or 2 on the 4-point scoring system). Chart review identified a total of 87.5% (155/177) of patients who received at least one unnecessary test during their first 24 hours of care (Figure). Of all 177 patients reviewed, 50.8% (90/177) had no change in management based on the laboratory or imaging studies ordered. Of all patients included, 49.2% (87/177) had a change in management. Thirteen percent (23/177) had an immediate change in management, of which 73.9% (17/23) were beneficial and 26.1% (6/23) were of no benefit. An additional 36% (64/177) of patients had a test that led to additional tests or procedures. Of these 64 patients who received additional tests or procedures, 43.8% (28/64) were beneficial, 50% (32/64) were of no benefit, and 6% (4/64) were harmful. Overall, 72.3% (128/177) of patients experienced no benefit or harms from testing, 25.4% (45/177) experienced benefit and 2.3% (4/177) harm. Test results that were harmful included 4 instances of unnecessary antibiotic prescription for asymptomatic bacteriuria. Test results that were judged to be beneficial included identifying cancer (4 patients), starting hemodialysis (2 patients), and receiving cardiac angioplasty and stenting (1 patient).
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-Christina Koch, MD, Katherine Roberts, MD, Christopher Petruccelli, MPH, Daniel J. Morgan, MD, MS
This article originally appeared in the May issue of The American Journal of Medicine.
