Apparently a crap load:
Several studies have identified the overuse of daily lab testing and how certain interventions can effectively reduce tests ordered. A study by Miyakis et al. examined the effects of disclosing lab test costs on the frequency at which healthcare providers ordered these tests. 24,482 laboratory tests were ordered before the intervention (mean 2.96 tests/patient/day). Among those, roughly 70% were not considered to have contributed towards management of patients (mean avoidable 2.01 tests/patient/day). After costs of tests were disclosed, the avoidable tests/patient/day were significantly decreased (mean 1.58, p = 0.002), but containment of unnecessary ordering of tests gradually waned during the semester after the intervention. (1) A study by Kumwilaisak et al. examined how the implementation of formal guidelines effected how laboratory tests were ordered. 1,117 patients were enrolled. After the institution of the guidelines, the number of laboratory tests decreased by 37% (from 64,305 to 40,877). Furthermore, this result was still present at 1 year. (3)
For a brief time as a medicine resident, I did a rotation in a developing country (Botswana, Africa), and as a member of the housestaff of this teaching hospital, we were expected to draw all the labs ourselves. Needless to say, the number of unnecessary labs I ordered dropped precipitously.
From a renal standpoint, I also think we are often guilty of "over-ordering" labs such as PTH, vitamin D level, iron studies, etc–at our hospital they are part of the "default" checklist for the dialysis nurses to draw automatically during a patient's first dialysis on a given admission. Not surprisingly, there are several frequent fliers who get admitted frequently, and therefore have a PTH drawn every 2 weeks or so. Unfortunately, it is often just easier to order all these duplicate labs rather than looking up the old values that may be present in, say, outpatient dialysis records. Maybe someday we will have a universal medical records system to deal with this.
I continue to really enjoy your blog!
I did my residency at Indiana University in Indianapolis. The county hospital, Wishard, has a phenomenal electronic medical record with physician order entry. One of the features of the POE is that when you ordered an expensive test (CT scan, echo, etc) the computer would tell you the date and result from the last time the test had been ordered. I believe it also displayed the cost of the test.
One of my attendings (Marc Overage) was King of the Nerds who created the system and told me that just providing this info resulted in a huge reduction in utilization.
Speaks to how much we need better information systems.
Also thanks for the feedback. Means a lot coming from you.
As a pre-vet college student with an interest in human health care, I am fascinated by these systems-analysis type studies. While there is certainly a need in all fields for some sense of personal accountability and responsibility, it's amazing to me how much human behavior is affected by the way a system is set up to emphasize or de-emphasize certain information, or incentivize/discourage behaviors.
As a smaller scale example of the IU system's effects, the equine hospital where I work recently changed the way clients are billed for hospitalization and use of nursing care. It used to be that there were 5 strata of care based on the rough number of treatments/intensiveness of care (from just boarding to a recumbent horse requiring 24 hour one-on-one care). Now, there is a base hospitalization rate, to which each treatment adds a couple dollars. A "flow sheet" (full set of patient vitals/mini-physical) is $4 and a TPR is $3 — not a ton of money for the client who may be spending hundreds to thousands of dollars a day for a sick horse*, but enough that I have noticed residents ordering fewer flows and TPR's for horses who are just there for minor elective surgery. The billing for med. administration, of course, does not affect the treatment plan (the admin fee pales in comparison to the drug costs, which have not changed), but the theory is that billing is more equitable when done this way.
* Most bills for mild-moderate illness are in the $2K – $6K range total, but some severe conditions can result in bills of $15K-$25K or more — severe enterocolitis with high fluid needs, ex-lap with resection/anastamosis and intensive post-surgical care, and neonatal HIE/sepsis tend to be the most expensive of the relatively common conditions we see.