Inappropriate laboratory testing in internal medicine inpatients: Prevalence, causes and interventions

Vrijsen, Bram E. L.; Naaktgeboren, Christiana A.; Vos, Laura M.; Solinge, Wouter W. van; Kaasjager, H. A. H.; Berg, Maarten J. ten

doi:10.1016/j.amsu.2020.02.002

Cited by 39 publications

(62 citation statements)

References 22 publications

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“…"I'm often a bit defensive...I guess that's partly that legal thing" [38] "I think the whole medical-legal thing also makes people more inclined to CT [computed tomography] someone even if they have a pretty low suspicion just 'cause no one wants to be sued" [39] "I think litigation is a problem; you miss one neck... fracture or bleed in the brain you are going to court" [47] Factor Articles Illustrative quotes Clinician knowledge and understanding 25 articles [2,3,5,15,29,32,33,35,37-39,42−44,47,52,53,59−66] "How much work [laboratory testing] is, how much it costs, how much normal results can uctuate, things like that, I think we know very little about that" [3] "Nothing can really go wrong [with overutilization]" [3] "You understand the natural course of disease and the point in time at which you have to make a decision to do something different" [29] "When I'm admitting a patient or doing clinical work, it's kind of affected my thought process to where I think a little bit more about 'do I really need to get this test? ', 'will it really change management?…”

Section: Results Of Narrative Reviewmentioning

confidence: 99%

“…Need to explain the limitation of check-ups" [ "Lab testing is often only done for the doctor's peace of mind." [3] "I am worried if they don't have a full assessment and I miss something that it is going on with their heart that is not apparent because ECGs [electrocardiograms] and clinical examinations are not very precise" [29] "You're sitting there with someone who has a sudden-onset splitting headache, but otherwise you see nothing alarming… A CT scan for an acute headache. Even if the pre-test chance is 0.01.…”

Section: Results Of Narrative Reviewmentioning

confidence: 99%

“…They'll tell you what they want done" [51] "If we order more tests and we make sure we have every test ordered that might possibly be needed, the patient's happy and leaves in their ED [emergency department] stay" [51] "I'll say "well you just had one two years ago, you're on treatment, it was stable from the year before, and I don't think you need one"… what does usually happen is that they usually win" [64] "Can improve relationship between patients and doctor" [65] "Check-ups are largely patient driven secondary to media/public health generated anxiety" [ "There are situations where I've ordered an echo when I otherwise would not have because guidelines mandated" [29] "I think there's more, as much as we've developed these decision rules-I think there's a lot to be said about just experience" [39] "I think people are wary of practicing not in line with that and then they have potential then for criticism" [46] "There's plenty of guidelines, but they're all different and there's nothing o cial...there's no hard and fast rule" [46] "Because I work in a teaching practice, my residents are very devoted to guidelines. A lot of them are driven by the more recent guidelines" [64] Financial incentives 20 articles "Well, often the supervisor just says to run some tests, and I just accept that without question" [3] "I recently ordered a lipase, but then the gastroenterologist called me and said: in this hospital, we always combine it with an amylase." [3] "If an experienced cardiology colleague says we should do another echo, I would not feel strong enough to say no" [29] "If the neurologist had written, "There's nothing the matter" ...…”

Section: Results Of Narrative Reviewmentioning

confidence: 99%

“…Overtesting has become a growing concern in contemporary healthcare, [1][2][3] with worldwide movements such as the Choosing Wisely, Less Is More, and Too Much Medicine campaigns bringing the issue to the fore. [1,[4][5][6][7] Despite this, awareness and understanding of overtesting amongst the public, patients and clinicians remains limited.…”

mentioning

confidence: 99%

“…[1,[4][5][6][7] Despite this, awareness and understanding of overtesting amongst the public, patients and clinicians remains limited. [3,8,9] Screening and diagnostic tests are integral to clinical management, whether they are routine blood pressure measurement, blood tests, imaging studies or more specialised investigations. However, overuse of screening and diagnostic tests can lead to harm through misdiagnosis, false positive results and false negative results.…”

mentioning

confidence: 99%

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Why do clinicians overtest? A narrative review and workshop group discussion exploring influences on clinician overtesting as possible causes of overdiagnosis

Lam

Pickles

Stanaway

et al. 2020

Preprint

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Background: Screening and diagnostic tests provide important information to guide clinical management. Overtesting however may cause harm to patients and the healthcare system, including through overdiagnosis. Clinicians are ultimately responsible for test requests, and therefore are ideally positioned to prevent overtesting and overdiagnosis. Through this narrative literature review followed by group discussion at a conference workshop (Preventing Overdiagnosis Conference [PODC], Sydney, 2019), we aimed to identify and categorise factors that influence clinicians to request potentially unnecessary screening and diagnostic tests that could result in overdiagnosis.Methods: Articles exploring factors affecting clinician test ordering behaviour were identified through a systematic search of MedLine in April 2019, forward and backward citation searches and content experts. Two authors screened abstract titles and abstracts, and two authors screened full text for inclusion. Identified factors were categorised into a preliminary framework which was subsequently presented at the PODC for iterative development.Results: The MedLine search yielded 542 articles; 55 were included. Another 10 articles identified by forward-backward citation and content experts were included, resulting in 65 articles in total. Following small group discussion with workshop participants, a revised thematic framework of factors was developed: ● “Interpersonal” – pressure from colleagues and medical culture; pressure from patients and doctor-patient relationship● “Contextual” – clinician knowledge and understanding; cognitive biases and experiences; contemporary medical practice and new technology● “Environmental or workplace” – guidelines, protocols and policies; financial incentives; time constraints, physical vulnerabilities and language barriers; pre-emptive testing to facilitate subsequent care; availability, ownership and ease of access to tests● “Intrapersonal” – fear of malpractice and litigation; intolerance of uncertainty and risk aversion; sense of medical obligation Conclusion: Through this thematic framework, clinicians can become more aware of their test ordering behaviour and feel empowered to limit overtesting and overdiagnosis. This framework may also guide the development of a scale assessing clinician knowledge, attitudes and practices around overtesting and overdiagnosis, to facilitate measurement of the effects of clinician-targeted interventions to prevent overdiagnosis.

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