Elsevier

Clinica Chimica Acta

Volume 411, Issues 21–22, 11 November 2010, Pages 1596-1602
Clinica Chimica Acta

Invited critical review
Managing the demand for laboratory testing: Options and opportunities

https://doi.org/10.1016/j.cca.2010.07.022Get rights and content

Abstract

The possibilities for ordering laboratory testing in hospitals inevitably need to be managed, given physicians' knowledge on the use of laboratory testing, their attitudes towards test ordering, the constant increase in testing and the limited resources available. On the assumption that some tests may not be strictly necessary or are even redundant, this paper reviews various methods to manage the demand for laboratory tests, evaluating the extent to which these methods are applicable and effective in daily practice. The most promising new management tools seem to be computerised laboratory management systems (CDSS), a reimbursement system based on the diagnosis–treatment combination (as in The Netherlands), and the allocation of laboratory budget to those requesting laboratory services.

Introduction

Which laboratory testing is genuinely needed is an ongoing point of discussion [1], [2], [3], [4]. Various international studies have suggested that 8–30% of laboratory requests can be called into question, a figure that varies per practitioner, hospital and country and depends on the definition of ‘superfluous’ testing. A crucial question here is whether, given the doctors' attitudes towards laboratory testing, the social context in which they operate and the recent changes in the field of medicine (Table 1), [2], [5], [6], [7], [8], a certain inefficiency in test ordering (provocatively often described as over-utilisation or misuse) is avoidable. Nevertheless, the continuing increase in test requests [4] (6–8% annually in our hospital in recent years) and pressure on resources clearly calls for some form of management of test-requesting behaviour. Non-budgeted laboratory testing is perhaps not so great a problem, but budgeted costs, like all costs for hospital care in The Netherlands, certainly are. Naturally, redundant laboratory testing is also undesirable from both a societal and patient perspective [4]. This paper focuses primarily on budgeted laboratory testing, offering a qualitative overview of the management possibilities to influence the demand for testing.

Section snippets

Approach

The author first sketched out the topic of this paper based on his personal insight and experience as a certified clinical biochemist/chemical pathologist (since 1993) and head of the clinical laboratory with about 180 employees of a large teaching hospital (since 2006). Several different categories for managing the test-requesting were distinguished. These were discussed with colleagues (three other departmental clinical biochemists and the operational manager) and various physicians (internal

What types of testing can be superfluous?

Broadly speaking, the issue here is what a particular test yields in relation to what it costs. For diagnostic purposes, the yield of a specific test depends on its predictive value, as determined by its sensitivity and specificity. These are typical characteristics of the test itself, in relation to the clinical context in which it is used and other testing carried out simultaneously or beforehand. When tests have a low predictive value for the differential diagnosis or disease being

Discouraging or not automatically fulfilling test requests

The most straightforward method to interfere with potentially questionable test requests seems to be contacting practitioners by telephone or email. Most laboratories have long used this method, especially to check on the use of expensive, difficult, uncommon or obsolete tests. However, laboratory specialists rarely have clinical insight and oversight with regard to the patient; caution is therefore required when confronting practitioners with supposedly erroneous requests. It is not feasible

Discussion and recommendations

This paper attempts to outline the means of managing the demand for laboratory testing. It assesses the application, effectivity and feasibility of existing management methods and various new possibilities (Table 3). The assessment provided, of course, is undeniably subjective. Concrete evaluation of the effectivity of each of these management methods would demand a far-reaching business-economic analysis, which was beyond the scope of this paper (if possible at all). Nevertheless, this

Acknowledgement

I wish to thank Ms. Allison Edwards, Maastricht, for her help in conceiving this manuscript.

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