By Abby S. Van Voorhees, MD, July 01, 2013
In this month’s Acta Eruditorum column, Physician Editor Abby S. Van Voorhees, MD, talks with Leonard S. Feldman, MD, about his recent JAMA Internal Medicine article, “Impact of Providing Fee Data on Laboratory Test Ordering: A Controlled Clinical Trial.”
Dr. Van Voorhees: We as physicians spend a lot of time learning about laboratory testing for a given clinical setting. Sometimes it is driven by a patient’s diagnosis, other times the medication that we have them taking. Most of this education centers on the appropriateness of a given test in a specific clinical situation. Let’s start our conversation with a few comments about why the cost of laboratory tests is important. Help us understand the magnitude of this problem.
Dr. Feldman: There are many reasons why costs are important. One of the main ones is that health care spending is out of control; it’s been well-documented that we are spending money in our health care system at an incredible rate, much higher than any other country in the world, without getting the bang for our buck that we should be in terms of better health care outcomes. So the cost of everything should be a part of the solution as we think about how to provide high-value, cost-conscious care. The system is going to implode if we’re not able to rein in costs.
One way to do that is to make sure when we’re ordering tests that we are thinking about whether that test is indicated, reminding ourselves that there is a monetary cost associated with it, and remembering that there are downstream costs associated with false positives as well. Uwe Reinhardt at Princeton does a blog in the New York Times; he showed a graph looking at the cumulative percentage increase in the volume of physician services per Medicare beneficiary from 2000 to 2009. For tests and imaging, there’s about an 85 percent cumulative increase over that 10-year period. [pagebreak]
Dr. Van Voorhees: In dermatology we often focus on the costs of procedures. Did the cost of procedures increase as significantly over that 10-year period?
Dr. Feldman: Not quite. Tests and imaging led the way. Other procedures were at about a 65 percent increase over that 10-year period, while major procedures and E/M coding were each just over 30 percent.
Dr. Van Voorhees: Isn’t defensive medicine one of the main culprits for excessive test ordering? Is there evidence that there are other causes too?
Dr. Feldman: There are defensive medicine issues. But that’s not why the residents at Johns Hopkins are ordering these frequently ordered tests every day. They’re not thinking to themselves, “If I don’t order this test I’m going to get sued.” They’re doing it because they think it’s what their senior resident expects. It’s a learned behavior. Maybe over time, when they’re an attending physician, they might start thinking about the defensive medicine aspect, but that’s not why they learn to order tests on a regular basis.
It’s the inexpensive but frequent tests that really drive the costs. In the outpatient world there’s also a patient expectation factor that plays into this. There’s insufficient understanding of the limitations and operating characteristics of tests. If you don’t know how test results might change the post-test probabilities or your management, you shouldn’t be ordering the test. There’s also the problem of repeated testing by providers who don’t have access to the results of tests that have already been performed by others. And then there may be some economic incentives for testing, but I think those factors play a much smaller role overall. [pagebreak]
Dr. Van Voorhees: Containing costs — not a new idea. What have we known prior to your work? What strategies have been implemented? Are they effective at lowering the frequency of ordered tests?
Dr. Feldman: There have been a number of different studies on this in the past. One of the reasons we did this study was that previous studies have had very complicated and intrusive interventions. In 1983, Grossman et al reviewed about five intervention strategies that had been used back then to try to contain costs educational strategies, feedback strategies to compare actual ordering behavior with ordering protocols, cost-awareness strategies, rationing strategies, and market-oriented financial incentive and risk-sharing strategies. So this is not new. These strategies have been discussed for a long time.
But many of the strategies that are out there involve ongoing educational efforts. In a residency program where you have new interns brought in every year you need to teach those interns every year and keep reinforcing this with the senior residents. That’s a lot of work for residency programs around the country to add to their already large curriculum. Giving individualized feedback to the resident takes a lot of time. Extra clicks on the ordering system that ask if you really want to order or if you know how much something costs — adding those extra clicks to an already busy provider’s days was something we didn’t consider a good idea. We wanted something that would be efficient to roll out and exportable from the standpoint of not requiring tremendous resources to implement it at other sites. [pagebreak]
Dr. Van Voorhees: Tell us about your study. Were doctors penalized for ordering lab studies or other diagnostic tests? What happened?
Dr. Feldman: We wanted to see if we could make that basic connection in the minds of our providers, and particularly our residents, that what they were ordering actually costs money, and see if that would change their behavior. We took 70 lab studies and divided them into groups of the most inexpensive but commonly ordered lab studies and the most expensive but often infrequently ordered lab studies. We randomized tests in those two groups into an active group and a control group. We wanted to see if would we be able to impact the ordering behavior of our providers by having those studies in the active group have their costs displayed in the computerized provider order entry system (CPOE). So when someone went to order a test, they wouldn’t need to press any more buttons, but they would see, in an additional column to the right of the test they were about to order, the cost. We didn’t fill in costs for every test — just those that were randomized to the active group. We had a six-month baseline period with no costs displayed, and then exactly a year later we did a six-month intervention period during which we displayed the costs of the labs that were randomized to the active arm and did not display the costs of the labs that were randomized to the control arm. We wanted to see if we would decrease the number of tests ordered within the active arm, as well as what would happen to the control arm. [pagebreak]
What we saw was that we were able to significantly decrease the number of labs ordered per patient and the overall cost of the labs that were ordered in the active arm. Interestingly, in the control arm, the costs went up a significant amount, but not nearly as much as they were reduced in the active arm. The number of tests ordered per day also went up in the control arm, but again, not nearly as much as the number of tests ordered per day went down in the active arm. One of the main drivers for this is that the comprehensive metabolic panel (CMP), which contains all of the electrolytes but also includes LFT results, was ordered much less. CMPs were in the active arm and cost about $15 per day. Instead the basic metabolic panels, BMPs, which cost around $3 less than the CMP and were in the control arm, were ordered much more often. Providers decided they didn’t need to know the LFTs every day so they ordered fewer CMPs and more BMPs. That was a really good decision from a high-value, cost-conscious care perspective. Another example was the ionized calcium. It turns out that you get calcium results in your BMP and CMP, it’s just not an ionized calcium. The ionized calcium test was in the active arm, and we saw a large decrease in the number of ionized calciums ordered without a corresponding increase in another lab. Providers realized that, in most cases, you get all of the information you need about calcium just from the BMP or CMP.
Another issue, particularly with CPOEs, is that it’s easy to have a test repeated on a daily basis when you order it the first time; you just hit the repeat button and the patients have their blood drawn every day, no matter what. We were hoping that our providers would think about whether they should have that repeat button on and, if you have that repeat button on, why not order the BMP instead of the CMP? We certainly saw evidence that that happened.
The day we rolled out the study, I heard residents say they were excited to see the costs for the tests they were ordering and had not thought about it before. We didn’t have responses like, “Oh, costs shouldn’t be involved in health care,” or “Why would they give us this information?” Just, “This is great, the more information we have the more empowered we are.” That was very reassuring. [pagebreak]
Dr. Van Voorhees: Do you think that these findings are applicable in the dermatologic community? We are not often hospital-based, and are less regularly dealing with inpatients. Would you anticipate that we would have similar outcomes?
Dr. Feldman: Where we had the biggest bang for our buck was in frequently ordered tests that otherwise seem inexpensive but add up when you’re ordering thousands and thousands of them. In the world of dermatology I don’t imagine there’s the same volume of inexpensive but frequently ordered tests.
But the basic philosophy remains the same: We should only be ordering tests that we think are going to change outcomes or management. We should know why we’re ordering tests and how we’re going to use the results; we should understand the tests we’re ordering and not then order other tests based on spurious results or results we can’t interpret because you wouldn’t have been able to interpret it no matter what result you got. Our approach should always be high-value and cost-conscious no matter what the setting. My guess is that dermatologists’ ordering habits are not in the same ballpark as internists in an inpatient setting so I don’t know if you’d see, overall, the same cost savings. But the basic premise is germane to all.
The bottom line is that you need to order tests when you think it will make a difference in the patient’s care. My hope is that the dermatology community orders more tests when caring for patients with a high pre-test probability for significant disease processes where the results of the tests are likely to change management and improve the patient’s health outcomes. Then it’s really appropriate to order the tests! But when we’re ordering tests in low pre-test probability situations or when the test isn’t going to change management, I think we can all learn to not test just for the sake of testing. Then we may really begin to provide high-value, cost-conscious care.
Dr. Feldman is assistant professor of medicine and pediatrics at the Johns Hopkins University School of Medicine. His article was published online April 15 in JAMA Internal Medicine, 2013;():1-6. doi:10.1001/jamainternmed.2013.232.