After a complicated stay in the hospital, my patient was finally ready to be discharged. After all he had been through, I was excited to tell him the good news. “You will be leaving this afternoon,” I said, heartened by the smile I saw spreading across his face. He thanked me, and then said something that made me cringe. “Finally! I thought you guys were going to keep sticking me with needles forever.” He was referring to practice of routine morning labs, a practice familiar to anyone who has been hospitalized in America. Every day, at the request of physicians, hospital staff members draw blood from patients to test it for abnormalities. Before morning rounds even begin, physicians have access to some basic labs, like blood electrolyte levels and cell counts, from each of their patients. Embarrassed, I apologized and wished him luck. But I later realized that I had kept ordering blood work on him even though his blood tests had been normal for several days. Why? Much has been made about the inefficiencies of the American health care system. It overtreats patients, subjecting them to potential harm. It is enormously expensive. And it is wasteful. Nothing epitomizes these qualities better than the practice of routine morning labs. It’s easy to see why morning labs are overutilized. With just a few clicks of a mouse, physicians can order blood tests for each of their patients. Worse, at first glance, this effortless endeavor appears to be free of any real consequences. In most hospitals, prices for laboratory tests are not displayed on ordering screens. And we rarely have to draw the blood ourselves, which takes time and could prompt greater reflection on whether the tests are necessary. Patients can refuse the tests, but in my experience, most do not. On the other hand, the fear of missing a laboratory abnormality that could have been fixed, like a low red blood cell count, provides a powerful, if inappropriate, incentive to test. The only readily apparent downside of testing is that the patients are forced to endure the transitory discomfort of a needlestick. It should be no surprise that in most hospitals, ordering blood tests has become a routine process, often devoid of any serious consideration of the possible harms that could result. But studies have found that excessive blood draws have serious drawbacks. A 2011 study found that they were an independent risk factor in the development of hospital-acquired anemia. Laboratory tests can result in false-positives, which can subject patients to unnecessary treatments that may do them harm. And, in rare cases, needlesticks can cause serious injury. Routine testing is also expensive. In North Carolina, for example, a single basic metabolic panel can cost up to $284. Summed over a physician’s patient census, the bill for lab testing can add up quickly. And routine testing is wasteful, sometimes yielding little valuable clinical information. Within the context of a health care system where cost pressures are becoming increasingly dire, this is problematic. If the American health care system is to reduce wasteful spending, it will need to cut back on unnecessary diagnostic testing. Cutting down on routine laboratory testing seems like a reasonable place to start. So what can we do about it? Research has shown that forcing physicians to actually consider the consequences of their actions can reduce wasteful testing. Allowing them to see how their practices stack up to those of their peers, for example, and displaying cost information on ordering screens have been shown to change their ordering patterns for the better. Preventing physicians from ordering multiple labs at once and providing greater education on the issue may also help. Patients, too, can help out. By questioning whether daily blood draws are actually necessary, they can play a crucial role in curtailing the waste. These interventions, by the way, appear to be safe. A comprehensive program to reduce unnecessary laboratory testing at an academic medical center in San Francisco led to an 8 percent reduction in such testing and over $2 million in savings over three years. Patient mortality and 30-day hospital readmission rates were unchanged. Rethinking how we use morning blood draws won’t fix all of the American health care system’s problems. But it would result in many benefits, like reduced costs and harm to patients. It’s worth a try. My patient certainly would have appreciated it. Source
