Clinical decision support / Health care quality

Why More Testing Doesn’t Mean Better Patient Care

May 30, 2016

The amount of available tests, treatments, and medical procedures available to Canadian patients is vast. However, ordering tests and procedures simply because they are available does not necessarily reflect best practices in patient care, and could potentially even cause harm to patients. Ordering practices that aren’t based on the latest clinical evidence not only escalate operational costs for hospitals, putting an increased burden on Provincial health care budgets, but may not necessarily result in improved or positive patient outcomes.

Eliminating unnecessary, costly tests and procedures

Choosing Wisely Canada, an initiative by the Canadian Medical Association, has identified a number of tests and procedures that have been flagged as unnecessary, and yielding low-value results, depending on particular clinical parameters, and recommend against them, depending upon the clinical indications.

One such low-value test researchers identified was routine blood workups prior to a low-risk, ambulatory surgery, such as cataracts removal, carpal tunnel surgery, and colonoscopies. Performing blood work on these patients hasn’t proven to have any added benefit for physicians in terms of vital clinical information, or preventing surgical complications. Rather, it can actually be more detrimental as it could cause greater patient anxiety, discomfort during the blood procurement, and even cause delays in the surgeries if errors in the tests lead to false positives or other abnormal results. Individually, each blood test may be relatively inexpensive, however, with nearly 30% of patients receiving routine blood tests prior these low-risk surgeries, this can lead to substantial cumulative costs.

A resting electrocardiogram (ECG) has long been the test of choice to determine risk of heart disease, based on abnormal blood pressure, palpitation, or chest pain. However, this procedure is highly susceptible to abnormal, nonspecific results, which can lead to a cascade of additional downstream tests, and lead to increased patient anxiety. In fact, 30% of individuals who have diagnosed heart disease have been found to have normal ECG results, while up to 30% to 50% of people with healthy hearts will yield abnormal ECG results. An ECG typically costs approximately $50 per patient – a significant cost when added up across a hospital or health system.

Ordering tests based on evidence

Reforming clinician ordering practices is just one of the many ways to not only improve health care towards a more patient-centric, outcomes-focused model, but can also help alleviate rising operational costs for hospitals across Canada. Currently, of the $42 billion dollars spent annually on health care in Ontario, 75% of that is spent on individual patients; this includes the tests and procedures ordered for each particular patient.

A key way to improve this problem is by equipping doctors and other health professionals with ordering privileges, such as pharmacists, nurse practitioners, and physician assistants with tools that will help inform their ordering practices based on actual clinical evidence. For example, electronic order sets, or medical checklists, that are built using the latest clinical research and evidence can help guide and support clinicians throughout a patient visit, determining which course of action is most suitable for each particular patient. Specific alerts and prompts can help ensure that unnecessary tests aren’t being ordered, and vice versa.

Order sets help standardize care across a facility or region, ensuring that clinicians are following the same evidence-based protocols, leaving little practice variability when it comes to ordering tests that may or may not be deemed necessary. One study out of the Institute for Health Care Research and Improvement in Dallas, Texas investigated the direct cost savings associated with implementation of a standardized heart failure order set in an in-patient setting at the Baylor University Medical Center. Results indicated a 51% decrease of in-hospital mortality rates of patients with heart failure, which lead to $1909 of annual direct cost savings since having instituted the heart failure order set.

The implications of streamlining and standardizing ordering practices across Canada’s hospitals will make all the difference towards optimizing patient outcomes and moving towards more of a patient-centric care model, while simultaneously reducing waste of valuable financial and operational resources.

Notes

  • Norton, A. ECG heart screening may not do any good, says expert panel. Reuters. September 21, 2011. Retrieved from: http://www.thestar.com/life/health_wellness/news_research/2011/09/21/ecg_heart_screening_may_not_do_any_good_says_expert_panel.html
  • Wodchis, WP, Austin PC, Henry DA. A 3-year study of high-cost users of health care. CMAJ January 2016.
  • Kirkham KR, Wijeysundera DN, Pendrith C, Ng R, Tu JV, Boozary AS, Tepper J, Schull MJ, Levinson W, Bhatia RS. Preoperative laboratory investigations: rates and variability prior to low-risk surgical procedures. Anesthesiology. 2016; Jan 28.
  • David J. Ballard, Gerald Ogola, Neil S. Fleming, Brett D. Stauffer, et al. Impact of a standardized heart failure order set on mortality, readmission, and quality and costs of care. International Journal for Quality in Health Care. 2010; Vol 22:6, 437-444
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