American College of Physicians (ACP), the US Preventative Services Task Force (USPSTF) and the American Board of Internal Medicine Foundations’ “Choosing Wisely” Campaign Encourage Better Utilization of Laboratory Tests
The American Board of Internal Medicine Foundation (ABIMF) is working with the world’s largest independent product testing organization – Consumer Reports – on a program called “Choosing Wisely.” It is a campaign to get physicians and patients to discuss whether a particular test is likely to improve patient health or an outcome. There are over 375,000 physicians in seventeen different specialty societies participating in the initiative.
Recently, the ABIMF paired with the American Society for Clinical Pathology (ASCP) to extensively review the literature and develop a list of recommendations regarding laboratory testing. Tests were selected, or targeted, if they met three criteria: 1) if the test was performed frequently and evidence exists that the test either offers no benefit or is harmful, 2) the test is costly and doesn’t prove higher quality care and 3) eliminating it or changing to an alternative test is within the control of the physician. The final list is below and is not meant to be complete, but rather to provide a starting point that would result in more effective use of resources.
Ten Laboratory Tests Physicians and Patients Should Question:
- Don’t perform population based screening for 25-OH-Vitamin D deficiency.
- Don’t perform low risk HPV testing.
- Avoid routine preoperative testing for low risk surgeries without a clinical indication.
- Only order Methylated Septin 9 (SEPT9) to screen for colon cancer on patients for whom conventional diagnostics are not possible.
- Don’t use bleeding time test to guide patient care.
- Don’t order an erythrocyte sedimentation rate (ESR) to look for inflammation in patients with undiagnosed conditions. Order a C-reactive protein (CRP) to detect acute phase inflammation.
- Don’t test Vitamin K levels unless the patient has an abnormal international normalized ratio (INR) and does not respond to vitamin K therapy.
- Don’t prescribe testosterone therapy unless there is laboratory evidence of testosterone deficiency.
- Don’t test for myoglobin or CK-MB in the diagnosis of acute myocardial infarction (AMI). Instead, use troponin I or T.
- Don’t order multiple tests in the initial evaluation of a patient with suspected non-neoplastic thyroid disease. Order thyroid-stimulating hormone (TSH), and if abnormal, follow up with additional evaluation or treatment depending on the findings.
In addition to these ten tests, there are many other recommendations from the Choosing Wisely Campaign that include laboratory testing. For example:
- Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.
- Don’t perform PSA to screen for prostate cancer in men under the age of 50, or over the age of 74.
Screening and diagnostics tests are under the spotlight of questionable practices, not only by the ABIMF, but also by the American College of Physicians (ACP). In 2012 ACP’s High Value, Cost-Conscious Care Initiative listed 37 clinical scenarios – half of which encompassed clinical lab tests. By targeting lab tests, these national campaigns have sparked enormous amounts of controversy due to the paucity of studies in the literature addressing overuse of lab tests. Additionally, there are fewer guidelines surrounding laboratory testing and they are just not evaluated in the same way therapeutic procedures are.
Controversy surrounding screening lab tests is also sparked within the general public. For example, in 2008, when the US Preventative Services Task Force (USPSTF) made a strong negative statement against PSA screening at any age – there was a large public outcry with media coverage. A study published four years earlier in JAMA found that the public had strong opinions surrounding cancer screening. The majority of respondents preferred to be screened for cancer even if no treatment were available. In addition, 74% indicated that they believed that finding cancer early via screening saved lives most, or all of the time.
The controversy surrounding screening lab tests can also be observed within the medical community. When researchers evaluated changes in national screening rates before and after the USPSTF recommendation against PSA screening the results were striking. They found that PSA screening rates were unchanged in all age groups before and after the press release – indicating that even physicians had completely ignored, or didn’t understand the recommendation.
Understanding appropriate use of screening and diagnostic laboratory tests and communicating the complexity is extremely difficult. Now more than ever we need laboratories and pathologists who understand the evidence base of lab testing to align and work more closely with clinicians. Hopefully then, controversy can be lessened and the solution framed not in terms of simply increasing or decreasing testing, but rather to ensure that the right tests are used at the right time on the right patients.
- The ABIM Foundation. Choosing Wisely Campaign. 2015.
- ACP High Value, Cost-Conscious Care Initiative 2010. (www.acponline.org).
- Schwartz LM. Et al. Enthusiasm for Cancer Screening in the United States. JAMA 2004;29(1):71-8.
- Prasad SM. Et al. 2008 US Preventative Services Task Force Recommendations and Prostate Cancer Screening Rates. JAMA 2012;307(16):1692-1694.
Author: Sarah Daccarett, MD, FCAP