Slowly, but surely, efforts being made by the American Board of Internal Medicine (ABIM) Foundation’s, Choosing Wisely campaign are taking hold, making measurable progress in improving laboratory/medical procedure utilization through education about evidence-based recommendations. The program’s intent is to promote conversations between patients and physicians about the best care plans that eliminate unnecessary tests and procedures.

ASCP’s Contribution to Choosing Wisely

ASCP recently released five new recommendations for lab test ordering (for a total of 25–view the full ASCP list). The added recommendations are as follows:

  • Don’t request just a serum creatinine to test adult patients with diabetes and/or hypertension for CKD; use the Kidney Profile (serum Creatinine with eGFR and urinary albumin-creatinine ratio).
  • Don’t transfuse plasma to correct a laboratory value; treat the clinical status of the patient.
  • Don’t order IgM antibody serologic studies to assess for acute infection with infectious agents no longer endemic in the US, and in general avoid using IgM antibody serologies to test for acute infection in the absence of sufficient pre-test probability.
  • Do not perform peripheral blood flow cytometry to screen for hematological malignancy in the settings of mature neutrophilia, basophilia, erythrocytosis, thrombocytosis, isolated anemia, or isolated thrombocytopenia.
  • Don’t perform Procalcitonin testing without an established, evidence-based protocol.1

Top Performing Recommendations

ABIM shared a list of the top 12 Choosing Wisely recommendations that are being successfully used to improve lab procedure orders. The most effective recommendations (from various specialty societies) are from the following categories:

  • Use of antibiotics in patients with upper respiratory infections
  • Imaging for nonspecific low back pain
  • Imaging for uncomplicated or stable headaches
  • Vitamin-D testing
  • Repetitive CBC and labs
  • In-patient blood utilization
  • Routine annual cervical cytology screening (Pap tests)
  • Benzodiazepines for adults 65 years of age and older
  • Preoperative testing in patients scheduled to undergo low- and/or intermediate-risk non-cardiac surgery
  • Telemetry in non-intensive care unit
  • Antibiotics beyond 72 hours for inpatients with no signs of infection2

Choosing Wisely in Action

Education for providers and patients about best orders is particularly important in rural areas with higher poverty and lower literacy. A recent project called “Reaching Rural Providers, Patients and Communities,” in collaboration with the Michigan Health Improvement Alliance (MiHIA), used Choosing Wisely handouts and materials at four rural health sites. By sharing this educational information with patients, not only did the patients learn, the caregivers did as well, realizing the value of taking time to explain certain health condition and options to patients. 3

Improving Test Utilization

In another real-life example of Choosing Wisely in action, at Griffin Hospital in Connecticut, they used daily meetings to discuss lab orders for CBCs and electrolyte panels. They discovered that:

  • Often providers are unaware when a lab test has already been ordered.
  • No reasoning is required for ordering lab test.
  • Assumptions were made that missing lab tests in the chart meant they were not ordered.

After monitoring for a year, Griffin reduced the volume of CBCs and electrolyte panels by 9% with no adverse consequences and avoided collection of several thousand unnecessary ccs of blood. 4

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Notes

  1. ASCP.org. (n.d.). Twenty-five things physicians and patients should question. Retrieved from https://www.ascp.org/content/docs/default-source/get-involved-pdfs/25-things-to-question.pdf