Resident attitudes and practice towards ordering laboratory tests at a teaching hospital

From the 2019 HVPAA National Conference

Dr. Rajat Thawani (Maimonides Medical Center), Dr. Steve Obanor (Maimonides Medical Center), Dr. Susan Lin (Maimonides Medical Center), Dr. Joseph Gotesman (Maimonides Medical Center), Dr. Aviva Tobin-Hess (Maimonides Medical Center), Dr. Lana Glantz (Maimonides Medical Center), Dr. Parul Kakar (Maimonides Medical Center), Dr. Lawrence Wolf (Maimonides Medical Center), Dr. Melvyn Hecht (Maimonides Medical Center)

Background

The healthcare costs in the United States are increasing, which is a cause of concern to patients, governments, health economists, and medical professionals around the world. The United States has the highest health care expenses, with health care expenditures in 2015 approaching 18% of gross domestic product. High-value, cost-conscious care aims to assess the benefits, harms and costs of interventions, and subsequently offer care that adds value. With the advances in medicine, the difficulty in reducing health care costs has been proven difficult, but increase in costs is associated with inaccessibility to healthcare, and difficult sustainability. Many interventions have been targeted towards physicians as a mean to reduce health care waste, while maintaining quality care. Studies have shown that laboratory testing is overused, and is known to add a considerable burden to healthcare costs, without adding too much value.  Apart from the cost of the test, they increase personnel workload, can cause iatrogenic anaemia, implicate further testing for spurious testing, further adding to costs, and lead to decreased patient satisfaction.

Residents are front line in delivering health care and an intervention at their stage would be more effective, and early in their career would help them carry the principle throughout their career, and transmit to future generation of doctors when they become leaders in healthcare.

Objective

Our study is the first step in a long term implementation plan for resident education and intervention to reduce ordering daily labs at the hospital.

Methods

We conducted an online survey that was circulated to resident and fellows asking about their lab ordering practice – frequency of ordering unnecessary lab tests, and reasoning behind it. We also asked them if they believe if the decreasing laboratory burden would improve resident wellness.

Results

We had 139 responses, out of which 66 (47%) were from the Department of Internal Medicine. 115 (82.7%) believed that they had definitely ordered unnecessary tests, out of which 82 thought that they ordered these tests daily or multiple times a week. Surprisingly, only 22.3% (31/139) felt that they had some to total control on ordering these labs. On further asking about reasoning behind ordering these labs, 68.3% (95/139) believed that it was out of habit and institutional culture, followed by 49.6% (69/139) residents who were worried about uncomfortable interaction with the attending, followed by 46.8% (65/139) were uncomfortable when they did not know the numbers. Irrespective of their practices, 81.3% believed that unnecessary labs add to their workload, and 94.2% believed that ordering only necessary labs would be a better use of their time.

Conclusions

Residents are aware that they order unnecessary laboratory tests multiple times a week. The most common reasons include culture, lack of education about utilisation, and fear of uncomfortable interaction with the attending. Excess, irresponsible lab ordering increases workload as per residents, and they would rather think about the lab ordering.

Clinical implication

We plan to take these reasons into account, and educate residents, follow a bottom up approach in education, and measure the change made in the number of labs ordered.