Researchers observe that over-utilization of lipid tests by many physicians represents a waste of healthcare resources

Up to one-third of coronary heart disease (CHD) patients undergo lipid testing that may be unnecessary. This is one finding from a credible study involving 28,000 patients that could focus more attention on the overuse of lipid tests and similar medical laboratory tests by physicians.

Most pathologists and clinical laboratory managers will welcome the findings of this study. It is widely recognized within the laboratory medicine profession that many physicians regularly order inappropriate medical tests. This has been a problem for decades and is the source of much wasteful spending.

The lipid testing study is significant because of the large volume of lipid tests performed annually in the United States. Any attention to this problem can help improve utilization of this important test and result in substantial savings to the healthcare system.

Repeated Lipid Testing Wastes Healthcare Resources

Researchers at the Michael E. DeBakey VA Medical Center (VAMC), Houston, conducted a study of almost 28,000 CHD patients, according to a recent story published online at internalmedicinenews.com (IMN). IMN reported that study subjects had well-controlled lipid levels, with excellent mean baseline levels of LDL cholesterol (70 mg/dL), non-HDL cholesterol (94 mg/dL), triglycerides (123 mg/dL), and HDL cholesterol (43 mg/dL).

In a recent study of the appropriate use of lipid testing by clinicians, Salim S. Virani, M.D., Ph.D. (pictured above), and his associates at the Health Policy, Quality & Informatics Program at Houston VA Health Services Research and Development Center of Excellence accessed data on 28,000 CDH patients to identify existing clinical practices. The researchers concluded that lipid test utilization could be improved with adoption of more defined evidence-based medicine algorithms and protocols. (Photo by Houston Veterans Administration.)

“One-third of patients having CDH with LDL-C levels at goal underwent repeat lipid panels,” wrote Salim S. Virani, M.D., Ph.D., and his co-authors in an analysis published at jamanetwork.com. Virani is an investigator at the Health Policy, Quality & Informatics Program at Houston VA Health Services Research and Development Center of Excellence. He is also a staff cardiologist at the DeBakey VAMC.

Researchers noted that these patients were already being treated aggressively, according to the IMN story. That suggests that repeat lipid testing of these patients likely represents overuse or waste of healthcare resources, the study authors observed.

34% of Patients Had Repeat Lipid Tests within Six Months

The patients in the study had made a primary care visit to a Veterans Affairs medical center or community-based outpatient clinic during a one-year period. Researchers determined that a total of 34% of the repeat lipid tests were done within six months of an index test, while 80% were done within nine months. The results of these retests were notably similar to those of the index lipid panels, the authors reported.

During the period analyzed, Virani and his associates found that physicians ordered 12,686 “redundant” lipid panels. Each test cost an average of $16. “This is equivalent to $203,990 in annual costs for one VA network, and does not take into account the cost of the patient’s time to undergo lipid testing and cost of the provider’s time to manage these results and notify the patient,” the investigators revealed.

Clinicians Tend to Order Repeat Lipid Tests in Complex Cases

The VAMC study showed that patients with concomitant high blood pressure or diabetes as the most likely to undergo repeat lipid panels, although redundant testing is commonplace even in healthy patients. “[This] points toward a tendency of health care providers to order frequent laboratory testing in complex patients,” Virani and his co-authors wrote. “Frequent lipid testing in these patients likely represents providers’ practice to order comprehensive laboratory tests (including lipid levels), rather than focusing on one clinical issue (e.g., ordering only glycated hemoglobin measurement to assess diabetes control).

“Repeat lipid testing likely provides a sense of comfort to the providers that they are being vigilant in following up on their patients with CHD, although a repeat lipid panel may not be indicated,” noted Virani and his associates in the IMN story. At the same time, they observed that such repeat lipid testing could represent both an overuse and a waste of health resources.

“[The study] delivers an important message regarding a type of waste that is likely widespread in healthcare and that goes under the radar because it involves a low-cost test,” observed Joseph P. Drozda, Jr., M.D., in an invited commentary accompanying Virani’s report. “It is precisely these low-cost, high-volume tests and procedures that need to be addressed if significant savings from reduction of waste are to be realized,” Drozda declared.

Lipid Study in United Kingdom Drew Similar Conclusions

In 2011, researchers at the University of Oxford in the United Kingdom assessed the rates of measurement of lipid levels (total cholesterol, high-density lipoprotein, triglyceride) for diagnosis and monitoring over the previous 20 years.

“There appears to be considerable over-monitoring that may not benefit patients, while also straining laboratories and incurring considerable economic costs to the [National Health Service] and personal costs to patients,” the researchers wrote in a paper published on the National Institutes of Health website.

These studies are significant for at three reasons:

• One, they are a demonstration of how researchers are using access to data on large numbers of patients to identify opportunities to improve the value of healthcare services.
• Two, the results of these studies could point to a reduction in volume of specimens flowing to central clinical laboratories if physicians become better at ordering lipid tests in appropriate cases.
• Three, the studies identify existing clinical practices that could be improved with adoption of more defined, evidence-based medicine algorithms and protocols.

Pathologists and clinical laboratory managers can be hopeful that one consequence of this lipid test study and others like it is that physicians take a keener interest in improving their utilization of medical laboratory tests, which would make information from consultations with pathologists much more valuable. On that point, progressive clinical laboratory organizations could use the findings of these studies as a way to educate their client-physicians about appropriate test utilization in ways that add value.

—Pamela Scherer McLeod

Related Information:

Quality improvement initiatives required to reduce repeat lipid testing

Correlates of Repeat Lipid Testing in Patients with Coronary Heart Disease

The rise of cholesterol testing

A third of CHD patients may undergo unnecessary lipid testing

The rise of cholesterol testing: how much is unnecessary