As was highlighted in the U.S. Institute of Medicine's report “To Err is Human,” there are no national guidelines about appropriate laboratory monitoring, and experts do not agree on the appropriate standards of monitoring. Now a new study, published recently in the Journal of General Internal Medicine, seeks to ascertain the factors that influence how and when physicians order laboratory tests. Researchers at the Meyers Primary Care Institute in Massachusetts studied the electronic medical records of 31,417 patients and 278 providers in a large multispecialty New England group practice. The study includes information about prescriptions for 34 high-risk conditions and their 60 associated tests.
For recommended tests, the rate of physician ordering varies greatly. For example 95% of patients taking potassium receive an order for a potassium level, but less than half of patients on Lithium receive orders for a blood count (42%) or creatinine level (49%), as is recommended. Tests measured yearly (e.g., Digoxin level) were more likely to be ordered than those required more often (e.g., AST/ALT levels in patients on Rifampin).
Specialists are more likely to order the recommended tests for the medications used in the study than primary care providers. Older patients, men, and people already using other medications are also tested more regularly. Younger patients and people who do not often visit doctors receive test orders. Younger physicians and those who are familiar with the testing guidelines associated with a specific medication are more likely to use laboratory tests to monitor their patients. The researchers also found that the so-called “black box warnings” on certain medications, which regularly alert practitioners to the need to run associated tests, are not always heeded. Read the article.
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