Article in press - uncorrected proof
Clin Chem Lab Med 2009;47(12):1461–1465
2009 by Walter de Gruyter • Berlin • New York. DOI 10.1515/CCLM.2009.335
Minireview
Appropriate utilization of clinical laboratory tests
Marı́a Concepción Alonso-Cerezo1,*, José
Simón Martı́n2, Miguel Angel Garcı́a Montes3
and Verónica Marcos de la Iglesia4
1
Servicio de Análisis Clı́nicos, Hospital Universitario
de La Princesa, Madrid, Spain
2
Instituto Universitario de Evaluación Sanitaria,
Facultad de Medicina, Universidad Complutense,
Ciudad Universitaria, Madrid, Spain
3
Área de Laboratorio, Hospital Moncloa (ASISA),
Madrid, Spain
4 and are usually inexpensive; fourth, there are few
Chemistry Servicio de Análisis Clı́nicos, Hospital
Universitario de La Princesa, Madrid, Spain
Abstract
Background: The use of laboratory tests has been
increasing in recent years due to various factors
affecting laboratories, physicians, legal aspects, or
patients themselves.
Methods: The efficacy of laboratory tests must be
evaluated on the basis of the clinical benefits that they
provide in terms of prevention, diagnosis, follow-up,
or treatment; with the aim of optimizing health results
in general.
Results: There are techniques that can be used to
determine the clinical validity of the efficacy, effect-
iveness, and safety of treatment or preventive meas-
ures performed on individuals with abnormal tests, as
well as providing an economic evaluation of the pro-
cess. Once the test is incorporated into clinical serv-
ice, it must be evaluated by retrospective audits in
test utilization. To improve the use of laboratory tests,
many strategies have been devised that incorporate
clinical practice guidelines (CPGs), the conduct of pro-
fessionals and the patients, and organization of the
process. We discuss the importance of the involve-
ment of health professionals.
Conclusions: Strategies in relation to CPGs, conduct
of professionals, conduct of patients, or organization
of health care processes improve the use of tests in
relation to clinical processes. Laboratory profession-
als have the appropriate knowledge and can improve
the quality and efficacy of health care.
Clin Chem Lab Med 2009;47:1461–5.
Keywords: appropriate use; efficacy; improvement;
laboratory professionals; laboratory results.
*Corresponding author: Alonso-Cerezo Marı́a Concepción,
MD, PhD, Servicio de Análisis Clı́nicos, Hospital
Universitario de La Princesa, c/ Diego de León, 62, 28006
Madrid, Spain
Phone: q34 91 520 22 49, Fax: q34 91 520 22 17,
E-mail: calonsoc.hlpr@salud.madrid.org
Received March 28, 2009; accepted August 14, 2009;
previously published online October 28, 2009
2009/158
Introduction
The medical laboratory plays an important role in the
prevention, screening, diagnosis, and monitoring of
disease.
Laboratory analyses differ from other techniques in
certain aspects: first, there is only a slight probability
of harming the patient; second, it is not easy to find
consensus approved protocols among doctors to con-
trol their use; third, the techniques are easily available
objections to their implementation, and less (or no)
regulation for their provision; and finally, oftentimes
technological dissemination occurs before proper
evaluation (1).
The use of laboratory services by physicians has
increased over the past decades (2). The increase in
the use of laboratory services is attributed to factors
impacting laboratories. This includes facilitated access,
the introduction of autoanalyzers, development of
new tests, and availability. Other factors increasing
laboratory utilization include lack of physician train-
ing in clinic management, legal aspects, and demand
from patients themselves who are increasingly
becoming aware of health problems (3).
Occasionally, physicians request inappropriate tests
that can result in unnecessary discomfort for the
patient. These tests can increase the risk of generat-
ing false positive results and can lead to further inter-
vention and other medical referrals that are really not
necessary. In addition, the use of the laboratory is a
determining factor in the consumption of health care
resources which represents -2%–3% of the total
healthcare expenditure in Europe (4). Although the
cost of an individual test is low, due to the high usage
of this technology this results in inappropriate con-
sumption of resources. These resources could be
redistributed in order to improve the delivery of
healthcare.
With respect to inappropriate use of the clinical lab-
oratory, variability in the use of laboratory tests is
going to have consequences for the patient. This is
because testing that is not efficacious is being per-
formed. It has been estimated that 30% of laboratory
tests that have been performed were repeated within
30 days (5).
Frequent problems that decrease both the efficiency
and quality of laboratory diagnostic testing are: inap-
propriate utilization, abuse, and ignorance of diag-
nostic tests (6).
Professionals should pursue a more rational use of
diagnostic and therapeutic resources, especially con-
sidering the inherent costs which are due to abuse or
inappropriate utilization. Thus, improvement in ben-
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1462 Alonso-Cerezo et al.: Appropriate utilization laboratory tests
efits derived from laboratory testing is an obligation
of the specialists in the laboratory. The appropriate
use of the laboratory is imperitive for optimum med-
ical practice. If there is improper use, this must be
corrected (7).
This minireview first describes the factors that hind-
er the appropriate use of laboratory tests, and second
outlines the development of potential strategies to
improve the clinical utilization of laboratory tests.
Obstacles and strategies for the improvement
of utilization of laboratory tests (Table 1)
Appropriateness of clinical practice guidelines
Clinical practice guidelines (CPGs) are tools used to
support strategies to enhance the quality of health
care. CPGs offer the best scientific evidence about a
clinical condition or a specific procedure. CPGs stan-
dardize clinical practice and can result in cost effective
use of resources, thereby increasing efficiency and
effectiveness.
Since the 1980s, huge efforts in developing and dis-
seminating guidelines, protocols, and standards of
practice have been made, however, obstacles remain
for implementation of CPGs (8).
Implementation of CPGs is challenging, being influ-
enced by a variety of factors pertaining to the unique
characteristics of individual CPGs and the social con-
text in which they are developed and implemented
(9). Success in implementation can be ensured by
trouble-shooting problems and obtaining commit-
ment by physicians to the entire process (10).
In the case of requests for laboratory tests, it has
been noted that the recommendations contained in
the guidelines are not followed by a large percentage
of physicians working in various clinical settings (11).
Improving guidelines, using the right path for
implementation, making them more understandable
and establishing reliable protocols are key steps for
optimizing the use of laboratory resources (12–14).
Professionals’ conduct
Many factors in medical practice, such as knowledge
and behavior influence professional conduct. It is
known that not all doctors understand the details in
the recommendations. They may not easily remem-
Table 1 Obstacles and strategies for improving the use of
laboratory tests.
1. Appropriateness of clinical practice guides
2. Professional’s conduct
a. Knowledge
b. Behavior
3. Patient’s conduct
4. Organization of the care processes
a. Appropriate use in the medical laboratory
b. Other factors
i. Health authority administration
ii. Adequacy of human and economic resources
iii. Time for implementation
ber them because of the sheer number and the many
changes they entail. To improve knowledge, several
strategies for dissemination have been identified.
Passive dissemination, such as sending educational
materials is usually ineffective. Active dissemination
strategies seem to be more effective in the long-term,
although it requires major effort and commitment. In
this intervention, the use of local opinion leaders is
included (15).
Many factors influence professional conduct – e.g.,
attitude, concern over legal aspects of medical prac-
tice, training, sources of information, availability or
use of appropriate tools, ingrained habits, tolerance
for uncertainty in diagnosis, need for a rapid answers,
clinical experience, and ethics of the individual pro-
fessional. In addition, this process is influenced by
external factors, such as management, the patients
themselves, and even the pharmaceutical industry
(16–18).
Changing physician’s behavior to cause them to
request more appropriate tests is difficult to achieve.
Among the strategies that have been proposed
include: continuous training (19), changing the man-
ner of requests for laboratory tests and a redesign of
the requirements for a specific test (20), getting more
feedback and placing reminder messages on request
forms (21), setting policies referring to requests for
laboratory tests (22), giving financial incentives (23),
improving the rationale (24), computer-decision sup-
port (25), providing information about testing costs
and making expert systems available for clinical
decisions (26).
Professionals in medical laboratories have excellent
knowledge that can help improve the quality and effi-
cacy of health care. Working as a team, professionals
in the laboratory and clinics can support the role of
laboratory specialists in clinical councils for selecting
tests and interpreting/using results, improving the
use of the tests, and remaining relevant in effecting
changes in management and organization of the
laboratory (27, 28).
Patients’ conduct
The factors that condition patient’s conduct can mod-
ify the appropriate use of laboratory tests. A patient’s
behavior is influenced by factors, such as educational
level, attitude, understanding of the illness, balance
between benefits and risks of treatment or how it is
managed, the use of the Internet to gain health infor-
mation (e.g., Lab Test Online) and communication
with physicians (29–31). There are times that a patient
cannot see their doctor or undergo the test or treat-
ment; other times, the patient could have added the
request himself/herself simply because it was too
easy to do so in the request form.
Changing patient behavior is difficult and requires
effort, time, and motivation. Improved physician and
patient communication, as well as patients assuming
a more active role, can help close some of these gaps
and improve test use. However, studies on the effec-
tiveness of advice show that this is successful in
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Alonso-Cerezo et al.: Appropriate utilization laboratory tests 1463
5%–10% of patients only (32). Patient brochures sub-
stantially improve monitoring of their condition (10).
To prevent patients from making the requests
themselves, the laboratory information system (LIS)
is connected to the clinical information system in such
a way that the request is generated directly in the cen-
tral services of the laboratories when requested by a
professional. It should not be assumed that the intro-
duction of physician orders in the LIS can provide
better use; rather, this may increase error rates (33).
The organization of the care processes
Several professionals or health care units cooperate
in any healthcare activity. To make this process more
efficient, communication and coordination are impor-
tant so that information can flow and the patient can
receive the best treatment possible. The efficacy and
efficiency of the process and its results will depend
on the coordination of the activities.
Clinical laboratory practice takes a part in the clini-
cal process by following procedures that have previ-
ously been established with other medical services.
Professionals in medical laboratories need to work
with their clinical colleagues to ensure that all tests
are necessary and appropriate to the patient.
Appropriate use in the medical laboratory The effi-
cacy of laboratory tests must be measured and eval-
uated in relation to their clinical benefit in terms of
prevention, diagnosis, follow-up, or treatment; with
the goal of optimizing the use of health care resour-
ces. To consider a test as clinically useful, it must sat-
isfy the conditions of analytical accuracy, precision,
reliability, sensitivity, and specificity, as well as clini-
cal sensitivity, specificity, and predictive values. In
addition, economic assessment must compare other
alternatives and see which provides less cost or great-
er benefits in terms of health care. It is necessary to
define the use of evidence and identify and quantify
potential sources of error and sources of analytical
variation and biological variation (34, 35).
The introduction of a laboratory test without previ-
ous evaluation of efficacy prevents the appropriate
use of medical testing. Correct utilization of a test in
clinical practice must be evaluated by performing ret-
rospective audits. This is how many studies evaluate
whether tests are based on criteria recommended by
CPGs (36) and determine the necessity of improving
the utilization of laboratory tests (37).
The term ‘‘appropriate utilization in clinical labora-
tory’’ refers to the entire process. This includes the
external and internal aspects of the laboratory in the
pre-analytical, analytical, and post-analytical stages
(38). Most laboratory errors occur in manual pre-
analytical processes. The development of procedures,
provisions for training, improving inter-departmental
cooperation, and implementation of advanced infor-
mation technology and robotics in the pre-analytical
phase (specimen collection and pre-analytical sample
handling) has improved the accuracy and clinical effi-
ciency of laboratory processes (39). Accurate detec-
tion and management of unsuitable specimens are
needed. Several scientific societies have published
recommendations for improving the detection and
management of specimens in clinical laboratories
(40).
For many biochemical tests involving blood or
urine, the reference interval is simply defined as
two standard deviations from the mean of a healthy
population. Therefore, by definition, about 5% of the
results of each test are labeled, perhaps incorrectly,
as abnormal. In the interpretation of the test, the phy-
sician cannot assess the statistical basis for the ref-
erence interval of the test and underestimates the
risk of false positives (41). The use of interpretative
comments can be used as a strategy for improving
the transmission and communication of laboratory
results, and help in their interpretation so that appro-
priate action is taken (42). The use of longitudinal
comparison of data is another important step in this
process. This means that results should be interpret-
ed with respect to its difference or bias with earlier
results obtained from the same individual. This allows
one to evaluate the significance of the change
between two successive measurements. This is useful
in monitoring and follow-up of various clinical
conditions (43). The LIS can be used to calculate the
longitudinal comparison of data.
Other strategies for improving the utilization of
tests is the development of expert systems for prior-
itizing and interpreting laboratory tests. Depending on
the results of the initial laboratory tests, the expert
system makes the implementation and interpretation
of new tests easier and more organized. As a conse-
quence of the use of expert systems in the analysis,
there will be a decrease in test utilization, the time for
producing a result, and the cost (44).
At present, it is essential to have a LIS that merges
laboratory management with treatment of analytical
data. The LIS is applied to the process of health care,
research, and laboratory management. The integrity
of laboratory information generated for other diag-
nostic, clinical, or administrative tasks represents an
added value. The LIS is a valuable resource. It can
be coupled with software that can measure quantita-
tive and qualitative differences in the utilization of the
tests, provide an interpretation of these data, follow
the recommendations of CPGs, and offer an effective
model for monitoring results. The LIS facilitates the
completion of the audit and feedback of CPGs to help
reduce unnecessary test use. Finally, it can provide
training to physicians. The clinical database registra-
tion file is effective as a support tool for making clin-
ical and administrative decisions (45, 46).
Health authority administration The health authority
administration has the responsibility for evaluating
public health programs, develop quality policies and
ensure that these are effectively implemented (47).
To improve the use of laboratory tests, first, it is
necessary to make the health management organiza-
tion a major part of the health care plan. Second, the
organization should help managers in the dissemi-
nation of guidelines.
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1464 Alonso-Cerezo et al.: Appropriate utilization laboratory tests
Managers must establish a clinical attention pro-
gram, ensuring a process of continuous improvement
of health care processes as a strategy for applying
scientific evidence in daily practice. The manager’s
responsibility consists of facilitating the project and
providing support to the team and service manage-
ment (48).
Adequacy of human and economic resources For
implementing new diagnostic or therapeutic proce-
dures, human and economic resources are needed.
Without these elements, execution of the procedures
is unfeasible.
In clinical laboratories, tests are usually performed
when requested by the physician, regardless of the
frequency of request or the clinical indication. As a
consequence, inappropriate consumption of resourc-
es can occur. This action increases total health care
costs, as unnecessary tests represent a waste of re-
sources. More efforts must be spent on educating
physicians about costs and giving them access to
cost information (49).
Time for implementation This term refers to the
time physicians need to apply the recommendation,
time that they spend in the medical center or time
saved due to organizational changes. Lack of time
results in the incorrect utilization of the recommen-
dations with respect to the use of laboratory tests.
Appropriateness of the time of surgery with respect
to the patient’s condition represents an improvement
in health care quality (50).
Conclusions
The increasing use of laboratory tests has some inev-
itable clinical, organizational and economical conse-
quences. Studies of analytical and clinical validity,
clinical utility, and economic evaluation must precede
the incorporation of tests into clinical service. Audits
of test utilization with respect to clinical processes is
necessary for planing strategies to choose the best
test following CPGs, and improving existing strate-
gies. Laboratory professionals have the appropriate
knowledge and can help improve the quality and effi-
cacy of health care.
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