A 2017 report from the Canadian Institute for Health Information and Choosing Wisely Canada showed that in many clinical areas, up to 30% of tests and treatments are potentially unnecessary. While clinicians ultimately make decisions about which tests and treatments to order based on the assessment of the patient symptoms, many of these decisions can often be influenced by hospital systems and processes that, if outdated, can nudge clinicians toward ordering tests and treatments that do not reflect evidence-based guidelines and practices. This can expose patients to avoidable harm, lengthen wait times, and consume precious hospital resources.
Order sets, medical directives, laboratory order panels and computerized order entry systems, among others are examples of systems and processes that are commonly used in hospitals that can result in unnecessary testing regardless of the size of the facility, or expertise of the clinicians affiliated with the facility.
The PT/INR (prothrombin time/international normalized ratio) blood test was developed in the 1930s and validated for warfarin monitoring. The aPTT (activated partial thromboplastin time) was developed in the 1940s to screen for hemophilia in high-risk individuals and later validated for heparin monitoring. Despite these specific indications, both tests are often ordered as routine coagulation tests.
Hospitals can use various strategies to reduce unnecessary testing, primarily through educational initiatives and promoting awareness about Choosing Wisely. Coagulation testing represents an ideal area of focus since these tests are poorly understood by clinicians and often ordered indiscriminately.
Stakeholders including physicians, nurses, laboratory staff, and hospital administrator have a responsibility to ensure test utilization strategies are developed and implemented, e.g., uncoupling of PT/INR and aPTT testing options, presenting educational initiatives at grand rounds, distributing educational materials, and revising the order panels.
This story is an excerpt from IQMH Proficiency Testing Committee Comments - COAG-2109-PRE (available through the member portal, QView™). Information shared in this story and in the committee comments reflect currently available scientific literature and are subject to change as new evidence may alter future practices.