Investigations may not change your patient’s management plan for several reasons. In some cases, the patient’s pre-test probability for a condition is low, and further testing is not necessary (e.g., screening for breast cancer in younger women with low risk of breast cancer). Another example is unnecessary preoperative testing before a low-risk surgical procedure where the risk of complications is low. On the other hand, high-risk patients may warrant treatment irrespective of the test result; thus, testing in these patients would not influence the ultimate decision to treat (e.g., thrombophilia testing in patients with an unprovoked pulmonary embolism at high risk for recurrence is not helpful, since these patients should receive indefinite anticoagulation). Where possible, residents can refer to evidence-based clinical decision rules to guide appropriate testing or treatment – examples include the Well’s criteria or pulmonary embolism rule-out criteria (PERC) for pulmonary embolism, the Canadian CT Head Rule for CT scan of the head in a trauma patient, or the Centor criteria for likelihood of bacterial infection in adult patients with a sore throat.
Feely MA, et al. Preoperative testing before noncardiac surgery: guidelines and recommendations. Am Fam Physician. 2013 Mar 15;87(6):414-8. PMID: 23547574.
Kirkham KR, et al. Preoperative laboratory investigations: rates and variability prior to low-risk surgical procedures. Anesthesiology. 2016 Apr;124(4):804-14. PMID: 26825151.
Kirkham KR, et al. Preoperative testing before low-risk surgical procedures. CMAJ. 2015;187(11):E349-58. PMID: 26032314.
Rolfe A, et al. Reassurance after diagnostic testing with a low pretest probability of serious disease: Systematic review and meta-analysis. JAMA Intern Med. 2013;173(6):407-16. PMID: 23440131.
Rusk MH. Avoiding unnecessary preoperative testing. Med Clin North Am. 2016 Sep;100(5):1003-8. PMID: 27542420.
Stevens SM, et al. Guidance for the evaluation and treatment of hereditary and acquired thrombophilia. J Thromb Thrombolysis. 2016 Jan;41(1):154-64. PMID: 26780744.
Stevens SM, et al. Thrombophilic evaluation in patients with acute pulmonary embolism. Semin Respir Crit Care Med. 2017;38(1):107-20. PMID: 28208204.Share on Facebook Share on Twitter
Daily laboratory investigations can persist despite clinical stability for a variety of reasons (e.g., daily order without a stop date, not reassessing whether investigations are still needed). Observational studies suggest that resident physicians order routine daily CBC (complete blood count) and electrolyte panels more frequently than attending physicians. Daily phlebotomy contributes to patient discomfort and iatrogenic anemia. Studies support the safe reduction of repetitive laboratory investigations when patients are clinically stable without a negative impact on patient outcomes, including readmission rates, critical care utilization, adverse events, or mortality. Laboratory investigations should be ordered with a specific purpose which directly links to a specific management plan for patients.
Choosing Wisely Canada. Canadian Association of Pathologists: Five Things Physicians and Patients Should Question [Internet]. 2014 Oct 29 [cited 2017 May 19].
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Ellenbogen MI, et al. Differences in routine laboratory ordering between a teaching service and a hospitalist service at a single academic medical center – a survey and retrospective data analysis. South Med J. 2017;110(1):25-30. PMID: 28052170.
Konger RL, et al. Reduction in unnecessary clinical laboratory testing through utilization management at a US Government Veterans Affairs Hospital. Am J Clin Pathol. 2016 Mar;145(3):355-64. PMID: 27124918.
Melendez-Rosado J, et al. Reducing unnecessary testing: an intervention to improve resident ordering practices. Postgrad Med J. 2017 Jan 19. pii: postgradmedj-2016-134513. PMID: 28104806.Share on Facebook Share on Twitter
Patients are often ordered intravenous (IV) medications when oral (PO) options are available, appropriate, and equally bioavailable. Common examples include antibiotics that are highly orally bioavailable (e.g., fluoroquinolones), oral potassium replacement (which is more effective than IV replacement), proton pump inhibitors (PPI) including in the setting of many cases of acute gastrointestinal bleeding, and oral vitamin B12 replacement (as opposed to intramuscular injections, including in the context of pernicious anemia). Peripheral catheters increase the risk of complications, including extravasation, infections, and thrombophlebitis. Furthermore, IV medication administration is often significantly costlier, decreases patient mobility, and increases length of hospital stay and pharmacist and nursing workload.
Butler CC, et al. Oral vitamin B12 versus intramuscular vitamin B12 for vitamin B12 deficiency: a systematic review of randomized controlled trials. Fam Pract. 2006 Jun;23(3):279-85. PMID: 16585128.
Choosing Wisely Canada. Association of Medical Microbiology and Infectious Disease Canada: Five Things Physicians and Patients Should Question [Internet]. 2015 Sep 4 [cited 2017 May 19].
Cyriac JM, et al. Switch over from intravenous to oral therapy: a concise overview. J Pharmacol Pharmacother. 2014 Apr;5(2):83-7. PMID: 24799810.
Dellit TH, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007 Jan 15;44(2):159-77. PMID: 17173212.
Lau BD, et al. Budget impact analysis of conversion from intravenous to oral medication when clinically eligible for oral intake. Clin Ther. 2011;33(11):1792-6. PMID: 22001356.
Tsoi KK, et al. Meta-analysis: comparison of oral vs. intravenous proton pump inhibitors in patients with peptic ulcer bleeding. Aliment Pharmacol Ther. 2013 Oct;38(7):721-8. PMID: 23915096.Share on Facebook Share on Twitter
Discharges are commonly delayed for investigations that will not change acute management. Examples include biopsies, imaging to further investigate incidental findings, assessment by a specialist that is non-urgent, waiting for bloodwork results as part of a non-urgent diagnostic work-up, or echocardiography for patients with mild heart. Delayed discharges contribute to hospital over-crowding and negatively impact care efficiency. Crucially, longer lengths of stay is a risk factor for nosocomial infections, venous thromboembolism, pressures injuries, immobility, malnutrition, and deconditioning. Consider outpatient investigations when possible, if good follow-up can be assured.
Bhatia RS, et al. An education intervention reduces the rate of inappropriate echocardiograms on an inpatient medical service. JACC Cardiovasc Imaging. 2013 May;6(5):545-55. PMID: 23582360.
Canadian Association of Emergency Physicians. Overcrowding [Internet]. 2017 [cited 2017 May 19].
Gundareddy VP, et al. Association between radiologic incidental findings and resource utilization in patients admitted with chest pain in an urban medical center. J Hosp Med. 2017 May;12(5):323-8. PMID: 28459900.
Laurencet ME, et al. Early discharge in low-risk patients hospitalized for acute coronary syndromes: feasibility, safety and reasons for prolonged length of stay. PLoS One. 2016 Aug 23;11(8):e0161493. PMID: 27551861.
McNicholas S, et al. Delayed acute hospital discharge and healthcare-associated infection: the forgotten risk factor. J Hosp Infect. 2011 Jun;78(2):157-8. PMID: 21497945.
Richardson DB. The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay. Med J Aust. 2002;177:492-5. PMID: 12405891.
Webster BS, et al. The cascade of medical services and associated longitudinal costs due to nonadherent magnetic resonance imaging for low back pain. Spine (Phila Pa 1976). 2014 Aug 1;39(17):1433-40. PMID: 24831502.Share on Facebook Share on Twitter
When considering diagnosis or screening investigations, consider all available tests. It is prudent to consider the least invasive option that will have similar sensitivity and specificity to guide clinical decision making to minimize the potential for harm to the patient. For example, when diagnosing acute appendicitis in children, ultrasound should be considered before computed tomography (CT) scanning. Not only is ultrasound radiation- and contrast-free, but it has been shown to be equivalent to CT scanning in the diagnosis and management of acute appendicitis across several clinically-relevant endpoints, including time to antibiotic delivery, time to appendectomy, negative appendectomy rate, perforation rate, or length of stay. Another example is conducting a non-invasive urea breath test rather than invasive endoscopy to prove H. pylori eradication. The sensitivity and specificity of the urea breath test are superior compared to other diagnostic tests and the risk of patient harm is minimal compared to endoscopy.
Aspelund G, et al. Ultrasonography/MRI versus CT for diagnosing appendicitis. Pediatrics. 2014 Apr;133(4):586-93. PMID: 24590746.
Mathews JD, et al. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ. 2013 May 21;346:f2360. PMID: 23694687.
Mitchell H, et al. Epidemiology, clinical impacts and current clinical management of Helicobacter pylori infection. 2016 Jun 6;204(10):376-80. PMID: 27256648.
Mostbeck G, et al. How to diagnose acute appendicitis: ultrasound first. Insights Imaging. 2016 Apr;7(2):255-63. PMID: 26883138.
Perri F, et al. Helicobacter pylori antigen stool test and 13C-urea breath test in patients after eradication treatments. Am J Gastroenterol. 2002 Nov;97(11):2756-62. PMID: 12425544.
Shogilev DJ, et al. Diagnosing appendicitis: evidence-based review of the diagnostic approach in 2014. West J Emerg Med. 2014 Nov;15(7):859-71. PMID: 25493136.Share on Facebook Share on Twitter
There are often diagnostic approaches and treatment options that result in the same clinical outcome but are less invasive. Examples include the use of ultrasound instead of computed tomography (CT) scanning to diagnose acute appendicitis in children, or the use of an oral antibiotic that has similar oral bioavailability as its intravenous counterpart. Taking time to consider the diagnostic sensitivity and specificity of less invasive tests or the therapeutic effectiveness of less invasive treatments can minimize unnecessary patient exposure to harmful side effects of more invasive tests or treatments.
Adibe OO, et al. An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children. J Pediatr Surg. 2011 Jan;46(1):192-6. PMID: 21238665.
Choosing Wisely Canada. Association of Medical Microbiology and Infectious Disease Canada: Five things physicians and patients should question [Internet]. 2015 [cited 2017 Jun 5].
Choosing Wisely Canada. Canadian Association of Radiologists: Five things physicians and patients should question [Internet]. 2014 [cited 2017 Jun 5].
Dellit TH, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007 Jan 15;44(2):159-77. PMID: 17173212.Share on Facebook Share on Twitter
When ordering tests, it is important to always consider the diagnostic characteristics such as sensitivity, specificity and predictive value in light of the patient’s pre-test probability. Patients who are at very low baseline risk often do not require an additional test to rule out the diagnosis. Furthermore, evidence suggests that in such low-risk patients, diagnostic tests do not reassure patients, decrease their anxiety, or resolve their symptoms. Examples include the use of computed tomography (CT) scanning in low-risk patients to rule out pulmonary embolism, or pre-operative cardiac testing for patients prior to low risk surgery. Evaluation of baseline risk and the use of decision tools wherever possible, along with a ‘how will this change my management’ approach, can help to avoid unnecessary ‘rule out’ testing in patients.
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Choosing Wisely Canada. Canadian Cardiovascular Society: five things physicians and patients should question [Internet]. 2014 [cited 2017 Jun 5].
Choosing Wisely Canada. Canadian Society of Internal Medicine: Five things physicians and patients should question [Internet]. 2014 [cited 2017 Jun 5].
Kirkham KR, et al. Preoperative testing before low-risk surgical procedures. CMAJ. 2015;187(11):E349-58. PMID: 26032314.
Rolfe A, et al. Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA Intern Med. 2013;173(6):407-16. PMID: 23440131.
Stein EG, et al. Success of a safe and simple algorithm to reduce use of CT pulmonary angiography in the emergency department. AJR Am J Roentgenol. 2010 Feb;194(2):392-7. PMID: 20093601.Share on Facebook Share on Twitter
Patient requests sometimes drive overuse. For example, a parent might request antibiotics for his or her child who likely has viral sinusitis, or a patient might request magnetic resonance imaging (MRI) for low-back pain. Often patients are unaware of the benefits, side-effects and risks of tests and treatments. Taking time to explore a patient’s concerns, and counseling them about the relative benefits and risks of tests or treatments represents a patient-centered approach to ensuring the appropriate use of resources.
Brett AS, et al. Addressing requests by patients for nonbeneficial interventions. JAMA. 2012;307(2):149-150. PMID: 22235082.
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Chou R, et al. Imaging strategies for low-back pain: Systematic review and meta-analysis. Lancet. 2009 Feb 7;373(9662):463-72. PMID: 19200918.
Schumann SA, et al. Patients insist on antibiotics for sinusitis? Here is a good reason to say “no”. J Fam Pract. 2008 Jul;57(7):464-8. PMID: 18625169.
Smith SR, et al. Treatment of mild to moderate sinusitis. Arch Intern Med. 2012 Mar 26;172(6):510-3. PMID: 22450938.
Williams CM, et al. Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med. 2010 Feb 8;170(3):271-7. PMID: 20142573.Share on Facebook Share on Twitter
Unfortunately, in some learning environments, a hierarchy exists between supervisors and students that makes it difficult for students to feel comfortable speaking up. As a result, students might observe unnecessary care, but avoid saying anything for fear of potential consequences. Supervisors need to encourage students to feel free to question whether tests or treatments are truly necessary without fear of repercussion. The clinical training environment should be one where students feel safe to ask questions.
Moser EM, et al. SOAP-V: Introducing a method to empower medical students to be change agents in bending the cost curve. J Hosp Med. 2015 Sep 28. PMID: 26416013.Share on Facebook Share on Twitter
The clinical training years in medical school represent an important opportunity for students to translate what was learned in the classroom to the bedside. This can be a challenging time of great uncertainty for students. Students may order tests excessively due to a lack of clinical experience, or recommend investigations in order to build upon their personal experience.
Griffith CH 3rd, et al. Does pediatric housestaff experience influence tests ordered for infants in the neonatal intensive care unit? Crit Care Med. 1997 Apr;25(4):704-9. PMID: 9142039.
Hardison JE. To be complete. N Engl J Med. 1979 May 24;300(21):1225. PMID: 431674.Share on Facebook Share on Twitter
A “hidden curriculum” pervasive in the academic environment encourages medical students to search for zebras through extensive (and often unnecessary) diagnostic workups. Because restraint is often discouraged, students adopt the belief that faculty expect an exhaustive diagnostic approach, and feel that they need to demonstrate their knowledge, thoroughness and curiosity through test ordering. Students can overcome this practice by articulating why they chose not to order a specific test. This, combined with a shift towards ‘celebrating restraint’ by faculty can help to combat this pervasive practice in medical training.
Detsky AS, et al. A new model for medical education: celebrating restraint. JAMA. 2012 Oct 3;308(13):1329-30. PMID: 23032547.Share on Facebook Share on Twitter