Through a campaign aimed to assist patients and clinicians in talking about appropriate care choices, the American Society for Clinical Pathology (ASCP) recommended five tests that should prompt a discussion because those tests may be overused or incorrectly used for some patients.
The Choosing Wisely campaign, an initiative of the American Board of Internal Medicine (ABIM) Foundation, comprises than 35 healthcare societies that have already or will recommend five tests or procedures that may not be the best treatment option for all patients. Seventeen of these medical societies, including ASCP, shared the information that they decreed warranted consideration.
ASCP joined the Choosing Wisely campaign in 2012 to provide input on laboratory testing. Lee Hilborne, MD, MPH, FASCP, DLM(ASCP)CM, headed this effort. "We wanted to have a spectrum of different kinds of tests to guide what things people should think about as they are making choices about testing," Hilborne said.
He served as the 2011-2012 chair of the ASCP Institute Advisory Committee and was Past President of the medical society. He is professor of Pathology and Laboratory Medicine at the David Geffen School of Medicine at the University of California at Los Angeles; global health researcher, RAND Corporation, Santa Monica; and national medical director of Quest Diagnostics, Southern California.
Hilborne, along with a review panel of professionals in the pathology and laboratory medicine fields, reviewed a considerable amount of literature, including evidence-based research, to determine the five tests that patients and clinicians should question. "There are not just five of these tests that should be questioned, of course," Hilborne noted. "We decided on these because they are ordered with some frequency and either should not be done at all or should be done only in select patients." And in some cases, there are less costly or better test alternatives that should be ordered, he added.
The five recommendations include:
Do not perform population-based screening for 25-OH-Vitamin D deficiency.
"There's a large at-risk group for Vitamin D deficiency, but young, healthy people probably don't need to be screened," Hilborne said. "If doctors tested all their patients, most would be Vitamin D deficient if they had not been outside and aren't taking a supplement." The elderly, people with renal disease or going through cancer treatments, and those with dark skin pigmentation, along with other groups, are more at risk for Vitamin D deficiency and should be tested.
Do not perform low-risk human papillomavirus (HPV) testing. "There are very clear guidelines on what to do with Pap smear and HPV testing results, and managing patients with abnormal results," Hilborne said. However, there is no medical indication or treatment for those patients with low risk HPV. "So if you are not going to do anything with the test result, then what's the point? There's no medical benefit," Dr. Hilborne added. "You wouldn't change patient management as a result in a low-risk HPV test, so there's no reason to do the test."
Avoid routine preoperative testing for low-risk surgeries without a clinical indication. "We don't mean people who are coming in for liver transplants or heart problems," Hilborne said, "but in a minor procedure for a patient with an absence of a history, you're more likely to have a false positive than a true positive result." The majority of these preoperative tests performed on elective surgical patients are normal, the ASCP noted.
Only order Methylated Septin 9 (SEPT9) on patients for whom conventional diagnostics are not possible. "This blood test used to screen for colon cancer is fairly similar in purpose to fecal immune tests and stoolguaiac test," Hilborne told ADVANCE. "Those tests are available and consistent with national guidelines and considerably less expensive. If the clinician cannot convince the patient to have the other tests for whatever reason, this test may be used as an alternative." However, SEPT9, a molecular diagnostics test that is just entering the market and is not currently recommended by gastroenterologists and internists in their national guidelines, he added.
- Do not use bleeding time tests to guide patient care. This older test has been replaced by newer coagulation tests. Bleeding time tests also leaves a scar on the forearm, ASCP noted. "What you are looking for with the tests is important, but there are better alternatives out there," Hilborne said.
Scott Warner, laboratory manager at Penobscot Valley Hospital, Lincoln, Maine, and ADVANCE blogger, commented on the importance of the Choosing Wisely campaign's mission. "The laboratory has a clear role in educating clinicians and patients on both ends of the care spectrum," he said. "We are in a unique position in this regard as the professionals providing the value in the laboratory service."
Having the laboratory community participate in the Choose Wisely campaign was a great way to make professionals more visible as part of the healthcare continuum. "This campaign represents a great opportunity for those in pathology and laboratory medicine to be part of the mainstream and what's going on in healthcare, and making sure healthcare is right," Hilborne stressed. "We look forward to working with laboratory partners and the healthcare community on future developments. We see this as a beginning and not a flash in the pan."
Amanda Koehler is a freelance writer.