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Managing Inappropriate Requests of Laboratory Tests: From Detection to Monitoring
Maria Salinas, PhD; Maite López-Garrigós, PhD; Emilio Flores, PhD; Maria Leiva-Salinas, MD, PhD; Alberto Asencio, MD; Javier Lugo, MD; and Carlos Leiva-Salinas, MD, PhD
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Managing Inappropriate Requests of Laboratory Tests: From Detection to Monitoring

Maria Salinas, PhD; Maite López-Garrigós, PhD; Emilio Flores, PhD; Maria Leiva-Salinas, MD, PhD; Alberto Asencio, MD; Javier Lugo, MD; and Carlos Leiva-Salinas, MD, PhD
This study shows automatic, practical, simple, and effective strategies designed in the laboratory, in consensus with requesting clinicians, to improve laboratory test appropriateness.
Studies to identify inadequacies in test requests by reviewing patients’ medical records are expensive, cumbersome, and difficult to perform. However, identifying such inadequacies is possible—using indirect means—by measuring differences in test utilization among geographical areas (ie, multiple countries or regions within a single country).20,21 Indicators that can be used in such scenarios include the number of tests per 1000 residents in a certain area13,22,23 or per 1000 medical admissions,22 test-ordering ratios,24 or by comparing the number of requests with guidelines or disease prevalence.25,26 In our case, we detected that the relative ratio of FT4 and TSH testing was not in accordance with a published, generally accepted (in Spain) target of <0.25.16 Additionally, the underrequesting of s-Ca tests was detected in our region by utilizing the indicator “requests per 1000 inhabitants,” which was significantly lower than in other Spanish areas.15 Testing for tBil was considered to be inappropriate since it is not recommended as a screening method for liver disease in primary care.27

A second way to detect whether over- or underrequesting is taking place is through retrospective studies of the number of requests in the LIS patient database. In fact, we utilized this approach to identify inappropriate test requests for hospitalized patients. Unnecessarily repetitive testing was observed for certain tests—probably due to human error, as hospitalized patients’ medical records were kept manually, not with computers.

Once inappropriate testing levels have been identified and addressed, indicators play a crucial role in evaluating the success of interventions and to check if they are maintained over time. Regarding process indicators, for instance, as was expected, once the s-Ca strategy was established, the requests for this test began to increase, both in absolute numbers and relative to the s-Glu test requests. When relative indicators are used, it is important to also measure, simultaneously, a warning indicator referring to a test whose demand is not influenced by the strategy to identify potential external confounding factors not related to the established intervention. The success of the strategies to diminish overrequesting of FT4 and tBil tests, and to eliminate redundant tests in hospitalized patients, also needs to be assessed through the use of indicators. Of particular interest is that indicators that measure request ratios of 2 related tests, such as FT4 and TSH, have 2 different applications: identification of inappropriate request and monitoring after intervention.

A very significant issue in implementing any major change is the ability to sustain the intervention. Most—such as educational or administrative strategies—may produce excellent results during the first months of application that, unfortunately, are not maintained over time.28 However, laboratory professionals have at their disposal excellent information systems that can be utilized to improve requesting in a sustained manner,17,24,29 and the study findings did show that the results of interventions were maintained over time in every strategy.

Just as process indicators are, outcome indicators must be designed before establishing the strategy. Although the outcome indicators are as straightforward as measuring the decrease of unnecessary treatments,29 cost savings,24 or new diagnoses,17 they are crucial to discovering if the laboratory has become more efficient and/or is enhancing its contribution to patient management. Indeed, the importance of monitoring after intervention establishment is always important, but it is especially crucial when it comes to correcting the underrequesting of certain tests. In a case like ours, in which we were investigating increased requesting of s-Ca tests and, consequently, increased economic expenses, it was crucial to be able to monitor the strategy’s success in such a systematic and detailed manner so that we could decide in a very short period of time whether to stop or continue the intervention. In fact, in the case of s-Ca, a preliminary pilot study—with very carefully chosen outcome indicators—was designed, established, and evaluated before maintaining the intervention over time. The preliminary pilot study strategy ended after 4 months, at which time we reviewed patient medical records to obtain the preliminary results of outcome indicators.17 In view of the number of HPT cases detected, and the low cost of every case identified, we decided to restart the strategy and maintain it indefinitely. Moreover, the strategy regulates itself. As time passes, there will be fewer patients who haven’t had their s-Ca tested in the previous 3 years, and consequently fewer s-Ca tests will be added by means of the strategy.

The study results indicate that the strategies do not just enhance laboratory contribution to diagnosis. In fact, through s-Ca strategy, the clinical laboratory becomes the protagonist in diagnosis. It is LIS that, in a continuous way over time, is identifying new cases of HPT. Additionally, the economic savings accrued by correcting laboratory test overrequests will improve the effective use of laboratory resources.


This study has certain limitations. First, the study indicator results, referred to as tests per 1000 inhabitants (residents in the investigators’ area), could be considered as research with local importance. These settings might not be appropriate for large testing elsewhere because they were designed for a local population/health service system in Spain. Additionally, in certain environments, a written test request is required for that test to be performed; our s-Ca strategy would not be possible under this requirement.

Another potential limitation is that the strategy we designed for hospitalized patients was to avoid test redundancy due to human errors in manual requesting because the hospitalized patients’ medical records are not computerized. It was not based on previous studies regarding minimal retesting intervals, defined as the minimum time before a test should be repeated, based on the properties of the test and the clinical situation in which it is used.30-33 Finally, the calculated economic savings of the study may not apply to other countries or settings, since our laboratory belongs to the Public Health Network, where reagent prices are relatively low.


The study demonstrates a simple approach to detect inappropriate requests of laboratory tests and to monitor results after appropriate interventions, using process indicators. Indicators that are customized according to the type and to the phase of the strategy are essential to measure the potential impact on patient results. Outcome indicators measure the laboratory’s contribution to the diagnosis; to monitoring or preventing diseases; to becoming a protagonist in diagnosis; and to leading the healthcare system towards the most effective uses of its resources.


The authors would like to express their deep gratitude to José Manuel Ramos Rincón, MD, PhD, for his valuable and constructive suggestions during the review of this paper.

Author Affiliations: Clinical Laboratory, Hospital Universitario de San Juan, San Juan de Alicante (MS, ML-G, EF, JL), Alicante, Spain; Department of Biochemistry and Molecular Pathology, Universidad Miguel Hernández (MS, ML-G, ML-S), Elche, Alicante, Spain; Department of Dermatology, Hospital General Universitario de Alicante (ML-S), Alicante, Spain; Primary Care Center of Muchamiel, Alicante-San Juan Health District (AA), Muchamiel, Alicante, Spain; Department of Radiology, University of Virginia (CL-S), Charlottesville.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (AA, EF, ML-G, JL, CL-S, ML-S, MS); acquisition of data (EF, ML-G, MS); analysis and interpretation of data (EF, ML-G); drafting of the manuscript (AA, EF, ML-G, JL, CL-S, ML-S, MS); critical revision of the manuscript for important intellectual content (AA, EF, ML-G, JL, CL-S, ML-S, MS); statistical analysis (EF, ML-G); and supervision (MS).

Address Correspondence to: Maria Salinas, PhD, Clinical Laboratory, Hospital Universitario de San Juan, Carretera Nacional 322, s/n 03550, San Juan de Alicante, Alicante, Spain. E-mail:

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