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Table.  
Attitudes Toward Laboratory Testing by Health Care Provider Type
Attitudes Toward Laboratory Testing by Health Care Provider Type
1.
Thavendiranathan  P, Bagai  A, Ebidia  A, Detsky  AS, Choudhry  NK.  Do blood tests cause anemia in hospitalized patients? the effect of diagnostic phlebotomy on hemoglobin and hematocrit levels.  J Gen Intern Med. 2005;20(6):520-524.PubMedGoogle ScholarCrossref
2.
The American Board of Internal Medicine. Choosing Wisely. http://www.choosingwisely.org/resources/. Accessed November 21, 2016.
3.
Hooker  RS, Brock  DM, Cook  ML.  Characteristics of nurse practitioners and physician assistants in the United States.  J Am Assoc Nurse Pract. 2016;28(1):39-46.PubMedGoogle Scholar
4.
Sedrak  MS, Patel  MS, Ziemba  JB,  et al.  Residents’ self-report on why they order perceived unnecessary inpatient laboratory tests.  J Hosp Med. 2016;11(12):869-872.PubMedGoogle ScholarCrossref
5.
Cipher  DJ, Hooker  RS, Guerra  P.  Prescribing trends by nurse practitioners and physician assistants in the United States.  J Am Acad Nurse Pract. 2006;18(6):291-296.PubMedGoogle ScholarCrossref
6.
Hughes  DR, Jiang  M, Duszak  R  Jr.  A comparison of diagnostic imaging ordering patterns between advanced practice clinicians and primary care physicians following office-based evaluation and management visits.  JAMA Intern Med. 2015;175(1):101-107.PubMedGoogle ScholarCrossref
Research Letter
Less Is More
August 2017

Association of Attitudes Regarding Overuse of Inpatient Laboratory Testing With Health Care Provider Type

Author Affiliations
  • 1Head and Neck Division, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
  • 2Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
  • 3Department of Quality and Safety, Memorial Sloan Kettering Cancer Center, New York, New York
  • 4Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
JAMA Intern Med. 2017;177(8):1205-1207. doi:10.1001/jamainternmed.2017.1634

Routine hospital laboratory testing is common, and unnecessary tests can harm patients.1 Multiple professional societies have recommended against routine laboratory testing in hospitalized patients.2

Advanced practice health care providers (APP), including nurse practitioners (NP), and physician assistants (PA), increasingly care for hospitalized patients and order tests3; registered nurses (RN) may also influence ordering. To our knowledge, no studies have evaluated attitudes of nonphysician health care providers toward inpatient laboratory testing.

We performed a cross-sectional survey among various physician and nonphysician inpatient providers to describe differences in attitudes and beliefs regarding laboratory testing.

Methods

The study was conducted at Memorial Sloan Kettering Cancer Center, and the survey was adapted from a previously administered survey.4 All NPs, PAs, RNs, and medical doctors (MDs) with inpatient duties during the 2-week survey period in 2015 received emails linking to the anonymous survey. Survey completers received a free coffee. The study was deemed exempt by the institutional review board.

Survey items included health care provider type (RN, NP, PA, resident, fellow, attending physician), sex, the extent of unnecessary laboratory testing, and attitudes toward testing. Most responses used a 4-point Likert scale (strongly agree, somewhat agree, somewhat disagree, strongly disagree).

We used univariate descriptive statistics, dichotomized attitude and/or belief responses (strongly/somewhat agree vs strongly/somewhat disagree) and used the χ2 statistic to evaluate differences by health care provider type. We grouped trainees (residents and fellows) and APPs (NPs and PAs) for all analyses. Analyses utilized SAS statistical software, version 9.4 (SAS Institute).

Results

Among 1580 eligible participants, 837 (53%) completed surveys; 347 participants (41%) were RNs, 197 participants (24%) were attending physicians, 139 participants (17%) were trainees, and 154 participants (19%) were APPs. Most participants were women (n = 611 [73%]), particularly APPs and RNs (>90%). Response rates ranged from 46% (RNs) to 73% (attendings).

Overall, 60% of participants (n = 612) reported unnecessary laboratory testing on their unit, while 37% (n = 312) reported requesting unnecessary laboratory testing themselves in the last 6 months, with differences by health care provider type (testing on unit: trainees, 79% [n = 110]; APPs, 59% [n = 91]; attendings, 72% [n = 142]; RNs, 46% [n = 159]; and requesting testing themselves: trainees, 62% [n = 86]; APPs, 59% [n = 91]; attendings, 43% [n = 85]; RNs, 14% [n = 50]). Respondents most commonly reported attendings (54% [n = 451]) as those who would be uncomfortable with less testing and that unnecessary laboratory testing was intended to satisfy primary attendings (37% [n = 302]).

Attitudes toward laboratory testing varied by health care provider type (Table); RNs were more likely than others to value routine testing across multiple items. More physicians than APPs and RNs reported comfort with less testing.

Discussion

We found broad recognition of laboratory testing overuse among inpatient clinicians and attitudinal differences across health care provider types. Registered nurses were most likely to endorse the importance of daily testing and fear consequences of less testing, physicians were least likely to endorse the importance of daily testing, and APPs were intermediate.

Our finding that RNs and APPs value laboratory testing more than physicians is novel. The literature comparing APP and MD practice is mixed5,6; we found attitudinal differences that may drive important practice differences. Furthermore, RNs are important care team members despite not placing orders; little evidence describes their influence on the ordering process. We found that RNs generally favored more testing than other health care providers; the impact on test ordering is unclear.

Our findings regarding the role of attending physicians are notable. Nonattendings believed that attendings would be uncomfortable with less testing, but attendings themselves overwhelmingly endorsed less testing. Misperceptions of attendings’ beliefs may drive unnecessary testing, particularly in settings where APPs place orders. Improved communication within the care team could reduce laboratory testing and perhaps other excessive services.

Limitations to our study include its performance at a single center focused on the care of patients with cancer. Our response rate was modest though comparable to similar studies.4

Attitudes toward inpatient laboratory testing differ across health care provider types, highlighting the importance of studying overused services across care teams to optimize interventions.

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Article Information

Corresponding Author: Deborah Korenstein, MD, Department of Medicine, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave, New York, NY 10017 (korenstd@mskcc.org).

Accepted for Publication: March 15, 2017.

Published Online: June 12, 2017. doi:10.1001/jamainternmed.2017.1634

Author Contributions: Dr Korenstein had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Korenstein.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Roman, Masciale.

Statistical analysis: Roman, Masciale.

Administrative, technical, or material support: Roman, Yang, Korenstein.

Supervision: Korenstein.

Conflict of Interest Disclosures: None reported.

Funding/Support: Drs Roman and Korenstein’s work on this project was supported in part by a National Cancer Institute Cancer Center grant to Memorial Sloan Kettering Cancer Center (grant No. P30 CA008748).

Role of the Funder/Sponsor: The funder/sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Renee Gennarelli, MS, for extra statistical support; she was not compensated for her contributions.

References
1.
Thavendiranathan  P, Bagai  A, Ebidia  A, Detsky  AS, Choudhry  NK.  Do blood tests cause anemia in hospitalized patients? the effect of diagnostic phlebotomy on hemoglobin and hematocrit levels.  J Gen Intern Med. 2005;20(6):520-524.PubMedGoogle ScholarCrossref
2.
The American Board of Internal Medicine. Choosing Wisely. http://www.choosingwisely.org/resources/. Accessed November 21, 2016.
3.
Hooker  RS, Brock  DM, Cook  ML.  Characteristics of nurse practitioners and physician assistants in the United States.  J Am Assoc Nurse Pract. 2016;28(1):39-46.PubMedGoogle Scholar
4.
Sedrak  MS, Patel  MS, Ziemba  JB,  et al.  Residents’ self-report on why they order perceived unnecessary inpatient laboratory tests.  J Hosp Med. 2016;11(12):869-872.PubMedGoogle ScholarCrossref
5.
Cipher  DJ, Hooker  RS, Guerra  P.  Prescribing trends by nurse practitioners and physician assistants in the United States.  J Am Acad Nurse Pract. 2006;18(6):291-296.PubMedGoogle ScholarCrossref
6.
Hughes  DR, Jiang  M, Duszak  R  Jr.  A comparison of diagnostic imaging ordering patterns between advanced practice clinicians and primary care physicians following office-based evaluation and management visits.  JAMA Intern Med. 2015;175(1):101-107.PubMedGoogle ScholarCrossref
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