July 01, 2013
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Quality improvement initiatives required to reduce repeat lipid testing

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One-third of patients with CHD who reached target LDL levels underwent repeat lipid panels, suggesting that quality improvement efforts are needed to decrease unnecessary testing.

Salim S. Virani, MD, PhD, of the Michael E. DeBakey VA Medical Center and a researcher at the Health Services Research and Development Center of Excellence in Houston, and colleagues evaluated the number of patients with LDL levels lower than the Adult Treatment Panel III (ATP III) guideline-recommended LDL treatment target of 100 mg/dL who underwent repeat lipid testing within 11 months without medication intensification. They used data from patients with CHD in a VA network of seven medical centers with associated community-based outpatient clinics.

Salim S. Virani, MD, PhD 

Salim S. Virani

“In these patients, repeat lipid testing may represent health resource overuse and possibly waste of health care resources,” the researchers wrote.

Potential waste of resources

Virani and colleagues identified 27,947 patients with CHD and LDL levels less than 100 mg/dL — 9,200 (32.9%) of whom underwent repeat lipid testing without intensification of treatment during the next 11 months. This translated to 12,686 repeat panels, with a mean of 1.38 additional tests per patient, according to study results.

“With a mean lipid panel cost of $16.08 based on Veterans Health Administration laboratory cost data, this is equivalent to $203,990 in annual costs for one VA network,” the researchers wrote.

“These results represent health care resource overuse and possibly their waste,” Virani told Cardiology Today. “Apart from the costs associated with these lipid panels, this also carries with it the cost for the patient’s time to undergo a repeat blood test and cost for the health care provider’s time to follow-up on these results after redundant testing and to inform the patient about these results.”

After adjustment for facility level clustering, data showed that those with a history of diabetes (OR=1.16; 95% CI, 1.10-1.22), hypertension (OR=1.21; 95% CI, 1.13-1.30), higher burden of illness (OR=1.39; 95% CI, 1.23-1.57) and more frequent primary care visits (OR=1.32; 95% CI, 1.25-1.39) had higher odds of undergoing repeat testing. In contrast, patients treated at a teaching facility (OR=0.74; 95% CI, 0.69-0.80) or from a physician provider (OR=0.93; 95% CI, 0.88-0.98) and patients with a medication possession ratio of 0.8 or higher (OR=0.75; 95% CI, 0.71-0.80) were less likely to have a repeat lipid panel.

The researchers also assessed 13,114 patients with CHD who met the ATP III optional treatment target of less than 70 mg/dL. In this population, 8,177 (62.4%) with LDL levels less than 70 mg/dL underwent repeat lipid testing during 11-month follow-up.

“This represents an area of redundant testing in patients and represents an opportunity to improve health care efficiency and reduce health care waste,” Virani said.

Interpretations

In an invited commentary, Joseph P. Drozda Jr., MD, of the Center for Innovative Care, Mercy, in Chesterfield, Mo., lauded the researchers’ study, noting that, with the implementation of electronic health records, future reports will likely identify other areas that require improvement and where waste can be reduced.

“This well-conceived study on a large clinical database, which has the advantage of containing pharmacy data for use in tracking medication adherence, delivers an important message regarding a type of waste that is likely widespread in health care and that goes under the radar because it involves a low-cost test. However, it is precisely these low-cost, high-volume tests and procedures that need to be addressed if significant saves from reduction of waste are to be realized,” he wrote.

For more information:

Drozda JP. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.6808.

Virani SS. JAMA Intern Med. 2013;doi:10.1001/jamainternmed/2013.8198.

Salim S. Virani, MD, PhD, can be reached at the Health Services Research and Development (152), Michael E. DeBakey Veterans Affairs Medical Center, Section of Cardiovascular Research, Baylor College of Medicine, 2002 Holcombe Blvd., Houston, TX 77030; phone: 713-794-8517; fax: 713-748-7359; email: virani@bcm.edu.

Disclosure: One of the study researchers reports financial ties to Abbott, Adnexus, Amarin, Amylin, AstraZeneca, Bristol-Myers Squibb, Cerenis, Esperion, Genentech, GlaxoSmithKline, Idera Pharma, Kowa, Merck, Novartis, Omthera, Resverlogix, Roche, Sanofi-Synthelabo and Takeda. Drozda reports no relevant financial disclosures.