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The value of lab test utilization management—and the ASCP’s latest best practice recommendations for effective test utilization

Each year, the American Society for Clinical Pathology (ASCP) publishes a set of effective test utilization (ETU) best practice recommendations aimed at ensuring that patients receive the testing they need while preventing unnecessary or unhelpful tests. The 2024 update,1 which is the most recent, includes six recommendations:

    1. Use immature granulocyte count rather than manual band count in sepsis evaluation.
    2. Do not routinely monitor breast cancer patients with both CA 15-3 and CA 27.29.
    3. Do not order urine eosinophils for acute interstitial nephritis or when evaluating acute kidney injury.
    4. Do not routinely order thyroid hormone binding ratio assays to determine the free T4 index; use free T4 assays instead.
    5. Consider molecular-based testing for diagnosis of arboviral disease within the first seven days of symptom onset.
    6. Do not order bacterial (genital) culture for the diagnosis of bacterial vaginosis.

According to Sachin Gupta, scientific director of the ASCP’s Center for Quality and Patient Safety, these guidelines are intended to promote higher quality patient care, reduce healthcare costs, and ensure the efficient use of laboratory resources and personnel.

“These recommendations are curated by experts and focus on tests that are frequently performed but may offer no benefit, be harmful, or be costly without improving patient care,” he says. “By identifying and eliminating such tests, ASCP aims to bring the right test to the right patient at the right time. Additionally, these recommendations encourage meaningful conversations between laboratorians, clinicians, and patients about the necessity and potential impact of various tests and treatments.”

Choosing wisely

Each year, the ASCP accepts laboratorians’ suggestions regarding potential ETU recommendations. “The curation process involves a collaborative effort by various experts,” Gupta explains. “After receiving the suggestions, they are reviewed and vetted by ASCP member subject matter experts who ensure the recommendations are evidence-based and relevant. Additionally, colleagues from sister societies, such as the American College of Obstetricians and Gynecologists and the American Society for Microbiology, contribute their expertise. This multidisciplinary approach helps ensure that the recommendations are comprehensive and applicable across different areas of clinical practice.”

The final selections are made using stringent evidence-based criteria, including the test’s frequency of use, evidence of benefit or harm, cost, and the potential to improve patient care. This allows the ASCP to ensure that only the most relevant and impactful recommendations are included—and that their guidance aligns with that of broader initiatives.

Even so, not every recommendation covers well-trodden ground. “Some of this year’s ETU best practice recommendations came as a surprise to many in the medical community,” says Gupta. “One notable example is the recommendation against using manual band count in sepsis evaluation. This was unexpected because manual band count is still used to evaluate sepsis. The rationale behind the new recommendation is that manual band count is plagued with significant interobserver variability and limited sampling (only 100 leukocytes are evaluated), making it an imprecise and nonspecific test that offers little diagnostic information. Instead, the recommendation is to use immature neutrophils (>10 percent) because it is a more sensitive and specific test than manual band count in detecting infection.”

Another surprising recommendation Gupta points out is the call to reduce the use of genital culture for the diagnosis of bacterial vaginosis—mainly because there is no consensus on exactly which species may be involved in the bacterial imbalance.2 As a result, the 2024 ETU recommendations call for nucleic acid amplification testing rather than culture if possible and Gram stain with Nugent scoring if not.

Driving better diagnostics

“Clinical laboratory professionals play a crucial role in promoting better test utilization by leveraging ETU best practice recommendations and other strategies,” says Gupta. “They can provide ongoing education and training for healthcare providers about the latest guidelines, raising clinicians’ awareness of the most appropriate tests to order. By regularly reviewing test ordering patterns and providing feedback, they can help highlight areas of overuse or misuse and suggest alternatives. Additionally, fostering interdisciplinary collaboration between laboratory professionals, pathologists, and other healthcare providers ensures a coordinated approach to test utilization. Advocating for policies that support effective test utilization, such as value-based care models, further enhances these efforts.”

Gupta also emphasizes the role of laboratory leadership and administration in test utilization management. To this end, he lays out several key actions he believes lab leaders should take:

    • Improved stewardship. “First, lab leaders should form a Laboratory Stewardship Committee—a multidisciplinary team dedicated to optimizing the use of laboratory tests to improve patient care, reduce costs, and enhance efficiency. This committee can develop and implement clear, evidence-based guidelines for test ordering to ensure that tests are used appropriately and consistently across the organization.”
    • Evidence-based decision-making. “Analyzing laboratory data helps identify areas of waste and inappropriate test ordering, enabling prioritized interventions and measurable goals.”
    • Tools and management programs. “Integrating clinical decision support systems into electronic health records offers real-time guidance on test ordering, alerting clinicians to unnecessary tests and suggesting more appropriate alternatives. Implementing structured utilization management programs can help monitor and manage the use of laboratory tests, identifying patterns of over- and underuse and developing strategies to address them.”
    • Education and engagement. “Ongoing education and training for healthcare providers, including on the latest ETU best practice recommendations, is crucial. Educating patients on the necessity and impact of various tests can manage expectations and reduce demand for unnecessary testing.”

By taking these steps, lab leaders can optimize test utilization management, leading to improved outcomes and more efficient use of healthcare resources. Gupta emphasizes the importance of continuous improvement using patient-centric and evidence-based guidelines—especially those that, like the ASCP’s recommendations, are frequently updated. Such supports are valuable tools for raising awareness about appropriate test use, encouraging informed decision-making that ultimately results in better patient care.

References:

    1. American Society for Clinical Pathology. 2024 Effective Test Utilization Best Practices Recommendations. https://ascpcontentwebsite.blob.core.windows.net/content/docs/default-source/news-advocacy/etu_best_practices_doc.pdf.
    2. Khedkar R, Pajai S. Bacterial vaginosis: a comprehensive narrative on the etiology, clinical features, and management approach. Cureus. 2022;14(11):e31314. doi:10.7759/cureus.31314.

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