Letters, 9/17

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All and only the tests our patients need

Testing and sequencing methods continue to proliferate, and the medical-industrial complex-driven competition to offer more and larger panels for genetic and women’s health testing, to name just two examples, does not necessarily translate into better care. The direct-to-consumer genetic testing market is particularly troubling. Quality issues aside, interpreting genomic results for inherited cancer or reproductive genetic carrier testing when a variant is detected is not straightforward and should be reviewed in conjunction with a certified genetic counselor or ordering physician to determine individual risk. As a society we must heed priorities, including keeping the costs of health care down while ensuring all Americans receive the care they need. And laboratory medicine needs to lead the march toward value by making sure patients get all the tests they need—and only the tests they need.

The Affordable Care Act led the health care industry to look inward, seeking out ways to provide quality care while reducing costs. “Value-based care” became a buzzword, along with “precision medicine.”

Today, value-based care is becoming the norm: Hospitals seek to reduce needless admissions, reduce unnecessary medical procedures, and help people stay healthy and out of the hospital. Meanwhile, precision medicine became the blanket term for ensuring that patients receive targeted and effective treatments.

My colleagues and I have developed over the past decade many tests for primary and specialty care, including cancer, women’s health, and genetic disease. But as new, more accurate tests are devised, older ones do not necessarily fall by the wayside. Physicians continue to order them, despite newer tests that may be more rapid, more accurate, or more precise—or all three.

To be clear, patient care is not compromised; older tests still work, and work reasonably well in most situations. But in the world of diagnostic testing, newer tests often provide more clinically useful information and may have quicker turnaround.

It is up to us in the diagnostic medicine field to help break old habits, namely by educating our collaborators-in-care about how we can work together to streamline laboratory testing, directing our physician colleagues toward more efficient and more medically relevant tests. We must look inward and scour our own processes and offerings toward better utilization management. We must act as gatekeepers to the laboratory medicine test menu.

Some laboratories, like BioReference Laboratories, are doing just that. BioReference Laboratories has initiated a comprehensive review, starting with its esoteric test offerings in oncology, with the twin goals of reducing unnecessary testing and educating clients. In our multipronged approach we are doing the following:

• Minimizing duplicate and/or redundant esoteric testing by different methods and educating clinicians on why two tests are not necessarily better than one—for example, why FISH and PCR for the same target are most often redundant and unnecessary.
• Minimizing inappropriate esoteric testing—for example, cancer cytogenetic testing for non-cancerous diagnoses, such as fatigue.
• Eliminating serial testing that is not clinically indicated or not indicated as frequently as ordered, such as qRT-PCR for BCR/ABL1 more frequently than q3 months when in molecular remission (as per NCCN guidelines 1.2018 for CML).
• Assigning ICD-10 codes postanalytically based on esoteric test results to further refine the diagnosis electronically in the age of EMRs.
• At GeneDx, increasing participation in Pediatric Laboratory Utilization Guidance Services, or PLUGS.

For us, these efforts are more than just about fitting into the parallel tracks of value-based care and precision medicine. They’re about greatly reducing the diagnostic journey for patients. And that starts with them getting the appropriate tests. And only those tests.

James Weisberger, MD, EVP and Chief Medical Officer, BioReference Laboratories, Elmwood Park, NJ