Dr. Fletcher

May 18, 2017

Previously, Dr. Fletcher put lab utilization into practice as a corporate physician advisor resulting in cost savings and improved patient care. Now he’s helping ARUP do the same for other clients.

By avoiding unnecessary testing, patients and healthcare organizations can save money while still providing quality patient care. Tests that tend to be unnecessary are either overkill—there are less expensive tests that should be done first—or repeated when there is no need do so; for example, genetic tests are good for a lifetime.  

Why do clinicians order tests incorrectly?

Often, it can be traced back to the way the test is listed in electronic medical records (EMRs). It can be confusing. Sometimes tests have been built into a hospital’s order set and then get ordered automatically. For example, if someone comes in with chest pain, the order set may include a test for MTHFR, which may not be needed.

Tools exist to help hospitals and laboratories identify tests that are being unnecessarily ordered. For example, ARUP offers a UM+ dashboard that allows clients to track monthly volumes, identify outliers, and home in on tests that are being over- or misutilized.


The fix is usually quite simple; see the suggestions below for five tests where we see common missteps: 

Blood Disorder—Factor V Leiden

This test looks for a genetic mutation that is the most common cause for inherited thrombosis—a coagulation disorder in which patients are prone to blood clots. Sometimes it can result in the loss of multiple pregnancies.

Factor V helps your blood clot; protein C inactivates factor V to maintain balanced coagulation, giving the blood a proper consistency. If you have the factor V Leiden mutation, your factor V is resistant to protein C functionality and leads to excessive blood clots.

Clinicians will often order this genetic test when they should first order a test to measure the activated protein C (APC) resistance in the blood, which shows the prolongation time of blood clotting after APC has been added to a blood sample. If this test result shows abnormality, clinicians should order the factor V Leiden test for confirmation.

The fix: The genetic test costs more and isn’t always necessary. At ARUP, we do what is called a “reflex,” which means if the APC resistant test comes back abnormal, the sample is automatically sent for factor V Leiden testing—a genetic test that needs to be ordered only once in a lifetime.   

2.  Vitamin D Deficiencies—Vitamin D, 1 25-Hydroxy

This test is commonly misordered when a clinician suspects a vitamin D deficiency. It’s understandable why this happens—there are two tests with very similar names, each measuring different forms of vitamin D.

To measure the storage level of vitamin D in the body, Vitamin D, 25-Hydroxy should be ordered. This test checks the levels of vitamin D2 and D3, which are mostly derived from sunshine and food. Aside from osteoporosis, many diseases are loosely related to vitamin D deficiencies, even depression, so it gets suspected often.

1,25-dihydroxy, on the other hand, analyzes how a patient is metabolizing vitamin D. Often endocrinologists or nephrologists order this test if they are concerned about parathyroid issues or kidney disease. Also, this test is sometimes ordered to check the calcium metabolism levels.

Aside from the name confusion, the Vitamin D, 1,25-Dihydroxy test is often listed first in a test directory because it starts with “1.” If clinicians aren’t sure, they’ll often go with the first one or order both, when they only need one.

The fix: List the more common, 25-hydroxy, first in the EMR test menu.

3. Prostate Cancer—Prostate-Specific Antigen (PSA)

This test is used to screen for prostate cancer and is generally the only test needed unless results show borderline numbers (total PSA between 3–10 ng/mL). In this case, to take a closer look at the free PSA, a clinician might order a free PSA test. Free PSA are not bound to proteins and drop if cancer is present. Often, clinicians will automatically order both, when only the first one is needed.

The fix: If the first PSA test indicates questionable results, it can be reflexed to free PSA.

4. Blood ClottingMethylenetetrahydrofolate Reductase (MTHFR) 2 Variants

This is another test for people who have a blood clotting condition but for a different reason than factor V Leiden—it has to do with the homocysteine levels. High levels of this amino acid are linked to blood clots and can lead to heart attacks. High levels may indicate a mutation in the patient’s MTHFR gene.

Clinicians should first order a test that measures homocysteine levels, then the more expensive genetic test to confirm mutation. Instead, many go straight to the genetic test.

The fix: When listing the homocysteine test, add this additional copy in parentheses: (MTHFR screening test). Also, consider inserting a reflex option.

5. Testosterone Screening for Men

These are very popular tests right now. To screen for levels of testosterone in most adult males, the test to measure total testosterone should be ordered.

The test that measures free testosterone levels (not bound to a protein) should be ordered if the results for the total testosterone test are low or indeterminate.

Many clinicians will order a testosterone test that measures both total and free testosterone. The latter uses mass spectrometry, which is an expensive method and increases the cost.

The fix: Consider EMR prompts or education that steers the clinicians to order the total testosterone test first.

Tools exist to help hospitals and laboratories identify tests that are being unnecessarily ordered. For example, ARUP offers a UM+ dashboard that allows clients to track monthly volumes, identify outliers, and home in on tests that are being over- or misutilized. If changes are made, the dashboard shows the impact of these changes. Once misordered tests are identified, the fixes aren’t difficult; it might be as easy as educating a new staff member. Such simple changes can make big differences.

Dr. Andrew Fletcher is the new medical director of Consultative Services at ARUP, which offers decision-support tools and guidance for clients.

Peta Owens-Liston, ARUP Science Communications Writer