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The Quarterly 2011


Dear Editor

Dr Anne Duggan's article in The Quarterly June 2010 "When inexpensive tests have expensive outcomes" comments that the authors may be "describing the tip of an iceberg" of inappropriate test ordering.

Delving below the surface one finds that pathology utilisation and expenditure has been increasing for several decades 1. Over the past 30 years a number of studies estimated that more than 25% of hospital laboratory tests can be considered unnecessary, in that they do not add to diagnosis or management 1 yet sustainable strategies for reducing this unnecessary testing have proven elusive 1. The Pathology Utilisation Medical Project (PUMP) in Queensland, as discussed by Dr Nicki Murdock 3, is working to address this issue, and has shown improvements in pathology expenditure.

In their review of faecal occult blood testing, Friedman et al highlighted the cascade of further investigation, delays and adverse effects on patient care that these inappropriate tests create 4. Evidence of this can be seen elsewhere in health care; for example phlebotomy contributes significantly to anaemia in ICU patients, Von Ahsen et al finding that it "accounted for more than 17% of total blood loss" with unnecessary diagnostic testing identified as a contributor5, 6 The phenomenon is not confined to pathology, consider diagnostic radiology where figures of 10-30% for unnecessary use and consequent exposure to ionising radiation are concerning 7.

In the face of increasing emphasis on cost efficient care, Dr Duggan's article serves as a reminder that review of test ordering practices is important not only financially but also in improving the quality of patient care

Dr Eleri Carrahar
RACMA Candidate


1 Van Walraven C, Naylor D 1998,'Do we know what inappropriate laboratory utilisation is?' Journal of the American Medical Association, vol. 280, no. 6, p. 550-557.
2 Gopal G, Crook M, Tillyer M L 2003, 'Pathology tests: Is the time for demand management ripe at last?' Journal of Clinical Pathology, vol. 56, p. 243-248.
3 Murdock N 2010, 'Letter to the editor' The Quarterly, Royal College of Medical Administrators, December Vol. 43. No. 4
4 Friedman A, Chan A, Chin C, Deen A, Hammerschlag G, Lee M et al. 2010 'The use and abuse of faecal occult blood tests in an acute inpatient setting' Internal Medicine Journal, vol. 40, p. 107-111.
5 von Ahsen N, Muller C, Serke S et al. 1999 'Important role of nondiagnostic blood loss and blunted erythropoietic response in the anaemia of medical intensive care patients' Critical Care Medicine, vol. 27, p. 2630-2639.
6Barie P 2004, 'Phlebotomy in the intensive care unit: strategies for blood conservation' Critical Care, vol. 8, suppl. 2, p. s34-s36.
7Cascade P, Webster E, Kazerooni E 1998 ' Ineffective use of Radiology: The Hidden Cost' American Journal of Roentgenology, vol. 170, p. 561-564.

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