Why do doctors limit lab testing?

A brief comment on the judicious use of publicly funded testing in Ontario.

In public healthcare systems, like Canada, doctors often serve as gatekeepers for ordering testing to ensure the efficient use of limited resources, maintain quality patient care, and avoid unnecessary testing. This is why they are given a license to order publicly funded testing (OHIP insured). There are several reasons for this:

  1. Resource allocation: Public healthcare systems typically have limited resources, including funding, personnel, and equipment. Doctors must prioritize the use of these resources to ensure they are allocated efficiently and effectively to provide the best possible care for the largest number of patients.

  2. Cost control: Public healthcare systems are exclusively funded by taxpayers, and it is essential to control costs to ensure the sustainability of the system. By gatekeeping test ordering, doctors can minimize unnecessary testing and associated costs, allowing for more efficient use of public funds. Every dollar spent on an unnecessary Vitamin D test delays a knee replacement surgery.

  3. Evidence-based practice: Doctors are trained to base their clinical decisions on the best available evidence. By gatekeeping test ordering, they can ensure that tests are ordered only when they are likely to provide useful information to guide diagnosis, treatment, or management of a patient's condition.

  4. Minimize unnecessary testing: Unnecessary testing can lead to false-positive results, patient anxiety, and additional downstream testing or interventions that may not be needed. By acting as gatekeepers, doctors can minimize unnecessary testing and its potential harms.

  5. Patient safety: Some tests may carry risks or side effects, such as exposure to ionizing radiation or complications from invasive procedures. Doctors can help protect patient safety by carefully considering the potential risks and benefits of each test before ordering it.

  6. Continuity of care: Doctors are often responsible for coordinating and managing a patient's care. By gatekeeping test ordering, they can ensure that tests are ordered in a coordinated manner that supports the overall care plan, minimizing the risk of duplicative or conflicting tests and interventions.

Ordering unnecessary tests can result in a variety of negative consequences, including added costs, harm to patients, and delays in other necessary testing. Here are a few concrete examples to illustrate these issues:

  1. Unnecessary imaging studies: A patient with non-specific (i.e. vague) low back pain might undergo an MRI, even though guidelines recommend conservative management (i.e. physiotherapy) for most cases. The MRI may reveal incidental findings (we find something abnormal that is unrelated to the reason for the symptoms) like disc bulges, which are common and usually not the cause of the pain. This could lead to unnecessary follow-up tests, consultations, or even surgery, increasing costs and potentially causing harm without addressing the actual cause of the pain.

  2. Overdiagnosis and overtreatment: A healthy individual requests a privately-funded screening test for a particular cancer, despite not being in a high-risk group or having any symptoms. The test returns a false-positive result, leading to a series of follow-up tests and biopsies, which are then borne by the public healthcare system. The patient may undergo surgery or other treatments for a condition they never actually had, incurring unnecessary costs, risks, and emotional distress. In essence, the cost for follow up of abnormal results falls to the public system.

  3. Delaying other testing: In Ontario, wait times for MRI scans can already be lengthy, sometimes up to 12 months. A hospital with a limited number of MRI machines and technicians experiencing an influx of patients receiving unnecessary MRIs for headaches with no concerning features could lead to even longer wait times for patients who truly need an MRI for a more urgent condition, such as a suspected brain tumor or stroke. This delay could result in poorer outcomes for patients who genuinely require the test for appropriate diagnosis and treatment.

  4. Shift of cost burden: While privately requested tests may initially shift the cost burden to the individual, any follow-up testing or treatment required as a result of abnormal findings will often be borne by the public healthcare system. This can strain resources, divert funds from other necessary healthcare services, and ultimately affect the overall efficiency and effectiveness of the public healthcare system. We already have a 2+ year wait time for knee replacements in Ontario. This will increase wait times.

These examples demonstrate how unnecessary testing can have a range of negative consequences, including added costs, harm to patients, and strain on public healthcare resources, such as exacerbating already long wait times. It is essential for healthcare providers to carefully consider the appropriateness of tests and prioritize evidence-based, patient-centred care to minimize these risks and optimize the use of limited healthcare resources.

While gatekeeping test ordering can help optimize resource use and patient care in public healthcare systems, it is essential that the process remains patient-centred, evidence-based, and transparent. This approach ensures that patients receive the appropriate tests and treatments they need while minimizing unnecessary testing and healthcare costs.

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