According to a study conducted at the University of Michigan, doctors may be increasing costs and patient worry when they order multiple blood tests at once. While physicians believe they are acting in their patient’s best interest by trying to expedite a diagnosis, the over-ordering of liver blood tests could be having unintended consequences.
Two new studies published in the Journal of Hospital Medicine and the Journal of Hepatology, recommend that doctors should first order tests to rule out common liver issues, before moving on to rarer conditions. They also advocate for changes to the physician’s computer program used to order the tests, which encourages them to refrain from checking all the boxes when ordering liver tests.
“Physicians are legitimately thinking they’re doing the right thing by ordering the full ‘panel’ of tests, being thorough and trying not to miss anything,” said Dr. Elliot Tapper, a gastroenterologist and researcher at the University of Michigan Health System. “In the hospital, they may be doing what a consulting liver specialist has suggested.
“But they’re not aware of, or thinking about, the ramifications,” continued Tapper. “This can include false positives for rare diseases that can cause the patient and their family anxiety, and lead to unnecessary liver biopsies.”
In a hospital setting, Tapper says that patients should be tested for the most common causes of liver issues first, like hepatitis B, hepatitis C, gallstones and drug overdoses. If these tests return negative results, only then should patients be tested for rare genetic or autoimmune disorders. Tapper refers to this practice as “directed testing” because the diagnostics are aimed at ruling out the most likely cause of liver disease before moving on to other possibilities.
The most common causes of slightly elevated liver enzymes in outpatients include damage related to alcohol, obesity and diabetes, or Hepatitis infection. In addition to using available blood tests for these conditions, patients should also be assessed for non-alcoholic fatty liver disease using an ultrasound.
In a study of nearly 5,800 patients who received medical care for liver issues from a Harvard-affiliated hospital over a five-year period, 86 percent underwent blood tests for both common and rare liver conditions. Tapper and colleagues also noted that three of the most commonly-performed tests on patients with elevated liver enzymes, test for conditions that are unrelated to acute liver injury.
While the three tests together cost less than $65 per patient, their widespread over-use could add up to $40 million in unnecessary testing expenses each year. In addition to the financial cost of over-ordering, they can also present a personal burden on patient wellbeing.
Because tests for rare liver diseases – including hemochromatosis and autoimmune hepatitis – often return false positive results, patients must undergo a confirmatory biopsy. This period of time could cause unnecessary anxiety and worry for patients as they await results.
“The main message to all physicians with a patient with elevated liver enzyme levels is, think about what could really hurt my patient and what’s common, and direct your testing in that way first,” said Tapper. “If you find out on day seven that it’s actually a rare case of Wilson disease, the delay of a few days won’t have changed the treatment plan, or harmed the patient. But the dollar cost, and personal cost, can be much higher for those who receive false positives and unnecessary biopsies. Patients just want to be told straight-up what they have and what they should do.”