Advances in laboratory testing now enable physicians to order a wide range of tests for sexually transmitted and other infections – often from one sample and with a single laboratory form. This should be good news for clinicians and patients. After all, physicians can get more clinical information more efficiently, and their patients can avoid the inconvenience and discomfort of additional specimen collection.
So, what’s the problem? As stated in a recent New England Journal of Medicine editorial, "The Thousand-Dollar Pap Smear," many of these tests are unnecessary and the costs quickly add up (N. Engl. J. Med. 2013;369:1486-7). The author – a family practice physician in New Jersey – said she is no longer surprised to see lab charges of $1,000 or more for what began as a Pap test. And, when insurance will not pay, patients are often left footing the bill. Further, with nearly three-quarters of adult women in the United States undergoing Pap tests within the last 3 years and 10 million office visits annually for vaginal symptoms, the potential for wasted costs to the health care system due to extra testing becomes significant (Am. J. Obstet. Gynecol. 1991;165:1168-76).
Dr. Cheryl Pan
It is easy to blame labs for facilitating the ordering of unnecessary tests and for profiting from this practice. Many "add-on" tests are polymerase chain reaction–based and thus command high reimbursement rates. However, clinicians are the ones who ultimately decide which tests to order, and thus are in a unique position to combat the problem of test overutilization.
Before checking the boxes on a lab form, clinicians should follow their own checklist to help avoid overtesting.
Don’t let ‘one sample’ guide clinical decision making
Just because you can order a bunch of tests using one cervical cytology sample does not mean you should. For example, guidelines recommend that human papillomavirus (HPV) cotesting should only be done every 5 years for average-risk women, age 30 and older (CA Cancer J. Clin. 2012;62:147-72; Obstet. Gynecol. 2012;120:1222-38). Data have shown, however, that many clinicians do not adhere to current guidelines and order Pap and HPV tests too early and too frequently (Am. J. Prevent. Med. 2013;45:175-81).
The lab form makes it easy for physicians to order many sexually transmitted infection (STI) tests, like chlamydia, using the specimen collected for a Pap test. However, Centers for Disease Control and Prevention guidelines only call for chlamydia screening for women under age 25 or who are high risk (MMWR 2010;59(RR-12):1-110). Thus, only a small portion of women should ever be screened with a Pap specimen for all three tests: Pap, HPV, and chlamydia. Clinicians should become knowledgeable about current guidelines for cervical cancer screening and STI screening and testing, while also focusing on the clinical needs of the patient in front of them.
Know why you are ordering a test
Before ordering a test, clinicians should know how the results will impact their treatment decisions. It sounds simple, but in practice, other factors get in the way. These may include liability concerns or the desire to have as much information as possible, with the thought that if a test option appears on the lab form, perhaps it can assist with a diagnosis.
Consider the diagnosis of a patient with typical vaginitis symptoms – vaginal itching and discharge. Key to timely and accurate treatment is to identify the culprit infection – bacterial vaginosis (BV), trichomoniasis, or candidiasis (yeast infection) – or an infection combination, as each is treated differently. Within one of these categories, however, treatment is unlikely to vary. Most yeast infections, for example, are caused by Candida albicans, for which empiric treatment with miconazole or fluconazole almost always works. Some lab forms offer testing options for up to a dozen Candida organisms, including grouping several into a single panel that can be ordered by checking just one box. Such expensive lab testing for vaginitis should only be considered when treatment for the common pathogen fails.
Educate patients who insist on unneeded tests
As today’s patient becomes ever more aware of her health care options, she may at times insist on tests that are not indicated and will not lead to clinical treatment change. Clinicians have a responsibility to resist such pressure. This can be facilitated by educating the patient about the potential downsides – such as increased morbidity and out-of-pocket costs – of such unnecessary testing. Consider, for example, a 22-year-old woman who is eager to know her HPV status. She should know that she may well have HPV – many women her age do – and that it will likely resolve on its own, but such testing can lead to additional procedures such as colposcopy and biopsy, which are invasive, costly, and may carry later pregnancy risks.