A Quality Improvement Project: A Multifaceted Approach to Test Overutilization in Rheumatology

From the 2022 HVPA National Conference

Saloni Goyal DO (Lehigh Valley Health Network), Yasin Kanakrieh DO, Marie O’Brien DO, Amy Slenker MD, Kathryn Zaffiri MPH, James Ross MD


Inappropriate use of laboratory tests is a problem affecting health care systems around the globe attempting to create sustainable care. Various reports have estimated the percentage of unnecessary test and treatments is anywhere between 10 to 70% depending on the healthcare setting. (1)


In this quality improvement project, we aim to decrease unwarranted serological tests in the initial workup of suspected rheumatological disorders by removing extraneous laboratory tests from the electronic medical record.


In the initial phase of the project, we created a pathway that delineated the step-wise approach of tests to order when suspecting a rheumatological disorder. In particular, we emphasized the initial test should be the ANA with reflex and not the comprehensive ANA. The ANA with reflex has the advantage of being a two step process. Only if positive, will the second test be reflexed to more specific serologies. This pathway was included within the electronic medical record order set for easy reference to providers. In the second phase of the project we targeted education towards the departments inappropriately ordering the comprehensive ANA: neurology, orthopedics, family medicine and internal medicine. In the third phase, we reviewed the cost and frequency of each serological test in the outpatient and inpatient setting from fiscal year 2020 and 2021. Our data review demonstrated that the comprehensive ANA and ANA without reflex were unnecessary in the inpatient setting. The findings were presented to the hospital’s Test Utilization Committee. On February 15, 2022, both the comprehensive ANA and ANA without reflex were removed from the inpatient EMR. In the outpatient setting, the comprehensive ANA was removed from favorites of all providers except the rheumatology department.


We identified the comprehensive ANA to be unnecessary in the inpatient setting. In the 2020 fiscal year, the ratio of ANA with reflex to comprehensive ANA was 5,922 to 3,198. Similarly, in the 2021 fiscal year, the ratio of ANA with reflex to comprehensive ANA was 8,484 to 4,235. Within this data, 64.98% of the total comprehensive ANAs ordered were negative. These tests were unnecessary and could have been avoided if the ANA with reflex had been ordered as the initial test. These extraneous tests pose a significant financial burden as the comprehensive ANA is 8 times the cost of the ANA with reflex. Following the removal of these tests, we will continue to monitor the financial savings of the inpatient and outpatient interventions at 3 to 6 month intervals.


Our quality improvement project approached test overutilization by providing education to targeted departments, introducing easily accessible resources, and removing extraneous laboratory tests from the electronic medical record.

Clinical Implications

We believe this multidisciplinary approach can be replicated in healthcare systems across the country to reduce cost burden as well as decrease anxiety and confusion among providers and patients.


Beriault DR, Gilmour JA, Hicks LK. Overutilization in laboratory medicine: tackling the problem with quality improvement science. Crit Rev Clin Lab Sci. 2021 Sep;58(6):430-446. doi: 10.1080/10408363.2021.1893642. Epub 2021 Mar 11. PMID: 33691585.

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