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Excessive tests don’t benefit patient, do increase cost in age-related immune disorder

A series of tests physicians routinely order to help diagnose and follow their patients with an elevated antibody level that is a marker for cancer risk, often do not benefit the patient but do increase health care costs, pathologists report.

A study in The American Journal of Clinical Pathology suggests that instead of ordering individual tests, physicians request an initial workup for the age-related disorder, monoclonal gammopathy, said Dr. Gurmukh Singh, chief of the Section of Clinical Pathology and Walter L. Shepeard Chair in Clinical Pathology at the Medical College of Georgia at Augusta University.

Once pathologists interpret results of a screening serum protein electrophoresis – which identifies which and how much of the excessive antibody, or immunoglobulin, called M-protein, is present – and examine the patient’s medical record, they can decide in a stepwise fashion what, if any, additional tests are needed, said Singh, the study’s corresponding author.

What Singh found instead in a fourth-month review of experience at a medium-sized teaching hospital in Georgia as well as an earlier study in Missouri, is that nearly half the time, well-intended physicians treating the patients are ordering tests that don’t ultimately benefit their patients.

This study reviewed the history of 237 patients age 19-87 who had a total of 1,503 episodes of testing. In addition to serum protein electrophoresis, or SPEP, many patients also had serum immunofixation electrophoresis – which also helps detect the level and type of excessive antibody – and/or serum free light chain assays, which likewise provide a precise measure of the antibody level. A patient’s physician may order this series of tests dozens of times over several months.

“About 40-50 percent of the second tests are not needed or adding value,” said Singh, who, along with his colleagues, propose an algorithm that would put more of the decision-making in the hands of pathologists interpreting the tests and could improve those percentages at the nation’s hospitals.

“These are stepwise things. If it’s a new patient, do this; if it’s a known patient, do that. Results drive it. That will reduce the number of tests that are done without in any way being of detriment to the patient or the quality of care,” Singh said.

Examples of when the two subsequent – and more expensive – tests would be done at least once, is in a new patient when M-protein is first found, he said. The additional tests might also be beneficial for patients under treatment for multiple myeloma, to ensure that there are no trace amounts left of the abnormal protein.

In the series of tests they examined, only 46 percent of the serum immunofixation electrophoresis and 42 percent of the serum free light chain assays were warranted, the researchers report. They found the two tests were ordered multiple times in patients in whom the antibody, or monoclonal protein, were easily detected with SPEP. In fact, for most patients with measurable levels of M-protein, SPEP can be used to follow the course of the disease and treatment, they write.