Factors Associated with Ordering Laboratory Monitoring of High-Risk Medications

Published in: Journal of General Internal Medicine, v. 29, no. 12, Dec. 2014, p. 1589-1598

Posted on RAND.org on December 11, 2014

by Shira H. Fischer, Jennifer Tjia, George Reed, Daniel Peterson, Jerry H. Gurwitz, Terry S. Field

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Research Question

  1. What factors influence whether a physician will order recommended laboratory testing to monitor patients taking high-risk medications?

BACKGROUND: Knowledge about factors associated with provider ordering of appropriate testing is limited. OBJECTIVE: To determine physician factors associated with ordering recommended laboratory monitoring tests for high-risk medications. METHODS: Retrospective cohort study of patients prescribed a high-risk medication requiring laboratory monitoring in a large multispecialty group practice between 1 January 2008 and 31 December 2008. Analyses are based on administrative claims and electronic medical records. The outcome is a physician order for each recommended laboratory test for each prescribed medication. Key predictor variables are physician characteristics, including age, gender, specialty training, years since completing training, and prescribing volume. Additional variables are patient characteristics such as age, gender, comorbidity burden, whether the medication requiring monitoring is new or chronic, and drug-test characteristics such as inclusion in black box warnings. We used multivariable logistic regression, accounting for clustering of drugs within patients and patients within providers. RESULTS: Physician orders for laboratory testing varied across drug-test pairs and ranged from 9 % (Primidone–Phenobarbital level) to 97 % (Azathioprine–CBC), with half of the drug-test pairs in the 85-91 % ordered range. Test ordering was associated with higher provider prescribing volume for study drugs and specialist status (primary care providers were less likely to order tests than specialists). Patients with higher comorbidity burden and older patients were more likely to have appropriate tests ordered. Drug-test combinations with black box warnings were more likely to have tests ordered. CONCLUSIONS: Interventions to improve laboratory monitoring should focus on areas with the greatest potential for improvement: providers with lower frequencies of prescribing medications with monitoring recommendations and those prescribing these medications for healthier and younger patients; patients with less interaction with the health care system are at particular risk of not having tests ordered. Black box warnings were associated with higher ordering rates and may be a tool to increase appropriate test ordering.

Key Findings

  • Specialists and physicians who ordered the medications more often were more likely to order recommended tests.
  • Younger patients and those with fewer interactions with the health care system were less likely to have tests ordered.
  • Ordering was more likely when the medication-test combinations had black box warning labels.

Recommendations

  • The rate at which recommended testing is ordered could be improved by educating physicians.
  • The source and strength of evidence behind monitoring guidelines should be more clearly delineated.

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