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The Tribune 25th Oct 2018

Laboratory tests are important diagnostic tools, central to guiding the investigation and management of many acute and chronic conditions. However, requesting a standard battery of blood tests without due regard to clinical indication has become the norm. 

Ordering the “full house” of blood count, urea and electrolytes, liver function tests, and C reactive protein might just be acting as a psychological comfort blanket for clinicians, masking an over-reliance on investigations or a lack of confidence in clinical judgment. 

In some cases, it may be dictated by the policy of ‘profit targets’ of the corporate hospital. 

Ordering unnecessary tests is also driven by the fear of missing important clinical details and the potential for subsequent litigation. 

‘Sink tests’

A disturbing revelation in a book by Dr Arun Gadre is the alleged wide prevalence of “sink tests”: pouring into a sink the blood or urine samples collected from patients for unnecessary tests upon the recommendation of a doctor and printing normal values on the medical report for all the tests that were not conducted. The doctor, meanwhile, is paid 40-60 per cent commission on each such test that he prescribed. 

The practice of ordering too many tests regardless of clinical need is wasteful and potentially damaging. 

 However, the waste associated with the practice of “package of tests” is damaging for clinicians, finance managers, and patients and leads to wasteful and potentially harmful medication. It is reported that nearly half of the abnormal investigations do not require any medication or another intervention. 

Analysing abnormal values

A typical routine blood test is the complete blood count, also called CBC, to count your red and white blood cells as well as measure your haemoglobin levels and other blood components. This test can uncover anaemia, infection, and even cancer of the blood. Another common blood test is the basic metabolic panel to check your heart, kidney, and liver function by looking at your blood glucose, calcium, and electrolyte levels. To check for heart disease risk, you may have a lipoprotein panel that measures levels of fats in your blood, like good cholesterol (HDL), bad cholesterol (LDL), and triglycerides.

A lab test tells us about the functioning of an organ. When a lab gives a report, typically it also mentions normal reference range — 0.84-1.21 mg/dL for creatinine. For a test of liver function (AST), it is 5-30 U/L. Values outside the range are considered ‘abnormal’. The reference range applies to a good percentage of the normal population, but not all. Its implications are important — a percentage of the normal population will have values outside this `normal range’. A value of 32 for AST would most likely mean that the person is among the remaining normal subjects, although the report highlights it as ‘abnormal’.  If we were to test 1,000 healthy individuals, 50 or more may have values outside the range for that test.

Such people are not necessarily diseased. However, abnormal values should not be ignored altogether. 

  • High BP itself can damage kidneys;

  • But so can some medication used to treat it.

  • Third, day-to-day variations in most parameters occur normally.

  • Lastly, differences between labs, within the lab, sample handling, can all contribute to variations in values.

So, an abnormal value should be analysed judiciously.

Test results can be abnormal for other reasons. If you get blood sugar test and you ate something before the test, or were drinking alcohol the night before or taking certain medications, your results could be temporarily above normal range, but not evidence of diabetes. A normal value may not be always a guarantee against disease, eg low tension glaucoma. The cutoff point is not sacrosanct. A man with prostate cancer may show a result in the normal range and results that are outside the normal range don’t mean a person has a disease. 

So, if the results are abnormal, your doctor may say not to worry. Why? Suppose that the result is abnormal, but has not changed significantly, it may not be worrisome. In many cases, lab values may look fairly above normal, but may be perfectly normal for that individual. 

Overly aggressive care also, as is done in the US, can harm patients, generating mistakes and injuries that are thought to cause many deaths each year. In India, where resources are scarce, and ignorance is abundant, the need to weed out unnecessary tests and wasteful medication due to abnormal values of the tests is felt more. 

Eleven common tests, procedures, and treatments, such as pre-operative tests, laboratory studies prior to surgery, and too frequent cancer screenings, account for 93 per cent of low-value services and 89 per cent of the estimated wasted spending. In India, the bulk of patients crowding the OPDs of hospitals like the PGI comprises patients who are panicked by minor symptoms caused due to faulty lifestyle, viz overeating or faulty eating, lack of exercise, obesity and its consequences, lack of water intake, lack of sleep, overuse of mobile, over-ambition and associated stress, misuse of medicines etc. 

Most of such problems can be prevented and patient load reduced by 80 per cent. This can be done by qualified and trained health guides, instead of doctors. This can save a lot of money and create millions of jobs, while ushering in a ‘healthy India’.


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