Over-Testing for Liver Conditions Can Increase Costs, Patient Harm

Physicians commonly order multiple blood tests at the same time to determine the underlying cause of symptoms indicating liver failure. While these tests can lead to a quicker diagnosis, new findings show that over-testing could lead to unnecessary worrying, biopsies, and costs.

In 2 new studies published by the Journal of Hospital Medicine and the Journal of Hepatology, the authors recommend physicians exclude rare liver issues prior to testing. The study authors also believe that software used for liver-related blood tests should remind them to make informed choices.

The authors did not see harm in an initial test for elevated liver enzymes, but are concerned about a multitude of other tests that happen after the first test.

"Physicians are legitimately thinking they're doing the right thing by ordering the full 'panel' of tests, being thorough and trying not to miss anything. In the hospital, they may be doing what a consulting liver specialist has suggested,” said researcher Elliot Tapper, MD, MS. "But they're not aware of, or thinking about, the ramifications. This can include false positives for rare diseases that can cause the patient and their family anxiety, and lead to unnecessary liver biopsies."

Dr Tapper recommends a more directed approach to liver testing, as opposed to the current method of undirected testing, according to the study.

Specifically, in hospital patients, directed testing means ordering initial tests for common problems, such as hepatitis B or C, gallstones, drug overdose, or blockage of blood vessels in the liver. After testing for those conditions comes back negative, tests should be conducted for rare autoimmune or genetic disorders.

In outpatients, conditions associated with alcohol, obesity, and diabetes are likely the cause of elevated liver enzyme levels, followed by hepatitis B or C, according to the study. The study authors recommend conducting those tests first, including an ultrasound for non-alcoholic fatty liver disease. Prior to testing for rare diseases, physicians should account for broader symptoms and lifestyle factors.

In both inpatient and outpatient settings, if patients say they’ve been excessively drinking alcohol, using intravenous drugs, or taking a drug known to cause liver damage, the prevalence of testing for rare conditions plummets, according to the study.

Tests for rare conditions, such as Wilson disease, hemochromatosis, autoimmune hepatitis, and primary biliary cholangitis, often elicit a false positive. Patients then must undergo a biopsy to determine if they have the condition, which can result in anxiety, pain, increased costs, and worrying.

In the Journal of Hospital Medicine study, the investigators analyzed liver testing orders for patients that experienced acute liver injury. Approximately 86% of patients underwent specialized testing for liver problems, and many patients also received same-day blood tests.

Over-testing for liver issues also increases costs for the patient and healthcare system. The study authors estimate that if each hospitalized patient with high levels of liver enzymes received the tests, it would cost more than $40 million a year. Biopsies could also increase hospital stays and cost more than $1500 per patient, according to the study.

In the Journal of Hepatology study, the authors created a model of liver testing used in the outpatient setting that included 10,000 adults with slightly elevated liver enzyme levels upon initial testing.

The authors discovered that a directed approach to liver testing would result in less false positives, and reduce liver biopsies by half, according to the study. Changes to pre-testing based on patient history and symptoms also were observed to impact further testing, and costs.

"The main message to all physicians with a patient with elevated liver enzyme levels is, think about what could really hurt my patient and what's common, and direct your testing in that way first," Dr Tapper concluded. "If you find out on day 7 that it's actually a rare case of Wilson disease, the delay of a few days won't have changed the treatment plan, or harmed the patient. But the dollar cost, and personal cost, can be much higher for those who receive false positives and unnecessary biopsies. Patients just want to be told straight-up what they have and what they should do."