Routine Pathology Testing Prior to Bronchoscopy has Limited Clinical Impact With Significant Economic and Environmental Costs

🩺 Clinical Context

In the era of “Choosing Wisely” and value-based care, the routine practice of ordering pre-procedural pathology or laboratory testing (e.g., coagulation panels, CBCs) for patients undergoing bronchoscopy is increasingly scrutinized. This study addresses the clinical utility, economic burden, and environmental impact of these “routine” orders. For the interventional pulmonologist, the core question is whether these tests—often performed reflexively—actually alter management or patient safety outcomes, or if they represent low-value care that contributes to hospital waste and unnecessary patient anxiety.

📊 Methodological Strengths & Weaknesses

• Strengths:
  • Multidimensional Analysis: The study uniquely bridges clinical utility with administrative and environmental metrics (cost and carbon footprint), providing a holistic view of hospital waste.
  • Real-world Application: By evaluating “routine” orders, the study captures the gap between evidence-based guidelines and actual clinical practice patterns.
• Weaknesses:
  • Retrospective Design: The study is inherently limited by its observational nature, which may not fully account for the “defensive medicine” rationale behind ordering these tests in complex, comorbid populations.
  • Generalizability: The economic and environmental impact calculations are highly dependent on the specific hospital system’s cost structures and supply chain, which may not be universally applicable.
  • Selection Bias: The study may not adequately capture the subset of patients with occult coagulopathy or hematologic disorders where these tests did provide actionable data, potentially underestimating the utility in high-risk cohorts.

💡 Takeaway for Fellows

1. Challenge the “Routine” Order: As an IP fellow, you are the gatekeeper of the procedural suite. Stop reflexively ordering coagulation panels or CBCs for every bronchoscopy. Use the American College of Chest Physicians (ACCP) guidelines: testing should be driven by clinical history (e.g., known liver disease, anticoagulation use, or bleeding diathesis) rather than institutional habit.
2. The “Hidden” Cost: Recognize that every order has a downstream cost—not just in dollars, but in environmental impact (reagents, plastic waste, energy consumption). Reducing low-value testing is a tangible way to improve your hospital’s sustainability.
3. Clinical Judgment Over Protocol: If a patient has a normal history and physical, the pre-test probability of a clinically significant abnormality that would change your procedural plan is negligible. Reserve testing for patients where the result will fundamentally change your management (e.g., holding anticoagulation or delaying the procedure).
4. Advocacy: Use these findings to update your institution’s electronic health record (EHR) order sets. Removing “routine” pre-procedural panels from default order sets is the most effective way to reduce low-value care.