Routine biochemical screening frequently bundles redundant tests when one is sufficient from a screening, diagnostic or monitoring perspective. For example, ALT is a more specific test to detect liver injury compared to AST. AST is rarely needed if the ALT is normal, and AST should only be ordered by physicians with experience in treating liver disorders or monitoring of diagnosed liver fibrosis with a validated score (e.g. FIB-4). Creatinine alone is sufficient to check kidney function because laboratories automatically report estimated GFR; urea is often an unnecessary addition. Uncoupling bundled tests within order sets for initial screening reduces low value testing.
Sources:
Barrett BJ, Randell EW, Mariathas HH, Mohammadi A, Darcy S, Wilson R, Brian Johnston K, Parfrey PS. The effect of laboratory requisition modification, audit and feedback with academic detailing or both on utilization of blood urea testing in family practice in Newfoundland, Canada. Clin Biochem. 2020 Sep;83:21-27. doi: 10.1016/j.clinbiochem.2020.05.008. Epub 2020 May 22. PMID: 32450078.
Mathura P, Boettger C, Hagtvedt R, Sweeney C, Williams S, Suranyi Y, Kassam N, Gill M. Reduction of urea test ordering in the emergency department: multicomponent intervention including education, electronic ordering, and data feedback. CJEM. 2022 Sep;24(6):636-640. doi: 10.1007/s43678-022-00333-w. Epub 2022 Jul 20. PMID: 35857240.
Mohammed-Ali Z, Bhandarkar S, Tahir S, et al. Implementing effective test utilization via team-based evaluation and revision of a family medicine laboratory test requisition. BMJ Open Quality 2021;10:e001219. doi:10.1136/ bmjoq-2020-001219. PMID: 33731485.
Strauss R, Cressman A, Cheung M, et al Major reductions in unnecessary aspartate aminotransferase and blood urea nitrogen tests with a quality improvement initiative BMJ Quality & Safety 2019;28:809-816. PMID: 31073091.