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Utilization analysis of laboratory tests using health insurance claims data: advancing nationwide diagnostic stewardship monitoring systems

  • Se-eun Koo ORCID logo , Jiyeon Kim ORCID logo and Kuenyoul Park ORCID logo EMAIL logo
Published/Copyright: July 15, 2025
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Clinical Chemistry and Laboratory Medicine (CCLM)
From the journal Clinical Chemistry and Laboratory Medicine (CCLM) Volume 63 Issue 11

Abstract

Objectives

Diagnostic stewardship aims to optimize laboratory testing practices by ensuring appropriate test utilization while minimizing unnecessary testing. However, the nationwide monitoring systems for laboratory test utilization remain underdeveloped. In this study, we analyzed nationwide health insurance claims data to identify inappropriate test utilization patterns and inform diagnostic stewardship interventions.

Methods

We analyzed the health insurance claims data from the Health Insurance Review and Assessment Service of Korea from January 2018 to December 2023. Three laboratory tests with concerns were evaluated. Inappropriate test utilization was classified based on adherence to recommended methodologies and institutional testing practices.

Results

The proportion of tuberculosis cultures performed using both liquid and solid media increased from 84.6 % in 2018 to 91.4 % in 2023; however, some institutions continued to perform >90 % of tests using only a single medium. Regional disparities were observed, with nonmetropolitan areas exhibiting higher rates of inappropriate tuberculosis testing. Stool ova and parasite tests showed a persistent reliance on direct smear-only methods. The correlation between endemic parasitic regions and the high proportions of direct smear-only tests suggests an urgent need for improved diagnostic methodologies. Despite longstanding recommendations against their use, bleeding time tests remained frequently ordered. The total number of bleeding time test claims exceeded 400,000 annually, with a limited decline over time.

Conclusions

Systematic monitoring frameworks based on nationwide claims data can identify inappropriate test utilization and support diagnostic stewardship efforts by informing targeted interventions, thereby optimizing laboratory resource allocation and enhancing patient safety.

Keywords: diagnostic stewardship; laboratory test utilization; health insurance claims data; inappropriate testing; nationwide surveillance
Corresponding author: Kuenyoul Park, Department of Laboratory Medicine, Sanggye Paik Hospital, School of Medicine, Inje University, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Republic of Korea, E-mail:

  1. Research ethics: This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The Institutional Review Board of Sanggye Paik Hospital waived the requirement for review of the study and the need to obtain informed consent (2023-11-012).

  2. Informed consent: Not applicable.

  3. Author contributions: Conceptualization: Park K. Data curation: Koo S. Investigation: Koo S and Kim J. Writing – original draft: Koo S. Writing – review & editing: Park K. All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  4. Use of Large Language Models, AI and Machine Learning Tools: None declared.

  5. Conflict of interest: The authors state no conflict of interest.

  6. Research funding: None declared.

  7. Data availability: The raw claims datasets generated and/or analyzed in this study are not publicly available because of the ethical restrictions imposed by the HIRA. All data used in this study were obtained from HIRA research data (M20241030002).

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Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/cclm-2025-0641).

Received: 2025-05-27
Accepted: 2025-07-03
Published Online: 2025-07-15
Published in Print: 2025-10-27

© 2025 Walter de Gruyter GmbH, Berlin/Boston

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. Advancing diagnostic stewardship through claims-based utilization analysis: toward a system-wide vision of diagnostic excellence
  4. Review
  5. Biomarkers in body fluids and their detection techniques for human intestinal permeability assessment
  6. Mini Review
  7. Challenges of using natriuretic peptides to screen for the risk of developing heart failure in patients with diabetes: a report from the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) Committee on Clinical Applications of Cardiac Bio-Markers (C-CB)
  8. Opinion Papers
  9. Reference intervals in value-based laboratory medicine: a shift from single-point measurements to metabolic variation-based models
  10. Overview of laboratory diagnostics for immediate management of patients presenting to the emergency department with acute bleeding
  11. What Matters Most: an Age-Friendly approach to pathology and laboratory medicine
  12. No fault or negligence after an adverse analytical finding due to a contaminated supplement: mission impossible. Two examples involving trimetazidine
  13. General Clinical Chemistry and Laboratory Medicine
  14. Utilization analysis of laboratory tests using health insurance claims data: advancing nationwide diagnostic stewardship monitoring systems
  15. Evaluating large language models as clinical laboratory test recommenders in primary and emergency care: a crucial step in clinical decision making
  16. A novel corrective model based on red blood cells indices and haemolysis index enables accurate unhaemolysed potassium determination in haemolysed samples – Hemokalc project
  17. Validation of (self-collected) capillary blood using a topper collection system as alternative for venous sampling for 15 common clinical chemistry analytes
  18. Acoustophoresis-based blood sampling and plasma separation for potentially minimizing sampling-related blood loss
  19. Clinical validation of a liquid chromatography single quadrupole mass spectrometry (LC-MS) method using Waters Kairos™ Amino Acid Kit reagents
  20. Robustness of steroidomics-based machine learning for diagnosis of primary aldosteronism: a laboratory medicine perspective
  21. Investigation of the possible cause of over-estimation of human aldosterone in plasma, using a unique, non-synthetic human aldosterone-free matrix
  22. Performance of afternoon (16:00 h) serum cortisol for the diagnosis of Cushing’s syndrome
  23. MAGLUMI® Tacrolimus (CLIA) assay: analytical performances and comparison with LC-MS/MS and ARCHITECT Tacrolimus (CMIA) assay
  24. Assessment of 2023 ACR/EULAR antiphospholipid syndrome classification criteria in a Spanish cohort
  25. Comprehensive evaluation of antiphospholipid antibody testing methodologies in APS diagnosis: performance comparisons across assay systems and clinical subtypes
  26. Candidate Reference Measurement Procedures and Materials
  27. Exploring commutable materials for serum folate measurement: challenges in cross-method harmonization
  28. Reference Values and Biological Variations
  29. Reference ranges for ionized calcium in plasma in Danish children aged 0 days to 3 years using laboratory registry data
  30. A step forward in pediatric hemophagocytic lymphohistiocytosis and autoimmune disease: pediatric reference interval for serum soluble IL-2 receptor and soluble CD163
  31. Cancer Diagnostics
  32. Cellular expression of PD-1, PD-L1 and CTLA-4 in patients with JAK2V617F mutated myeloproliferative disorders
  33. Diabetes
  34. Serum N-glycans as independent predictors of the incidence of type 2 diabetes: a prospective investigation in the AEGIS cohort
  35. Infectious Diseases
  36. An assessment of molecular diagnosis of tuberculosis and multi-drug resistant tuberculosis testing and quality assessment: findings of an international survey
  37. Letters to the Editor
  38. Targeting low-value laboratory care
  39. Is time a significant factor in the release of potassium from lithium heparin plasma and serum?
  40. External quality assessment in resource-constrained laboratories: a survey of practices and perceptions in Nepal
  41. Is successfulness of platelet clump disaggregation by vortexing influenced by platelet measurement methods?
  42. Oligoclonal banding analysis: assessing plasma use and time interval requirements for paired CSF and blood
https://doi.org/10.1515/cclm-2025-0641
Keywords for this article
diagnostic stewardship; laboratory test utilization; health insurance claims data; inappropriate testing; nationwide surveillance

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. Advancing diagnostic stewardship through claims-based utilization analysis: toward a system-wide vision of diagnostic excellence
  4. Review
  5. Biomarkers in body fluids and their detection techniques for human intestinal permeability assessment
  6. Mini Review
  7. Challenges of using natriuretic peptides to screen for the risk of developing heart failure in patients with diabetes: a report from the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) Committee on Clinical Applications of Cardiac Bio-Markers (C-CB)
  8. Opinion Papers
  9. Reference intervals in value-based laboratory medicine: a shift from single-point measurements to metabolic variation-based models
  10. Overview of laboratory diagnostics for immediate management of patients presenting to the emergency department with acute bleeding
  11. What Matters Most: an Age-Friendly approach to pathology and laboratory medicine
  12. No fault or negligence after an adverse analytical finding due to a contaminated supplement: mission impossible. Two examples involving trimetazidine
  13. General Clinical Chemistry and Laboratory Medicine
  14. Utilization analysis of laboratory tests using health insurance claims data: advancing nationwide diagnostic stewardship monitoring systems
  15. Evaluating large language models as clinical laboratory test recommenders in primary and emergency care: a crucial step in clinical decision making
  16. A novel corrective model based on red blood cells indices and haemolysis index enables accurate unhaemolysed potassium determination in haemolysed samples – Hemokalc project
  17. Validation of (self-collected) capillary blood using a topper collection system as alternative for venous sampling for 15 common clinical chemistry analytes
  18. Acoustophoresis-based blood sampling and plasma separation for potentially minimizing sampling-related blood loss
  19. Clinical validation of a liquid chromatography single quadrupole mass spectrometry (LC-MS) method using Waters Kairos™ Amino Acid Kit reagents
  20. Robustness of steroidomics-based machine learning for diagnosis of primary aldosteronism: a laboratory medicine perspective
  21. Investigation of the possible cause of over-estimation of human aldosterone in plasma, using a unique, non-synthetic human aldosterone-free matrix
  22. Performance of afternoon (16:00 h) serum cortisol for the diagnosis of Cushing’s syndrome
  23. MAGLUMI® Tacrolimus (CLIA) assay: analytical performances and comparison with LC-MS/MS and ARCHITECT Tacrolimus (CMIA) assay
  24. Assessment of 2023 ACR/EULAR antiphospholipid syndrome classification criteria in a Spanish cohort
  25. Comprehensive evaluation of antiphospholipid antibody testing methodologies in APS diagnosis: performance comparisons across assay systems and clinical subtypes
  26. Candidate Reference Measurement Procedures and Materials
  27. Exploring commutable materials for serum folate measurement: challenges in cross-method harmonization
  28. Reference Values and Biological Variations
  29. Reference ranges for ionized calcium in plasma in Danish children aged 0 days to 3 years using laboratory registry data
  30. A step forward in pediatric hemophagocytic lymphohistiocytosis and autoimmune disease: pediatric reference interval for serum soluble IL-2 receptor and soluble CD163
  31. Cancer Diagnostics
  32. Cellular expression of PD-1, PD-L1 and CTLA-4 in patients with JAK2V617F mutated myeloproliferative disorders
  33. Diabetes
  34. Serum N-glycans as independent predictors of the incidence of type 2 diabetes: a prospective investigation in the AEGIS cohort
  35. Infectious Diseases
  36. An assessment of molecular diagnosis of tuberculosis and multi-drug resistant tuberculosis testing and quality assessment: findings of an international survey
  37. Letters to the Editor
  38. Targeting low-value laboratory care
  39. Is time a significant factor in the release of potassium from lithium heparin plasma and serum?
  40. External quality assessment in resource-constrained laboratories: a survey of practices and perceptions in Nepal
  41. Is successfulness of platelet clump disaggregation by vortexing influenced by platelet measurement methods?
  42. Oligoclonal banding analysis: assessing plasma use and time interval requirements for paired CSF and blood
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