Laboratory Ordering Reduction and Cost Accountability (LORCA): A Value Driven Quality Improvement Initiative

From the 2018 HVPAA National Conference

Claire Ciarkowski (University of Utah School of Medicine), Nathan Wanner (University of Utah School of Medicine), Jeff Young (University of Utah), Antoine Clawson (University of Utah), Jacob Pettit (University of Utah)

Background

It is estimated 30-50% of laboratory testing ordered on hospitalized patients is unnecessary, can cause potential harm, and contributes to healthcare waste. In 2014, the hospitalist group implemented a multifaceted intervention that resulted in a 19% reduction in daily labs.  However, this intervention lacked timely feedback and clear provider attribution.

Objectives

To sustain the reduction of unnecessary labs ordering using a new LORCA tool.

Methods

LORCA was developed and implemented in January 2016 to provide cost and utilization feedback to attending providers on the University of Utah hospitalist service. The hospitalist service consists of 4 teaching teams with Internal Medicine (IM) residents and medical students, and 2 teams with Advanced Practice Clinicians (APC). LORCA monitors inpatient laboratory utilization by attending physician and medical team and provides a screen shot of the count and cost of labs per patient per 24 hours. APC teams have consistent exposure to LORCA feedback, while teaching teams have less consistent exposure due to residents’ rotations. LORCA can to compare an individual provider’s lab use to colleagues’ use as well as demonstrate team lab use and trends over time. LORCA’s impact was assessed by comparing lab ordering between hospitalist and other subspecialist services (cardiology, pulmonology, oncology, and hematology) who did not receive feedback as well as ordering behavior among the different hospitalist teams (teaching vs. APC).

Results

Data was collected from January 2016 through December 2017 on inpatients discharged by any IM service. A total of 19,296 visits (12,851 unique patients) were reviewed. Outcome measures include lab counts of basic metabolic panel (BMP), comprehensive metabolic panel (CMP) and complete blood count (CBC). Results were adjusted for Medicare Severity-Diagnosis Related Group and length of stay (LOS). The mean difference of lab ordering per visit between hospitalist and IM subspecialty teams was significantly different with hospitalist ordering less (BMP (-0.77, CI: -1.11 to -.43, p<0.001), CMP (-0.41, CI: -0.66 to -0.15, p=0.002) and CBC (-0.88, CI: -1.25 to -0.52, p<0.001). The mean difference of lab ordering among the hospitalist teams was not statistically different. (p=0.21).  However, when looking at the rate of decreasing usage among hospitalist groups, APC hospitalist teams are decreasing usage at a significantly faster rate (BMP (95% CI: -.04 to -.007, p<0.01), CMP (95% CI: -.02 to -.005, p<0.01) and CBC (95% CI: -.07 to-.03, p<0.01).

Conclusion

The implementation of the LORCA tool, the value culture established by the hospitalist service, and buy – in from hospitalist providers may have contributed to the significantly less lab ordering by hospitalist teams. In addition, the APCs’ consistent exposure to LORCA’s feedback may have an impact in decreasing usage rate.

Implications for the Patient

Daily lab ordering has potential harms, including hospital-acquired anemia. By reducing laboratory testing, quality of care may be improved through patient experience and potentially decrease costs. Using an electronic data monitoring tool can help sustain lab reduction efforts by providing specific and timely feedback.

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