Modifying Provider Ordering Behaviors to Reduce Low Value Care: Comparative Effectiveness Literature Review

From the 2018 HVPAA National Conference

Scott Shuldiner (Johns Hopkins School of Medicine), Joby Tsai (Johns Hopkins University), John Morkos (Johns Hopkins School of Medicine), Venkatasai Jasty (Johns Hopkins Hospital), Sarah Thompson (Johns Hopkins School of Medicine), Steve Park (Johns Hopkins Hospital), Matthew Alvin (Johns Hopkins School of Medicine), Brandyn Lau (Johns Hopkins Department of Radiology), Pam Johnson (Hopkins)


Unnecessary diagnostic tests contribute to the high cost of health care, with reports that $65 billion is spent each year on laboratory tests and 20-50% of imaging exams may be unindicated. As such, quality improvement leads around the world are working to reduce unnecessary lab and imaging tests.


To review published value-based quality improvement initiatives that targeted unnecessary labs or imaging, with 3 aims:

  1. describe the range of tests targeted and interventions used to modify ordering behavior
  2. correlate the type of intervention with the effectiveness of the initiative
  3. use this evidence to guide design of future value-based quality improvement initiatives


Given the diversity of tests and novelty of this type of quality improvement work, a number of Pubmed searches were performed, yielding >1200 articles, as detailed in Table 1. A reviewer manually scanned titles and abstracts on the basis of relevance and inclusion criteria: relevant topic, direct implementation of intervention to reduce lab or imaging test(s), and assessment of efficacy.

A total of 65 articles met inclusion criteria, including 33 laboratory QI initiatives and 32 radiology QI initiatives. Data pertaining to study type, target test, intervention, setting, sample size, results and statistical significance of results were extracted from each publication.


Laboratory initiatives targeted:

  • daily labs (N=10)
  • multiple outpatient labs (N=7)
  • multiple ED labs (N=3)
  • multiple inpatient labs (N=2)
  • UA and culture (N=3)
  • vitamin D levels (N=2)
  • BNP
  • chemistry
  • ESR
  • epilepsy drug levels
  • preoperative labs

Interventions to reduce unnecessary ordering included:

  • education (N=12)
  • clinical decision support at point of care (N=8)
  • provider feedback utilization reports (N=9)
  • changed order set or order entry page (N=7)
  • price information (N=5)
  • removed reflex ordering (N=2)
  • changed lab name (N=1)
  • algorithm (N=1)
  • modified clinic design (N=1)
  • removed the test  (N=1)
  • inpatient daily lab plan (N=1)
  • checklist (N=1)
  • social pressure (N=1)
  • added step to ordering process (N=1)

More than 1 intervention was used in 16 initiatives. Most studies (94%, 30/32) reported significant reductions in target lab utilization, precluding an evaluation of effectiveness.


Radiology initiatives targeted:

  • pulmonary CTA (N=9)
  • multiple imaging tests (N=6)
  • L-spine imaging (N=5)
  • nuclear cardiology (N=3)
  • DEXA (N=2)
  • head CT (N=2)
  • all CT
  • cardiac imaging
  • coronary CTA & pulmonary CTA
  • CT & bone scan in prostate cancer
  • pelvic ultrasound

Interventions to reduce unnecessary ordering included:

  • education (N=17)
  • CDS at the point of care (N=8)
  • provider feedback utilization reports (N=6)
  • price information (N=3)
  • modified CT or MRI screening policy (N=2)
  • radiation exposure information (N=2)
  • modified CT protocol indications (N=1)
  • standardized recommendations in radiology reports (N=1)

More than 1 intervention was used in 16 initiatives.

In contradistinction to lab appropriateness improvement, only 63% (20/32) of the radiology initiatives were effective in significantly improving practice, providing an opportunity for comparison. Effective initiatives more commonly included use of multiple interventions (35% vs 8%) and provider feedback reports (30% vs 0%).


Reduction of unnecessary imaging tests appears to be more challenging than labs, according to published evidence. Use of multiple interventions, and in particular provider feedback reports, should be considered when designing initiatives to reduce unnecessary imaging exams.

Implications for the Patient

The insights gleaned from this analysis may be used to inform the development of future successful value-improvement interventions, with the objective of effectively reducing unnecessary laboratory and imaging tests to improve efficiency of care, reduce the risk associated with lab and imaging tests, and decrease patients’ cost of care.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

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