From the 2019 HVPAA National Conference
Dr. Michael Daniel (Johns Hopkins School of Medicine), Dr. Amit Pahwa (Johns Hopkins School of Medicine), Dr. Sara Keller (Johns Hopkins School of Medicine), Prof. Linxuan Wu (Johns Hopkins School of Medicine), Prof. Laura Prichett (Johns Hopkins School of Medicine), Mr. Chanjun Park (Johns Hopkins School of Medicine), Dr. Lenny Feldman (Johns Hopkins School of Medicine)
Background
Routine laboratory testing in hospitalized patients results in increased blood draws and can lead to unnecessary phlebotomy and diagnostic information. The Choosing Wisely campaign has recommended a reduction in the frequency of this practice to decrease hospital-associated anemia and increase hospital cost savings. Providing feedback that compares an individual to the average of their peers is a strategy successfully used by other fields to reduce unnecessary practices.
Objective
To reduce unnecessary lab tests and the frequency with which patients undergo needlesticks among patients cared for by first year resident medicine physicians (interns) at the Johns Hopkins Hospital.
Methods
We performed a year-long cluster-controlled trial with a crossover at six months during 2017-2018 academic year. Every year, all first year housestaff at the Johns Hopkins Hospital are assigned to one of four general internal medicine firms. At the beginning of the first six-month period, interns on two of the four firms (Group 1) received weekly email reports of their personal ordering practices through a provider-level dashboard, and Group 2 did not. After the cross-over at six months Group 2 received the reports and Group 1 did not. Reports included the number of orders per patient-day, number of sticks per patient-day, estimated blood drawn per patient-day, and estimated tubes of blood drawn per patient-day compared to the intern class average. Housestaff were also surveyed at the beginning and end of the intervention about ordering practices, opinions, and experiences with the intervention.
Results
The 51 first year physicians were responsible for 23,864 individual orders over 1 year on the general medicine services. Interns in Group 1 and Group 2 had similar order rates in the first six months (between-group difference, 5.82%; 95% CI, -1.14% to 3.08%; P= 0.369). After the cross-over, the new intervention group, Group 2 had fewer orders than Group 1 (between-group difference, 13.91%; 95% CI, -5.99% to -0.76%; P= 0.011). Patients belonging to Group 2 in the second half of the year also had a lower stick rate (between-group difference, 10.62%; 95% CI, -0.68% to -0.02%; P= 0.039). All results were corrected for perceived patient severity using transfer to ICU and mortality statistics from each firm. With regards to the survey, at the beginning of the year, 86% of interns were interested in receiving feedback on their ordering practices which decreased to 70% of interns at the end of the year. Only 27% of interns, at the end of the year, felt knowing their ordering practices impacted their ordering decisions.
Conclusions
Providing internal medicine interns with data comparing their laboratory ordering practices with peers resulted in a decrease in order rates and decreased the frequency with which patients received laboratory draws in the second half of the year. This could possibly be a strategy to reduce unnecessary laboratory testing.
Clinical Implications
This project decreased how often patients were phlebotomized. This reduced the times that patients were stuck with needles, it reduced unnecessary blood removal, as well as decreased the cost associated with unnecessary lab draws.
