From the 2022 HVPA National Conference
Mackenzie Whitcomb BA (Oregon Health and Science University), Alysssa Andretta BA, Anne Smeraglio MD
While large hospital systems perform majority of laboratory studies in in-house facilities, a small subset of reference labs are outsourced to off-site laboratories. Reference laboratories account for a relatively small percentage of total test volume but are disproportionately expensive compared to in-house laboratory testing.1 Studies have demonstrated that reference labs are often clinically unnecessary.2 The absolute cost associated with clinically unnecessary reference labs has yet to be studied.
To identify and quantify waste from inpatient reference labs that were incorrectly ordered in duplicate within the Oregon Health & Science University (OHSU) hospital system. Examined total cost of inappropriately duplicated reference labs, frequency of duplicate reference labs by admitting service and provider type, and how time to reference lab resulting affected frequency of duplication.
This study is a retrospective analysis of all admitted patients with reference labs ordered during their hospitalization in 2019 at OHSU. A duplicate lab was defined as a reference lab that was ordered prior to an original lab resulting. Cost was calculated using the institution’s publicly available comprehensive pricing transparency list.3
4.51% of reference labs (n=1081) were ordered in duplicate in 2019. 127 different lab tests were ordered in duplicate; however, only a subset of these unique labs had a cost available in the price transparency list. The total cost associated with duplicate labs available on the price transparency list was $117,866.00. The most common labs ordered in duplicate were as follows: Unspecified lab other (28.03%, n = 303), Busulfan (15.73%, n = 170), Opiate confirmatory (4.81%, n = 52), Bile Acids, total (3.42%, n = 37), and Growth Hormone, serum (2.87%, n = 31). 6.38% of all duplicate labs were ordered by a single provider. 68.83% of duplicate labs took 1-6 days to result and 26.18% took over 6 days to result. 17.3% of duplicate labs were ordered by hematology/oncology. 57.82% were ordered by an attending physician and 25.25% by a resident.
This study identified $117,866.00 of waste simply by examining the cost of a subset of duplicate reference labs: This price is an underestimate as it does not include labs not listed on price transparency list (n=427, 39.5% of duplicate labs). “Lab other” was the most common duplicate lab. This indicates a free text order for reference labs not listed in OHSU’s electronic health record (EHR). It is possible that some of these were not duplicates but different free text reference labs. Quality improvement interventions should focus on introducing EHR clinical decision support so that providers are aware of pending send out labs. Efforts should be made to include a more robust set of laboratories on the price transparency list.
Duplicate labs ordered prior to an initial, identical lab resulting is a clear indication of hospital waste and injudicious use of resources. This information should help guide future institutional change; specifically, tailored EHR clinical decision support designed to alert an ordering provider of pending reference labs, particularly for those undesignated studies labeled “Lab Other.” This would discourage duplicate reference lab ordering and thereby mitigate waste. Understanding ordering patterns, including lab ordering by single or multiple providers or teams, high utilizers, and workflows that predispose towards unnecessary duplicate ordering will be helpful in ameliorating this waste.