Reducing Inappropriate Laboratory Testing: More Is Not Always Better

From the 2019 HVPAA National Conference

Dr. Manpreet Basuita (University of Toronto), Mr. Corey Kamen (University of Toronto, Institute of Medical Science), Ms. Cheryl Ethier (Mount Sinai Hospital, Toronto, ON), Dr. Christine Soong (University of Toronto, Mount Sinai Hospital)

Background/Objective

Routine blood work (RBW) is commonly ordered among medical inpatients. The basic panel of RBW includes a complete blood count (CBC), electrolytes, and creatinine. While the results from RBW may be beneficial for patient management, inappropriate or unnecessary repetitive testing may increase patient harm (i.e. hospital acquired anemia), length of stay (LOS), and result in inefficient resource utilization. One United States university-associated teaching hospital decreased costs by $1 million dollar when unnecessary RBW was reduced over a 3-year intervention. Our Choosing Wisely project examined current ordering patterns and developed evidence-based interventions to help decrease the number of tests ordered per day and ultimately reduce associated costs.

Methods

This prospective cohort study was conducted at Mount Sinai Hospital and included 6,424 patients admitted to the General Internal Medicine (GIM) service between April 2016 and March 2018. There was no minimum LOS. Patients were excluded if LOS was beyond 365 days and/or if admission to the ICU/CCU. A systematic multimodal intervention began in July 2016 with changes to the electronic medical record (EMR) which included restrictions on the ability to preorder repetitive RBW. In July 2017, the research team began to audit and provide real-time feedback in the form of statistics and graphs on ordering patterns to each GIM team every 2 weeks.

Results

The average number of tests ordered per inpatient day decreased from 1.19 tests ordered per inpatient day to 1.11, which represented a 6.7% reduction. The average cost per inpatient day decreased from $5.07, prior to the audit and feedback intervention, to $4.65 post-intervention (an 8.3% reduction). Based on the total LOS of 48,938 days across the overall study period, there was a savings of $20,553.96.

Conclusion

Results from this study suggest that a change in ordering behaviour for RBW is possible amongst clinicians, especially when brought about through an audit and feedback intervention. Moving forward, our goal is to decrease the negative outcomes and unnecessary costs associated with RBW to foster a culture of ordering tests when clinically indicated to improve quality of patient care.

Clinical Implications

Our study demonstrates that by educating residents and physicians on their bloodwork ordering patterns, it is possible to improve the quality of patient care. As our study shows a reduction in the average number of blood tests ordered per inpatient day, this ultimately translates into reduced patient harm (i.e. less needle-pokes, less likelihood of hospital-acquired anemia) and improved efficiency of resources that can be utilized in other areas of the healthcare system.

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