Reduction of Daily CBC/BMP Labs Among Internal Medicine Residents at Mount Carmel West

From the 2019 HVPAA National Conference

Dr. Jessica Weiss (Mount Carmel Health), Dr. Noah Hagen (Mount Carmel Health), Dr. Carter Battista (Mount Carmel Health), Mr. David Aufdencamp (Mount Carmel Health), Ms. Lynn Shaffer (Mount Carmel Health), Dr. Robert Battisti (Mount Carmel Health)

As part of the ABIM Choosing Wisely initiative, the Society of Hospital Medicine has emphasized repetitive complete blood count (CBC) and basic metabolic panel (BMP) testing among its top five practices that physicians and patients should question. Reduction of unnecessary laboratory testing is important not only for cost containment, but also for improved patient experience and avoidance of iatrogenic harm. It was found at Mount Carmel West, the direct charge of a CBC was $36 and BMP was $40. A literature review showed that a quality improvement project utilizing educational interventions including cost education and appropriate utilization of lab testing could be successful. Our internal medicine residency program is seeking to reduce unnecessary ordering of daily CBCs and BMPs on the general medicine floors with a goal of decreasing CBC/patient/day and BMP/patient/day each by 20%.

Interventions consisted of education and feedback and were tailored for internal medicine residents. Education included lectures, monthly reminders, email updates and lab cost badge displays. Residents were encouraged to evaluate each patient daily for the need for a CBC and BMP with feedback regarding each team’s progress provided monthly. This project used pre-intervention data from 07/2015 to 08/2016 to compare with post-intervention data from 09/2016 to 12/2017 in number of CBC and BMP orders per patient/day, which were then compared using the two-sample Poisson rate test for statistical significance.

Pre-intervention data from 07/2015 to 08/2016 showed a rate of 1.17 BMP/patient/day and average of 1.19 CBC/patient/day. Post-intervention data, 09/2016 to 12/2017, showed a decrease in the rate of BMP/patient/day from 1.17 to 0.90, a 23.1% reduction (p < 0.0001) and a decrease in CBC/patient/day from 1.19 to 1.06, a 10.9 % reduction (p = 0.0002). Average length of stay (LOS) was not different between the pre-and post-intervention periods with average baseline LOS 4.3 compared to post-intervention 4.1 (p=0.4246). Given our average daily census of 33.9 patients/day, this roughly translates to a reduction of 3,515 BMPs/year and 1,802 CBCs/year, a reduction in cost of care of approximately $191,424 per calendar year in direct testing costs.

This project was targeting a 20% reduction of CBC/patient/day and BMP/patient/day on the general medicine teams. With our educational intervention, we reduced BMP/patient/day by 23.1% and CBC/patient/day by 10.9%. Even by partly reaching our goal of 20% reduction, we decreased healthcare costs by several hundred thousand dollars per year. Since initial intervention, there has been a total reduction of $282,667 in cost of care. This quality improvement project took only 16 to 20 person-hours and a small cost to make lab cost badge displays. With more time and further education, we believe our goal reduction in CBC ordering can be reached.


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.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog