Cost Awareness Reduces Test Ordering

Jim Kling

May 16, 2011

May 16, 2011 — Informing healthcare practitioners of the high cost of phlebotomy leads to a reduction in the orders for phlebotomies, according to a study published in the May issue of Archives of Surgery.

Phlebotomy procedures have increased in recent years. These tests are often unnecessary and redundant, prompting institutions to introduce various steps to limit their use.

Normally, providers are not aware of the cost of a procedure to the patient. Some studies have suggested that when the cost is made evident, providers reduce the number of tests ordered, with no apparent adverse effects on healthcare, as measured by readmission rates, transfers to intensive care units, length of stay, diagnoses, or mortality.

As the study authors, Elizabeth A. Stuebing, MD, MPH, from the University of Miami, Florida, and Thomas J. Miner, MD, from Brown University, Providence, Rhode Island, described, postsurgical patients at teaching institutions often have complete blood cell counts and chemistry panels ordered for days, even when recovery was proceeding normally. The pattern is perpetuated by senior residents asking for lab results from junior counterparts without informing them of when the lab tests are justified. Surgical residents are also unaware of the procedures' costs.

The researchers considered several solutions, including altering the hospital computer system, but that was considered unrealistic. Interventions that had been shown to be effective had been instituted, but with unsatisfactory results.

The researchers conducted a prospective observational study centered around a weekly announcement of the cost of phlebotomy procedures to surgical house staff and attending physicians in 3 general surgical services.

At the beginning of the study, the researchers recorded mean phlebotomy charges of $147.73 per patient per day. After 11 weeks, that number was reduced to $108.11 per patient day (correlation coefficient, −0.76; P = .002.) The changes resulted in an overall savings of $54,967 during the study period.

Limitations of the study include lack of follow-up, short interval, inability to prove sustainability, and assessment of changes in ordering patterns, as well as cost savings for only 1 blood draw each day. Some patients have multiple blood draws ordered throughout the day. Therefore, cost savings may have been underestimated.

Cost Consciousness: A Powerful Weapon

Excessive ordering of lab tests is often blamed on the fear of “frivolous lawsuits” and “the need to practice defensive medicine," but the providers' and patients' lack of awareness of the cost of a procedure may be another important factor, according to A. Benedict Cosimi, MD, from Massachusetts General Hospital, Boston, in an accompanying editorial.

"Although some reports have suggested that similar educational programs have shown only short-lived effects, I believe that such simple, low-cost, and readily repeatable interventions provide one of the most easily applied strategies for influencing clinicians' test and medication requesting behavior," wrote the editorialist. "Stuebing and Miner have presented convincing evidence that cost consciousness can provide a potent weapon for reducing some of the wasteful medical spending that contributes to our overall health care bill, which currently is twice as much per person as that of most industrialized countries," Dr. Cosimi concludes.

The study authors and editorialist have disclosed no relevant financial relationships. The data were originally presented at the 91st Annual Meeting of the New England Surgical Society.

Arch Surg. 2011;5:524-527, 527. Abstract


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