Pam Harrison

October 24, 2014

TAMPA, Florida — Educating healthcare providers about the usefulness of various laboratory tests significantly reduces unnecessary testing and results in better patient care at a lower cost to the lab, according to several studies presented here at the American Society for Clinical Pathology (ASCP) 2014.

Investigators report a 75% decrease in orders for the 1,25-dihydroxyvitamin D test — which is the wrong test to assess vitamin D — after efforts to educate clinicians in the Western Connecticut Health Network.

Palawinnage Muthukumarana, MD, from Danbury Hospital in Connecticut, reports that laboratory savings added up to more than $3700.

"The goal of this project was to educate physicians who are not endocrinologists or nephrologists, using minimal information technology resources and minimal interruption of the daily workflow in the laboratory, to get the best patient outcomes," Dr Muthukumarana told Medscape Medical News.

"The intervention had a large impact on our laboratory, not just in terms of cost savings," but for patients as well, she said.

"Physician education and workflow improvements can markedly decrease incorrectly ordered 1,25-dihydroxyvitamin D tests," the researchers conclude. "Instituting a vitamin D management program can help provide high-quality and effective care, while simultaneously reducing healthcare costs."

Dr Muthukumarana and colleagues conducted a review of their laboratory information system for all 1,25-dihydroxyvitamin D orders. Of the 464 tests they identified during a 1-year period, approximately 60% had been ordered instead of the 25-hydroxyvitamin D test.

Incorrect Vitamin D Tests

They then implemented a number of measures to educate healthcare providers about the appropriate vitamin D test.

In the Western Connecticut Health Network, it is recommended that only endocrinologists and nephrologists order the 1,25-dihydroxyvitamin D test. Therefore, the researchers telephoned other clinicians in the network who had often ordered 1,25-dihytdroxyvitamin D tests to educate them on the difference between the two tests. Clinicians who ordered the test less often were sent an educational letter.

In addition, "we wrote a piece about vitamin D testing in our newsletter, which is published on the Danbury Hospital website, and we reviewed the Allscripts computer order entry screen for vitamin D testing," the researchers report.

Not only was there a steady reduction in the number of 1,25-dihyddroxyvitamin D tests ordered by clinicians during the 6-month study period, of the 62 orders for the test, 33 were changed to the appropriate test and eight were cancelled, Dr Muthukumarana noted.

Although the study is over, clinicians who order the 1,25-dihydroxyvitamin D test now who are not endocrinologists or nephrologists are sent an educational fax and asked if they meant to order the 25-hydroxyvitamain D test instead, she said.

In a related project, also conducted in the Western Connecticut Health Network, a laboratory audit showed that methylmalonic acid (MMA) testing was not being ordered appropriately.

Wrong Vitamin B12 Test

Serum MMA levels are elevated primarily in patients with a vitamin B12 deficiency, and less commonly in patients affected with methylmalonic academia. An MMA test should only be ordered as a confirmatory test when vitamin B12 levels are equivocal, explain Lauren Lippincott, MD, a pathology resident at the Danbury Hospital, and colleagues.

The researchers used the Mayo Medical Laboratories pernicious anemia testing algorithm to determine that MMA testing is warranted only if a patient's vitamin B12 level falls in the equivocal range of 150 to 400 ng/L.

To educate and encourage healthcare professionals to follow evidence-based practices and reduce unnecessary MMA testing, letters were sent to inform physicians about the MMA guidelines, an article on MMA testing was published in the hospital newsletter and distributed throughout the hospital network, and a pop-up notification screen in the electronic medical record system guided clinicians ordering MMA tests on appropriate use.

"This went into effect at the end of October last year," Dr Lippincott told Medscape Medical News. "Our people would first look to see if a vitamin B12 test was ordered, and then, if it did not fall into the 150 to 400 ng/L range, the MMA test would be cancelled and a notification letter would be faxed to the physician's office." If they had concerns or if there was a reason they needed to order the MMA test, they were invited to contact us, she explained.

With data extrapolated to the end of September of this year, "there has been about a 56% overall average reduction in MMA tests ordered," Dr Lippincott noted. Because "each test costs about $28, we've saved upward of $10,000 in the past year," she said.

The same blood sample can be used to test vitamin B12 status and MMA, so the lab can hold the sample, she explained, and, if the patient falls into a low category on the pernicious anemia testing algorithm, "we automatically send it out for MMA testing."

In an unrelated study, researchers sought to reduce the use of ionized calcium testing.

Ionized calcium identifies irregularities in calcium homeostasis. Jennifer Woo, MD, from the David Geffen School of Medicine at the University of California in Los Angeles, and colleagues found that the test was frequently and routinely measured in all patients at their institution, even in the absence of clinical indications, such as massive transfusions, end-stage renal disease, hypercalcemia of malignancy, and primary hyperparathyroidism.

Too Much Ionized Calcium Testing

The researchers implemented a resident education program to change physician ordering practices. Pathology residents created presentations and fliers to educate residents in internal medicine on the appropriate clinical indications for ionized calcium testing. Fliers reminded physicians that it should not be ordered as part of routine daily labs on every patient, and that serum calcium is included in the basic metabolic panel and is a reliable measure of calcium for most patients.

At baseline, three internal medicine units averaged 21.0 orders a day. Twenty-six weeks after the educational intervention, the average daily orders had dropped by about 63%, to an average of 7.7 orders a day (P < .001).

"It is our thought that resident interns are particularly subject to culture and systemic pressures, and may be unduly influenced to order routine labs," Dr Woo and colleagues report. "Constructing a dialogue between medical units and the laboratory early during medical training may be an effective tool for the proper utilization of laboratory tests and the enhancement of patient care."

Erik Jenson, MD, chief pathology resident at the Dartmouth–Hitchcock Medical Center in Lebanon, New Hampshire, said that they, too, have found that provider education is the best tool to address not only inappropriately ordered vitamin D tests, but also the concept of test utilization as a whole.

Physician Education

"In our own similarly structured prospective audit, we found that most of the providers we contacted with regard to inappropriately ordered 1,25-dihydroxyvitamin D very much appreciated the education we were able to provide about the intricacies of the vitamin D metabolic pathway and the subtle clinical differences in testing for 1,25-dihydroxyvitamin D and 25-hydroxyvitamin D," Dr Jenson told Medscape Medical News.

True, the upfront time investment in a prospective audit is a significant undertaking, he acknowledged. However, Dr Jenson and colleagues found that once the majority of their providers had been educated about appropriate vitamin D testing, "the number of inappropriately ordered tests dropped and continued to stay low."

Before the audit, Dartmouth–Hitchcock averaged 176 tests for 1,25-dihydroxyvitamin D a month — 67% of which were determined to be inappropriate, he reported.

Eighteen months after the audit, "we averaged 71 monthly tests, only 15% of which were determined to be inappropriate. This decreased rate of inappropriate testing signifies a shift to better patient care, as well as great financial savings for our laboratory. Our projected annual savings in send-out 1,25-dihydroxyvitamin D was estimated to be $56,000, or $4700 a month," he said.

Dr Jenson also observed that there is a growing interest among healthcare providers about vitamin D deficiency — declared by many experts to be an epidemic in the United States — and its ill effects on patient health.

"Our role as laboratory scientists is to help these providers make the best decisions for their patients based on the most appropriate tests available," he said.

Dr Muthukumarana, Dr Lippincott, Dr Woo, and Dr Jenson have disclosed no relevant financial relationships.


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