Education, Feedback Cut Unnecessary Lab Testing

Miriam E. Tucker

April 02, 2015

NATIONAL HARBOR, Maryland — An education and feedback intervention successfully reduced the number of daily blood tests ordered in hospitalized patients, leading to significant cost savings and potentially improved patient satisfaction, researchers report.

"Reduction of unnecessary lab testing is important for a number of reasons, including the avoidance of iatrogenic harm, such as hospital-acquired anemia and false-positive test results," said Kelly Cunningham Sponsler, MD, from the Vanderbilt University Medical Center in Nashville, Tennessee.

"Reducing inappropriate phlebotomy is a strategy for cost-containment and may also improve the patient experience," she added.

Results from a process-improvement initiative implemented at a single center were presented here at the Society of Hospital Medicine 2015 Annual Meeting.

The initiative was based on a Choosing Wisely report issued by the Society of Hospital Medicine, which lists repetitive complete blood counts (CBCs) and chemistry testing among the five practices that physicians and patients should question.

From January 2013 to January 2015, presentations were tailored to house-staff teams and direct-care hospitalist teams at Vanderbilt's tertiary care medical center. In addition, team members received informational emails and flyers, and displays reporting the price of lab tests were placed at clinical workstations.

Clinicians weren't given specific guidelines on when to order CBCs or basic metabolic profiles; instead, they were encouraged to "order blood tests mindfully rather than reflexively," explained Dr Sponsler.

A weekly email provided feedback on daily tests and basic metabolic profiles ordered by each team.

Table. Decrease in Orders With the Intervention

Mean Daily Orders per Patient Baseline Intervention P Value
House-staff teams      
   CBCs 0.90 0.52 <.001
   Basic metabolic profiles 1.05 0.76 <.001
Hospitalist teams      
   CBCs 0.51 0.31 <.001
   Basic metabolic profiles 0.69 0.44 <.001


For the house-staff teams, the proportion of patients with no lab tests ordered on any given day increased from 2.6% at baseline to 9.1% (P < .001). At a cost of $88 per CBC $160 per basic metabolic profile, estimated weekly cost savings averaged $20,288.

For the hospitalist teams, the proportion of patients with lab-free days increased from 12.8% at baseline to 27.1% (P < .001), and estimated weekly cost savings averaged $16,733.

The researchers performed an informal comparison of the intervention teams with groups not participating in the intervention. Teams from gastroenterology and cardiology services served as the control group for the house staff, and teams from geriatrics served as the control group for the hospitalists.

During the intervention period, the number of lab tests ordered by the control groups declined, although not as dramatically as in the intervention groups. The proportion of patients with lab-free days increased from 1.6% to 3.3% in the house-staff control group (P < .001), and from 13.0% to 17.0% in the hospitalists control group (P < .001).

Changing Hospital Culture

Dr Sponsler acknowledged that in the control groups, exposure to the intervention was not rigorously controlled for, so "contamination" was possible.

In fact, she said, "I think there was a lot of spillover, especially among house-staff services."

"Many of them could have rotated to the GI and cardiology control groups," she explained. From a quality-improvement standpoint, "we feel this is a good thing. The more spillover we have, the more reduction we have in overall utilization."

She added that her team is investigating differences in the patient populations and possible temporal trends that could have influenced the results. They've now rolled out the intervention to neurology and various surgery services at Vanderbilt.

More and more, she noted, "there's a general awareness and embracing of this Choosing Wisely initiative."

"We are seeing that simply by raising awareness and being proactive about tracking and sharing our data, we are able to influence clinician behavior in a meaningful way, which is translating into a true culture change in our institution," Dr Sponsler told Medscape Medical News.

"This discussion of value in healthcare, combined with improving the patient experience by decreasing phlebotomy, has been a relatively recent phenomenon," said Margaret Fang, MD, from the University of California at San Francisco, who chaired the abstract selection committee and the conference session.

"The most interesting thing about it was that they were able to really leverage a change in the culture and effectively garner the support of house staff and trainees who do the majority of ordering on academic teaching services," she told Medscape Medical News.

But Dr Fang cautioned that more information is needed on the potential unintended consequences of changing practice.

When Is Testing Needed?

"If you're reducing lab costs and the number of blood tests, are you potentially missing things that might adversely affect patients' health?" she asked.

Although the data argue against the need for routine daily testing, there is little guidance for clinicians on when such testing is needed. "Daily labs are one of those things for which we don't have much data. As a clinician, I would like to know how often you should order them," she explained.

Dr Fang pointed out that the literature supports the Choosing Wisely target with evidence that routine testing is related to increased anemia and associated mortality, and that outcomes appear to be similar in hospitals with different ordering practices.

"We know that variation exists and quality may be no different, so the question is, what is the optimal number?" she said.

A logical next step for this research would be to look at total hospitalization costs, she added. "You may reduce lab costs, but what if you have a complication related to missing something and that extends the hospitalization or contributes to increased cost?"

Dr Sponsler and Dr Fang have disclosed no relevant financial relationships.

Society of Hospital Medicine 2015 Annual Meeting. Presented on March 31, 2015.


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