Quality Improvement Project Cuts Unnecessary Laboratory Tests

Veronica Hackethal, MD

February 18, 2016

A multipronged quality improvement project, including the use of a value-driven outcomes computer tool, can decrease the number of laboratory tests and associated costs during hospital admissions, according to a study published online February 4 in the Journal of Hospital Medicine.

"A multifaceted approach to laboratory reduction through education, process change, cost feedback, and financial incentive resulted in a significant reduction in laboratory cost per day, laboratory cost per visit, and the ordering of common laboratory tests at a major academic medical center," first author Peter Yarbrough, MD, from the Department of Internal Medicine, Division of General Internal Medicine, University of Utah Medical Center, Salt Lake City, and colleagues write.

"Inappropriate laboratory testing is a contributor to waste in health care," the researchers note. About 30% to 50% of inpatient laboratory testing is considered unnecessary and can result in patient harm, including anemia, false positives, and interruption of badly needed patient sleep.

The retrospective, controlled trial took place at the University of Utah Medical Center. It included all patients older than 18 years admitted to the 500-bed hospital between July 2012 and April 2014 with the exception of those admitted to obstetrics, rehabilitation, and psychiatry.

The study compared changes in laboratory costs between patients cared for by hospitalists (intervention group; n = 6310) and those seen by nonhospitalists (control group; n = 25,586). The intervention targeted hospitalists because a prior analysis had suggested room for improvement in terms of reducing inpatient laboratory costs.

The intervention ran from February 1, 2013, to April 30, 2014, and had the goal of decreasing costs by changing the culture of routine laboratory test ordering.

First, the researchers evaluated inpatient workflow and did a literature review, which found that interns order laboratory tests most frequently.

Then they provided education to all providers involved, which included giving pocket cards listing the charges of most commonly ordered laboratory tests to internal medicine residents. The intervention also sought to standardize rounding and stimulate discussion of laboratory tests by requiring providers to do a checklist review of patient care with senior members of the team.

In addition, hospitalists received monthly feedback about laboratory costs via the value-driven outcomes tool. The Division of General Internal Medicine received a financial incentive (50% of shared cost savings to the hospital) for participation.

Results showed that the intervention reduced unadjusted mean laboratory costs per day from $138 before to $123 after the intervention (P < .001). Likewise, unadjusted mean laboratory costs per visit decreased from $618 to $558 (P = .005). The number of tests per day also decreased after the intervention.

The authors estimated that differences in laboratory costs in the intervention group compared with the control group would result in a savings of $251,427 (95% confidence interval, $20,370 - $482,484) during the first year. And if the control group implemented the intervention, laboratory cost savings during the first year would come to $1,321,669 (95% confidence interval, $107,081 - $2,536,256).

Limitations include the single-center nature of this study and its nonrandomized design. In addition, the baseline period started in July, when interns may have had the least experience ordering laboratory tests.

"[O]ngoing costs were minimal and related to any additional time spent during rounds to discuss laboratory tests," the authors conclude. "Thus, we feel that this intervention is feasible for wide replication."

One or more authors reports consulting for or receiving royalties for one or more of the following: US Office of the National Coordinator for Health IT, ARUP Laboratories, McKesson InterQual, ESAC Inc, JBS International Inc, Inflexxion Inc, Intelligent Automation Inc, Partners HealthCare, Mayo Clinic, the RAND Corporation, Duke University-owned CDS technology, Religent Inc, and Clinica Software Inc. One coauthor was formerly a co-owner of Clinica Software Inc but reports no current financial relationship with them.

J Hospital Med. Published online February 4, 2016. Abstract

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