Results of a Quality Improvement Project Aimed at Eliminating Healthcare Waste by Changing Medical Resident Test Ordering Behavior (original) (raw)
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A multifaceted hospitalist quality improvement intervention: Decreased frequency of common labs
Journal of hospital medicine, 2015
Common labs such as a daily complete blood count or a daily basic metabolic panel represent possible waste and have been targeted by professional societies and the Choosing Wisely campaign for critical evaluation. We undertook a multifaceted quality-improvement (QI) intervention in a large community hospitalist group to decrease unnecessary common labs. The QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered as daily within the hospitalist group. We performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the 7-month intervention period. Demographic and clinical data were collected from the electronic medical record. The primary endpoint was number of common labs ordered per patient-day as estimated by a clustered multivariable linear regression model clustering by ordering hospitalist. Secondary endpoints included...
Anaesthesia and Intensive Care, 2018
Unnecessary pathology tests performed in intensive care units (ICU) might lead to increased costs of care and potential patient harm due to unnecessary phlebotomy. We hypothesised that a multimodal intervention program could result in a safe and effective reduction in the pathology tests ordered in our ICU. We conducted a single-centre pre- and post-study using multimodal interventions to address commonly ordered routine tests. The study was performed during the same six month period (August to February) over three years: 2012 to 2013 (pre-intervention), 2013 to 2014 (intervention) and 2014 to 2015 (post-intervention). Interventions consisted of staff education, designing new pathology forms, consultant-led pathology test ordering and intensive monitoring for a six-month period. The results of the study showed that there was a net savings of over A$213,000 in the intervention period and A$175,000 in the post-intervention period compared to the pre-intervention period. There was a 28...
BMC Medical Informatics and Decision Making
BackgroundStudies have revealed inappropriate laboratory testing as a source of waste. This review aimed at evaluating the effects and features of CDSSs on physicians' appropriate laboratory test ordering in inpatient hospitals.MethodMedline through PubMed, SCOPUS, Web of Science, and Cochrane were queried without any time period restriction. Studies using CDSSs as an intervention to improve laboratory test ordering as the primary aim were included. The study populations in the included studies were laboratory tests, physicians ordering laboratory tests, or the patients for whom laboratory tests were ordered. The included papers were evaluated for their outcomes related to the effect of CDSSs which were categorized based on the outcomes related to tests, physician, and patients. The primary outcome measures were the number and cost of the ordered laboratory tests. The instrument from The National Heart Lung and Blood Institute (NIH) was used to assess the quality of the included...
The American Journal of Medicine, 2017
BACKGROUND: Overutilization of clinical laboratory testing in the inpatient setting is a common problem. The objective of this project was to develop an inexpensive and easilyimplemented intervention to promote rational laboratory utilization without compromising resident education or patient care. METHODS: The study comprised of a cluster-randomized, controlled trial to assess the impact of a multifaceted intervention of education, guideline development, elimination of recurring lab orders, unbundling of laboratory panels, and redesign of the daily progress note on laboratory test ordering. The population included all patients hospitalized on a general medicine service during two consecutive months on a general medicine teaching service within a 999-bed tertiary care hospital in Boston, MA. The primary outcome was the total number of commonly utilized laboratory tests per patient-day during two months in 2008. Secondary outcomes included a subgroup analysis of each individual test per patient-day, adverse events, and resident and nursing satisfaction. RESULTS: 5392 patient-days were captured. The intervention produced a 9% decrease in aggregate laboratory utilization (rate ratio 0.91, p = 0.021, 95% CI 0.84-0.98). Six instances of delayed diagnosis of acute kidney injury and 11 near misses were reported in the intervention arm. CONCLUSIONS: A bundled educational and administrative intervention promoting rational ordering of laboratory tests on a single academic general medicine service led to a modest, but significant decrease in laboratory utilization. To our knowledge, this was the first study to examine the daily progress note as a tool to limit excessive test ordering. Unadjudicated near misses and possible harm were reported with this intervention. This finding warrants further study.
International Journal of Clinical Practice
Background: Reducing unnecessary laboratory blood testing in the hospital setting represents a challenge to improve the adequacy of healthcare and a tricky task for teaching hospitals. Our hospital network actively participates in the Choosing Wisely Campaign and is engaged in avoiding unnecessary low value interventions and investigations. We aimed to study whether a multi-level approach combining educational and web-system based interventions, could be effective in reducing laboratory testing and related costs. Methods: Multicenter, proof of concept, prospective, observational, before and after study, in a network of public hospitals in Switzerland. All patients admitted between 1 January 2015 and 31 December 2017 were analyzed. A multi-level strategy based on online continuous monitor benchmarking and educational support was applied in the internal medicine services. The primary outcome was a significant reduction in the number of laboratory tests per patient and per day during the hospital stay. Secondary outcomes were reduction in the blood sample volume taken per patient and per day in laboratory costs. Results: Over the 36 months of the study, 33 309 admissions were analyzed. A significant reduction of laboratory tests per patient and per day of hospitalisation was found:-11%, P-value<0.001;-6%, P-value <0.001. The mean monthly blood volume, per patient and per day of hospital stay and laboratory costs per patient was also significantly re
Clinical Medicine
Haematology inpatients are subject to extensive blood testing and many of these tests could be deemed inappropriate as they are not indicated for monitoring or clinical symptoms. Unnecessary testing exposes the patient to the risks of phlebotomy and adds resources' strain to the NHS. Our aim was to reduce the number of inappropriate blood tests performed on haematology inpatient wards. Quality improvement projects (QIPs) were performed in four haematology units introducing inpatient blood testing schedules (BTS) or providing staff education on current schedules. A reduction in inappropriate or overall blood testing was achieved at every site where a BTS was implemented, with a median reduction in inappropriate blood testing of 24.7% and estimated cost savings of up to £38,438 per annum. This QIP can be safely adapted to a variety of inpatient settings and is associated with cost savings. This initiative could be extended to other inpatient departments throughout the NHS.
Decreasing Unnecessary Daily Labs by Choosing Wisely
Journal of patient safety and quality improvement, 2017
The utilization of laboratory services has increased across various healthcare settings. We assessed the impact of the implementation of a Quality Improvement project aimed at reducing Complete Blood Count (CBC) and Basic Electrolyte Panel (BEP) ordered by house staff physicians. Materials and Methods: This study with a pre-post design was conducted in a community hospital in Connecticut, USA. The study was performed between January 2014 and December 2016. At initiation of the project, a taskforce consisting of attending doctors and house staff physicians was created. The taskforce reviewed and determined the current practices of ordering CBC and BEP. The taskforce members analyzed every step of the process and unveiled circumstances where unnecessary CBC and BEPs were ordered. Based on the results of the analysis, a multi-level intervention of oneyear duration was then developed to address the ordering of unnecessary CBC and BEPs. The intervention consisted of daily decision making about labs during rounds, incorporating lab documentations planned for the next day into daily progress notes, including the rationale for these labs, audit and reporting of ordering practices to each medical team, and providing direct feedback to each house staff not providing appropriate documentation of lab rationale. The average numbers of CBC and BEP orders per patient days were used to assess the impact of our intervention. Results: After implementing this Quality Improvement program, the average number of CBC and BEPs per patient days ordered by the house staff physicians decreased (i.e., from 1.20 to 1.09; P<0.01, and from 0.88 to 0.80; P<0.01, respectively). This corresponds to a reduction of 9% in both CBC and BEP orderings per patient days. There were no unintended adverse consequences from the interventions. Conclusion: Our Quality Improvement initiative resulted in a reduction in CBC and BEP orderings per patient days by the house staff without adversely affecting our patients' length of stay or mortality.
American Journal of Medical Quality, 2017
Point of care (POC) laboratory testing is used to improve emergency department (ED) throughput but often overuses resources by duplicating formal laboratory testing. This study sought to evaluate the effect of a multimodal intervention on duplicate chemistry testing. This pre-post analysis included all visits to 2 urban EDs between June 2014 and June 2016. The multimodal intervention including provider education, signage, electronic health record redesign, and audit and feedback focused on reducing duplicate chemistry testing. The primary outcome was the number of duplicate chemistry tests per 100 visits. Autoregressive integrated moving-average models were used to account for secular changes. A total of 299 701 ED visits were included. The daily number of duplicate chemistry and POC chemistry tests significantly decreased following the intervention (3.3 fewer duplicates and 10.2 fewer POC per 100 ED visits, P < .0001). This implementation of a multimodal quality improvement intervention yielded substantial reductions in the overuse of blood chemistry testing in the ED.