Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy (original) (raw)
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Background: Overutilization of investigations, leads not only to excessive burden on the laboratory but also gives rise to a multitude of problems in patient management. Practice of evidence based laboratory medicine and awareness of cost effectiveness of tests amongst prescribing clinicians is hence of paramount importance to address this problem. Aim: The aim of this study is to analyse the prescribed requisitions for common hematological and biochemical tests and determine the prevalence of the “inappropriate” and “avoidable” tests. Materials and Methods: We conducted a retrospective cross- sectional study on hospital records of 150 male patients admitted to acute medical and surgical wards from 01 Dec 2015 to 29 Feb 2016 at a tertiary care teaching hospital located in North India. The tests requisitions for routine biochemical and hematological investigations during period of admission were analysed and categorized into three categories by a panel of three doctors: appropriate, inappropriate and avoidable. Results: In our study we analysed 10236 requisitions of common biochemical and hematological tests ordered for 150 admitted male patients and found that only 50.4% tests were clinically “appropriate”. 22.4% of the total tests performed were “inappropriate” and hence were wasteful. 27.2% of tests were categorized as “avoidable”. Conclusion: This study provides a detailed insight into the investigation requisition pattern for most common hematological and biochemical investigations which form a major part of workload in a clinical laboratory. The study shows that a considerable number of investigations are inappropriate and do not contribute to patient management in any manner. These tests are a drain on the resources and hence must be eliminated by formulation of strict guidelines and protocols. On the other hands there are some avoidable test orders which arise from inability of the clinicians to prescribe tests in accordance to pretest probabilities and evidence based practice. These avoidable tests can be reduced by interactive education of the clinicians.
Laboratory Tests Ordering Pattern by Medical Residents From a Brazilian University Hospital
American Journal of Clinical Pathology, 2016
Objectives: The adequacy of laboratory test orders by medical residents is a longstanding issue. The aim of this study is to analyze the number, types, and pattern of repetition of tests ordered by medical residents. Methods: We studied all tests ordered over a 1-year period for inpatients of an internal medicine ward in a university hospital. Types, results, and repetition pattern of tests were analyzed in relation to patients' diagnoses. Results: We evaluated 117,666 tests, requested for 1,024 inpatients. The mean number of tests was 9.5 per day. The test repetition pattern was similar, regardless of patients' diagnoses, previous test results, or duration of stay. The probability of an abnormal result after a sequence of three normal tests was lower than 25%, regardless of the diagnosis. Conclusions: Number of tests and repetition were both high, imposing costs, discomfort, and risks to patients, thus warranting further investigation. Upon completion of this activity you will be able to: • discuss the rational use of clinical laboratory tests. • consider the main factors to be assessed to justify a laboratory test request. The ASCP is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The ASCP designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit TM per article. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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 for Quality in Health Care, 2005
Background. Improving the appropriateness of testing behavior and reducing the number of laboratory tests have been recognized as essential parts of quality improvement. Objective. To assess the effectiveness of an administrative and a short-term educational intervention aimed at reducing clinical biochemistry laboratory utilization. Design. An analysis comparing utilization of laboratory tests performed on in-patients before and after the intervention.
Journal of Multidisciplinary Healthcare
Background: The use of diagnostic laboratory tests is increasing worldwide. Improper test utilization (ITU) is a common problem for all healthcare systems as it costs substantial expenses for the health systems and impacts optimal patient care. Purpose: The present small-scale survey aims to highlight the current practice of ITU among the labs and physicians, and investigate the actions of diagnostic laboratories towards ITU, and identify the reasons affecting test ordering decisions among physicians. Methods: A cross sectional study based on two different surveys was developed and distributed from March 2017 to April 2017 to laboratory supervisors and physicians (clinicians) at Hamad Medical Corporation (HMC), Qatar. Fourteen laboratory supervisors and eighty-nine physicians were surveyed about improper test utilization practices. The overall results are descriptive data. Results: The overall proportion of improperly utilized tests detected by the laboratory supervisors were 50.0%, 35.7%, and 14.3% for overused, misused, and underused lab tests, respectively. Among the physicians, 91% used the electronic ordering template to select the appropriate tests. Moreover, 78.7% of the physicians used the clinical guidelines, while 73% were not employing the laboratory handbook. Furthermore, 95.5%% of the physicians preferred to get feedback about inappropriate tests, while 51.1% were not receiving any, and 40.9% were rarely receiving. Finally, 67.4% were unaware of the tests' costs among surveyed physicians, and 63.6% showed a willingness to reduce their orders if the cost was high and unnecessary. Conclusion: The physician's and the laboratories' communication were inadequate and not systematized, causing ITU practices. The improvement strategy should focus on the communication between clinical labs and physicians and enhance physician implementation to order appropriate lab tests. This could be achieved by conducting legitimate educational methodologies, continuous feedback reviews, ongoing audits, executing health information technology instruments, engaging laboratory practice guidelines, and applying demand management and testing algorithms.
Techniques to Improve Physicians' Use of Diagnostic Tests
JAMA, 1998
To review the published literature on interventions aimed at improving physicians' use of diagnostic tests and to propose methodological standards for these studies. A further aim was to review selected studies using the PRECEDE framework, a behavioural model that helps categorise interventions based on which behavioural factors are being affected. Searching MEDLINE, EMBASE and HEALTHstar were searched for articles published between 1966 and January 1, 1998. The MeSH used for keyword and textword searching included: physician behaviour, physician practice patterns, laboratory use, test ordering, decision making, practice guidelines, appropriateness and education. Researchers in health services, health behaviour, and behaviour modification were contacted for proprietary and other nonpublished references. In addition, references of all articles obtained were scanned to identify others of potential interest. Only studies published in English were included. Study selection Study designs of evaluations included in the review Randomised and non-randomised studies were evaluated (the authors state that both were included because few randomised trials of interventions to modify diagnostic test behaviour exist). Specific interventions included in the review Interventions to improve physicians' use of diagnostic tests. Interventions were categorised according to the PRECEDE model of behaviour change. PRECEDE incorporates 3 types of factors that precipitate or inhibit behaviour changepredisposing, enabling, and reinforcing factors. Interventions were categorised according to which behavioural factor(s) were primarily targeted in the intervention. Educational interventions (e.g. lectures on cost-effective testing, and distribution of educational material regarding the clinical utility of prothrombin time testing) were considered to target predisposing factors. Utilisation or change audits primarily act to provide feedback and thus were categorised as reinforcing factors. Changes in the administration structure of test ordering (e.g. order form revisions, a limited number of chemistry and hematology tests allowed each day, elimination of standing laboratory orders) were analysed as enabling interventions. Participants included in the review Physicians including: first-year medicine residents, internal medicine residents, attending physicians, family medicine residents, surgical medicine residents, all surgery residents, all physicians, general practitioners, primary care physicians, emergency department physicians, family practice residents, and attending and resident physicians in an adult diabetes clinic. Outcomes assessed in the review Resource utilisation e.g. change in test volume or charges. How were decisions on the relevance of primary studies made? The authors do not state how the papers were selected for the review, or how many of the reviewers performed the selection. Assessment of study quality Five methodological characteristics were examined, giving a maximum total methodological score of 38. They were: patient characteristics (such as demographic and clinical characteristics), methods for allocating physicians to control or intervention groups, the delivery system (e.g. was the insurance status of the patients in the control and intervention
Format change of a laboratory test order form affects physician behavior
International Journal of Medical Informatics, 2009
Physician behavior a b s t r a c t Purpose: Our study was designed to find whether a change in physician ordering of laboratory testing could be obtained by the simple strategy of changing the set-up of the check-box laboratory order form that is embedded in a computerized medical record.