Reduction in Unnecessary Clinical Laboratory Testing Through Utilization Management at a US Government Veterans Affairs Hospital

Reducing Iatrogenic Blood Losses in Premature Infants

OBJECTIVE

Iatrogenic blood losses from repetitive laboratory testing are a leading cause of anemia of prematurity and blood transfusions. We used an implementation science approach to decrease iatrogenic blood losses during the first 3 postnatal weeks among very low birth weight infants.

METHODS

We performed qualitative interviews of key stakeholders to assess implementation determinants (ie, barriers and facilitators to reducing iatrogenic blood losses), guided by the Consolidated Framework for Implementation Research. Next, we selected implementation strategies matched to these implementation determinants to de-implement excess laboratory tests. The number of laboratory tests, amount of blood taken (ml/kg), and laboratory charges were compared before and after implementation using quasi-Poisson and multi-variable regression models.

RESULTS

Qualitative interviews with 14 clinicians revealed implementation-related themes, including provider-specific factors, recurring orders, awareness of blood loss and cost, and balance between over- and under-testing. Implementation strategies deployed included resident education, revised order sets, blood loss and cost awareness, audit and feedback, and the documentation of blood out. There were 184 and 170 infants in the pre- and postimplementation cohorts, respectively. There was an 18.5% reduction in laboratory tests (median 54 [36 - 80] versus 44 [29 - 74], P = .01) in the first 3 postnatal weeks, a 17% decrease in blood taken (mean 18.1 [16.4 - 20.1] versus 15 [13.4 - 16.8], P = .01), and an overall reduction of $290 328 in laboratory charges. No difference was noted in the number of blood transfusions. Postimplementation interviews showed no adverse events attributable to implementation strategies.

CONCLUSIONS

An implementation science approach combining qualitative and quantitative methods reduced laboratory tests, blood loss, and charges.

Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing

BACKGROUND

Healthcare agencies and perioperative professional organizations recommend avoiding preoperative screening tests for low-risk surgical procedures. However, low-value preoperative tests are still commonly ordered even for generally healthy patients and active strategies to reduce this testing have not been adequately described.

OBJECTIVE

We sought to learn from hospitals with either high levels of testing or that had recently reduced use of low-value screening tests (aka "delta sites") about reasons for testing and active deimplementation strategies they used to effectively improve practice.

DESIGN

Qualitative study of semi-structured telephone interviews.

PARTICIPANTS

We identified facilities in the US Veterans Health Administration (VHA) with high or recently improved burden of potentially low-value preoperative testing for carpal tunnel release and cataract surgery. We recruited perioperative clinicians to participate.

APPROACH

Questions focused on reasons to order preoperative screening tests for patients undergoing low-risk surgery and, more importantly, what strategies had been successfully used to reduce testing. A framework method was used to identify common improvement strategies and specific care delivery innovations.

KEY RESULTS

Thirty-five perioperative clinicians (e.g., hand surgeons, ophthalmologists, anesthesiologists, primary care providers, directors of preoperative clinics, nurses) from 29 VHA facilities participated. Facilities that successfully reduced the burden of low-value testing shared many improvement strategies (e.g., building consensus among stakeholders; using evidence/norm-based education and persuasion; clarifying responsibility for ordering tests) to implement different care delivery innovations (e.g., pre-screening to decide if a preop clinic evaluation is necessary; establishing a dedicated preop clinic for low-risk procedures).

CONCLUSIONS

We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to design their own quality improvement programs to reduce low-value preoperative testing given their unique structure, resources, and constraints.

Data-driven approach to identifying potential laboratory overuse in general internal medicine (GIM) inpatients

BACKGROUND

Reducing laboratory test overuse is important for high quality, patient-centred care. Identifying priorities to reduce low value testing remains a challenge.

OBJECTIVE

To develop a simple, data-driven approach to identify potential sources of laboratory overuse by combining the total cost, proportion of abnormal results and physician-level variation in use of laboratory tests.

DESIGN, SETTING AND PARTICIPANTS

A multicentre, retrospective study at three academic hospitals in Toronto, Canada. All general internal medicine (GIM) hospitalisations between 1 April 2010 and 31 October 2017.

RESULTS

There were 106 813 GIM hospitalisations during the study period, with median hospital length-of-stay of 4.6 days (IQR: 2.33-9.19). There were 21 tests which had a cumulative cost >US$15 400 at all three sites. The costliest test was plasma electrolytes (US$4 907 775), the test with the lowest proportion of abnormal results was red cell folate (0.2%) and the test with the greatest physician-level variation in use was antiphospholipid antibodies (coefficient of variation 3.08). The five tests with the highest cumulative rank based on greatest cost, lowest proportion of abnormal results and highest physician-level variation were: (1) lactate, (2) antiphospholipid antibodies, (3) magnesium, (4) troponin and (5) partial thromboplastin time. In addition, this method identified unique tests that may be a potential source of laboratory overuse at each hospital.

CONCLUSIONS

A simple multidimensional, data-driven approach combining cost, proportion of abnormal results and physician-level variation can inform interventions to reduce laboratory test overuse. Reducing low value laboratory testing is important to promote high value, patient-centred care.

Design and Implementation of Clinical LIS360 Laboratory Management System Based on AI Technology

In order to realize the automation, standardization, and informatization of clinical laboratory work, this research topic develops and accomplishes a set of laboratory information systems (LISs). According to the design methods of software engineering, we first understand user’s demand and the current work situation of clinical laboratory and establish the system case model using Unified Modeling Language (UML) modeling technique. During the system design period, we explain the key technology theories, network structure, system security policy and the connection scheme with hospital information system (HIS). During the system function design period, the system was designed with 6 modules, they are daily inspection work, inquire and statistics, quality control, data dictionary, system configuration, and other tools. Through establishing database model, we accomplish the system database structure design. After the system design, we perform system implementation and test, to show the interface of system implementation and test plan accordingly. The development and application of LIS360 laboratory information management system can greatly improve the management level of laboratory and promote the standardization, modernization, and science of laboratory management. This system has solved the traditional mode of sending test report sheet manually for many years in the laboratory and won valuable time for clinicians to know the patient's condition in time.

Interventions to reduce repetitive ordering of low-value inpatient laboratory tests: a systematic review

BACKGROUND

Over-ordering of daily laboratory tests adversely affects patient care through hospital-acquired anaemia, patient discomfort, burden on front-line staff and unnecessary downstream testing. This remains a prevalent issue despite the 2013 Choosing Wisely recommendation to minimise unnecessary daily labs. We conducted a systematic review of the literature to identify interventions targeting unnecessary laboratory testing.

METHODS

We systematically searched MEDLINE, EMBASE, Cochrane Central and SCOPUS databases to identify interventions focused on reducing daily complete blood count, complete metabolic panel and basic metabolic panel labs. We defined interventions as 'effective' if a statistically significant reduction was attained and 'highly effective' if a reduction of ≥25% was attained.

RESULTS

The search yielded 5646 studies with 41 articles that met inclusion criteria. We grouped interventions into one or more categories: audit and feedback, cost display, education, electronic medical record (EMR) change, and policy change. Most interventions lasted less than a year and used a multipronged approach. All five strategies were effective in most studies with EMR change being the most commonly used independent strategy. EMR change and policy change were the strategies most frequently reported as effective. EMR change was the strategy most frequently reported as highly effective.

CONCLUSION

Our analysis identified five categories of interventions targeting daily laboratory testing. All categories were effective in most studies, with EMR change being most frequently highly effective.

PROSPERO REGISTRATION NUMBER

CRD42021254076.

Use of Clinical Decision Support to Improve the Laboratory Evaluation of Monoclonal Gammopathies

OBJECTIVES

There is considerable variation in ordering practices for the initial laboratory evaluation of monoclonal gammopathies (MGs) despite clear society guidelines to include serum free light chain (sFLC) testing. We assessed the ability of a clinical decision support (CDS) alert to improve guideline compliance and analyzed its clinical impact.

METHODS

We designed and deployed a targeted CDS alert to educate and prompt providers to order an sFLC assay when ordering serum protein electrophoresis (SPEP) testing.

RESULTS

The alert was highly effective at increasing the co-ordering of SPEP and sFLC testing. Preimplementation, 62.8% of all SPEP evaluations included sFLC testing, while nearly 90% of evaluations included an sFLC assay postimplementation. In patients with no prior sFLC testing, analysis of sFLC orders prompted by the alert led to the determination that 28.9% (800/2,769) of these patients had an abnormal κ/λ ratio. In 452 of these patients, the sFLC assay provided the only laboratory evidence of a monoclonal protein. Moreover, within this population, there were numerous instances of new diagnoses of multiple myeloma and other MGs.

CONCLUSIONS

The CDS alert increased compliance with society guidelines and improved the diagnostic evaluation of patients with suspected MGs.

Do Perceptions about Palliative Care Affect Emergency Decisions of Health Personnel for Patients with Advanced Dementia?

Decision analysis regarding emergency medical treatment in patients with advanced dementia has seldom been investigated. We aimed to examine the preferred medical treatment in emergency situations for patients with advanced dementia and its association with perceptions of palliative care. We conducted a survey of 159 physicians and 156 nurses from medical and surgical wards in two tertiary hospitals. The questionnaire included two case scenarios of patients with advanced dementia presenting gastrointestinal bleeding (scenario I) or pneumonia (scenario II) with a list of possible interventions and 11 items probing perceptions towards palliative care. Low burden interventions such as laboratory tests and intravenous administration of antibiotics/blood were preferred. Palliative measures such as analgesia/sedation were chosen by about half of the participants and invasive intervention by 41.6% (gastroscopy in scenario I) and 37.1% (intubation/mechanical ventilation in scenario II). Medical ward staff had a more palliative approach than surgical ward staff in scenario I, and senior staff had a more palliative approach than junior staff in scenario II. Most participants (90.4%) agreed that palliative care was appropriate for patients with advanced dementia. Stress in caring for patients with advanced dementia was reported by 24.5% of participants; 33.1% admitted fear of lawsuit, 33.8% were concerned about senior-level responses, and 69.7% were apprehensive of family members' reaction to palliative care. Perceptions of health care workers towards palliative care were associated with preferred treatment choice for patients with advanced dementia, mainly in scenario II. Attitudes and apprehensions regarding palliative care in these situations may explain the gap between positive attitudes towards palliative care and the chosen treatment approach. Acquainting emergency care practitioners with the benefits of palliative care may impact their decisions when treating this population.

Strategies for utilisation management of hospital services: a systematic review of interventions

Background

To achieve efficiency and high quality in health systems, the appropriate use of hospital services is essential. We identified the initiatives intended to manage adult hospital services and reduce unnecessary hospital use among the general adult population.

Methods

We systematically reviewed studies published in English using five databases (PubMed, ProQuest, Scopus, Web of Science, and MEDLINE via Ovid). We only included studies that evaluated interventions aiming to reduce the use of hospital services or emergency department, frequency of hospital admissions, length of hospital stay, or the use of diagnostic tests in a general adult population. Studies reporting no relevant outcomes or focusing on a specific patient population or children were excluded.

Results

In total, 64 articles were included in the systematic review. Nine utilisation management methods were identified: care plan, case management, care coordination, utilisation review, clinical information system, physician profiling, consultation, education, and discharge planning. Primary case management was shown to effectively reduce emergency department use. Care coordination reduced 30-day post-discharge hospital readmission or emergency department visit rates. The pre-admission review program decreased elective admissions. The physician profiling, concurrent review, and discharge planning effectively reduced the length of hospital stay. Twenty three studies that evaluated costs, reported cost savings in the hospitals.

Conclusions

Utilisation management interventions can decrease hospital use by improving the use of community-based health services and improving the quality of care by providing appropriate care at the right time and at the right level of care.

Current state of laboratory test utilization practices in the clinical laboratory

Appropriate laboratory test utilization is of growing interest in the face of rising healthcare costs and documented evidence of over- and under-utilization. Building from published literature, laboratory organizations have recently published guidelines for establishing laboratory utilization management programs. However, systematic reviews and meta-analyses have consistently struggled to define rigorous evidence-based best practice recommendations due to the paucity of published data or the heterogeneity of available data. We sought to gain information about utilization practices and programs currently in use and which factors contribute to their success by distributing a survey among laboratory professionals. The survey received seventy-four eligible respondents. We observed a wide range in the duration of laboratory utilization programs and the number of stewardship initiatives. In addition, there was great variety in the utilization practices used and the tests or processes targeted by programs. There was similarity in how initiatives are evaluated and who is involved with utilization programs. Finally, respondents often credited a multidisciplinary committee, support from leadership, and strong IT support/data access as important factors for their program's perceived success. Many of these factors agree with previously published literature.

Canned Comments in the Hospital Laboratory Information System Can Decrease Microbiology Requests

OBJECTIVES

Phone calls to the microbiology laboratory can be to clarify culture results and provide education, but those calls also interrupt laboratory workflow. We characterized calls that the laboratory received and developed targeted comments to educate providers.

METHODS

Calls were logged and characterized, and we developed comments to address common call subjects. We applied the new comments to cultures and logged calls over the same interval the subsequent year. Data before and after implementation were analyzed.

RESULTS

Call volume decreased from 496 calls to 419 calls after implementation. There was a significant difference in level of training among callers (P < .005), but the nature of the calls did not change. Laboratory response showed an increase in release of previously generated data (eg, suppressed susceptibility results). Comments specifically developed to address intrinsic antibiotic resistance and common susceptibility patterns did not decrease call volume.

CONCLUSIONS

Implementation of comments in the laboratory information system decreased call volume, but targeted comments were less effective than anticipated.

Examination of Electrolyte Replacements in the ICU Utilizing MIMIC-III Dataset Demonstrates Redundant Replacement Patterns

Electrolyte repletion in the ICU is one of the most ubiquitous tasks in critical care, involving significant resources while having an unclear risk/benefit ratio. Prior data indicate most replacements are administered while electrolytes are within or above reference ranges with little effect on serum post-replacement levels and potential harm. ICU electrolyte replacement patterns were analyzed using the MIMIC-III database to determine the threshold governing replacement decisions and their efficiency. The data of serum values for potassium, magnesium, and phosphate before and after repletion events were evaluated. Thresholds for when repletion was administered and temporal patterns in the repletion behaviors of ICU healthcare providers were identified. Most electrolyte replacements happened when levels were below or within reference ranges. Of the lab orders placed, a minuscule number of them were followed by repletion. Electrolyte repletion resulted in negligible (phosphate), small (potassium), and modest (magnesium) post-replacement changes in electrolyte serum levels. The repletion pattern followed hospital routine work and was anchored around shift changes. A subset of providers conducting over-repletion in the absence of clinical indication was also identified. This pattern of behavior found in this study supports previous studies and may allude to a universal pattern of over-repletion in the ICU setting.

Factors Associated With Increased Laboratory Use in the Pediatric Cardiac Intensive Care Unit

BACKGROUND

Laboratory testing is frequently used to guide postoperative management and contributes to hospital resource utilization; however, there is little evidence identifying patient or clinical factors to inform the appropriate frequency of laboratory testing in the pediatric cardiac intensive care unit.

OBJECTIVES

To examine the factors associated with increased laboratory utilization following pediatric congenital heart surgery.

METHODS

For each patient, the total number of tests and types of laboratory tests were recorded. Patients whose number of tests was greater than the 90th percentile were categorized as increased laboratory use.

RESULTS

A sample of 250 unique patients and 909 nursing shifts were obtained for patient- and shift-level analyses. The top 10% of patients identified as the high laboratory utilization group (>128 laboratory tests). High-use group reported significantly younger patients and longer bypass time (P < .001). Patients in the highest Risk Adjustment for Congenital Heart Surgery 1 risk category were 34.7 times more likely to be in high laboratory utilization group (P = .006), independent of age at time of surgery and time on bypass (receiver operating characteristic curve = 0.855). At the shift level, time on bypass (P = .002), age younger than 30 days at surgery (P < .001), 3 to 5 years' registered nurse experience (P < .001), staff precepting (P = .03), and weekday shift status (P = .03) were all independently associated with high laboratory utilization.

CONCLUSIONS

There are multiple factors associated with increased laboratory utilization. Recognition of specific patient and nursing factors can be used to impact patient management.

The NSW Pathology Atlas of Variation: Part II-The Association of Variation in Emergency Department Laboratory Investigations With Outcomes for Patients Presenting With Chest Pain

STUDY OBJECTIVE

Laboratory test use varies across emergency departments (EDs), yet little is known about the effect of this variation on outcomes. The aim of this study is 2-fold: to stratify EDs into clusters based on similar test use, and to determine whether the clusters differ in patient operational outcomes among patients presenting to EDs with undifferentiated chest pain.

METHODS

We conducted a retrospective cohort study of 222,788 patients presenting with undifferentiated chest pain at 44 EDs across New South Wales, Australia, from January 2017 to September 2018. The operational outcomes measured in this study included ED length of stay, hospital admission, the Emergency Treatment Performance target, and 7- and 15-day all-cause and same-cause ED revisit rates. We performed a hierarchic cluster analysis to identify ED clusters and mixed-effects models to determine the association between the clusters and the operational outcomes.

RESULTS

Two ED clusters, moderate users (18 EDs) and high users (26 EDs), were identified. After adjustment for confounders, the median ED length of stay was greater by 15.7% (equivalent to 33.4 minutes) in high versus moderate users (95% confidence interval 6.62 to 25.52 minutes), and high users were less likely to achieve the Emergency Treatment Performance target versus moderate users (odds ratio 0.66; 95% confidence interval 0.50 to 0.86). There were no significant differences between the users in hospital admission and ED revisit rates.

CONCLUSION

Our findings suggest that reducing test use may reduce ED length of stay and improve the chance of achieving the Emergency Treatment Performance target.

Tackling the unknowns in understanding and management of hospital acquired anemia

Hospital acquired anemia (HAA) has been a recognized entity for nearly 50 years. Despite multiple hypotheses, a mechanistic understanding is lacking, and targeted interventions have not yet yielded significantly impactful results. Known risk factors include advanced age, multiple co-morbidities, low bone marrow reserve, admission to the intensive care unit, and frequent phlebotomy. However, confounding variables in many studies continues to complicate the identification of additional risk factors. Improved understanding of iron metabolism, erythropoiesis, and the erythroid iron restriction response in the last few decades, as well as the recent demonstration of poor outcomes correlating with increased transfusion have refocused attention on HAA. While retrospective database studies provide ample correlative data between 1) HAA and poor outcomes; 2) reduction of phlebotomy volume and decrease in transfusion requirement; and 3) over-transfusion and increased mortality, no causal link between reduced phlebotomy volume, decreased rates of HAA, and improved mortality or other relevant outcomes have been definitely established. Here, we review the current state of knowledge and provide a summary of potential directions to understand and mitigate HAA. There are at present no clear guidelines on whether and when to evaluate hospitalized patients for underlying causes of anemia. We thus provide a guide for clinicians in general practice toward identifying patients at the highest risk for HAA, decreasing blood loss through phlebotomy to the greatest degree feasible, and evaluating and treating reversible causes of anemia in a targeted population.

A deep learning solution to recommend laboratory reduction strategies in ICU

OBJECTIVE

To build a machine-learning model that predicts laboratory test results and provides a promising lab test reduction strategy, using spatial-temporal correlations.

MATERIALS AND METHODS

We developed a global prediction model to treat laboratory testing as a series of decisions by considering contextual information over time and across modalities. We validated our method using a critical care database (MIMIC III), which includes 4,570,709 observations of 12 standard laboratory tests, among 38,773 critical care patients. Our deep-learning model made real-time laboratory reduction recommendations and predicted the properties of lab tests, including values, normal/abnormal (whether labs were within the normal range) and transition (normal to abnormal or abnormal to normal from the latest lab test). We reported area under the receiver operating characteristic curve (AUC) for predicting normal/abnormal, evaluated accuracy and absolute bias on prediction vs. observation against lab test reduction proportion. We compared our model against baseline models and analyzed the impact of variations on the recommended reduction strategy.

RESULTS

Our best model offered a 20.26 % reduction in the number of laboratory tests. By applying the recommended reduction policy on the hold-out dataset (7755 patients), our model predicted normality/abnormality of laboratory tests with a 98.27 % accuracy (AUC, 0.9885; sensitivity, 97.84 %; specificity, 98.80 %; PPV, 99.01 %; NPV, 97.39 %) on 20.26 % reduced lab tests, and recommended 98.10 % of transitions to be checked. Our model performed better than the greedy models, and the recommended reduction strategy was robust.

DISCUSSION

Strong spatial and temporal correlations between laboratory tests can be used to optimize policies for reducing laboratory tests throughout the hospital course. Our method allows for iterative predictions and provides a superior solution for the dynamic decision-making laboratory reduction problem.

CONCLUSION

This work demonstrates a machine-learning model that assists physicians in determining which laboratory tests may be omitted.

Economic impact of clinical decision support interventions based on electronic health records

Background

Unnecessary healthcare utilization, non-adherence to current clinical guidelines, or insufficient personalized care are perpetual challenges and remain potential major cost-drivers for healthcare systems around the world. Implementing decision support systems into clinical care is promised to improve quality of care and thereby yield substantial effects on reducing healthcare expenditure. In this article, we evaluate the economic impact of clinical decision support (CDS) interventions based on electronic health records (EHR).

Methods

We searched for studies published after 2014 using MEDLINE, CENTRAL, WEB OF SCIENCE, EBSCO, and TUFTS CEA registry databases that encompass an economic evaluation or consider cost outcome measures of EHR based CDS interventions. Thereupon, we identified best practice application areas and categorized the investigated interventions according to an existing taxonomy of front-end CDS tools.

Results and discussion

Twenty-seven studies are investigated in this review. Of those, twenty-two studies indicate a reduction of healthcare expenditure after implementing an EHR based CDS system, especially towards prevalent application areas, such as unnecessary laboratory testing, duplicate order entry, efficient transfusion practice, or reduction of antibiotic prescriptions. On the contrary, order facilitators and undiscovered malfunctions revealed to be threats and could lead to new cost drivers in healthcare. While high upfront and maintenance costs of CDS systems are a worldwide implementation barrier, most studies do not consider implementation cost. Finally, four included economic evaluation studies report mixed monetary outcome results and thus highlight the importance of further high-quality economic evaluations for these CDS systems.

Conclusion

Current research studies lack consideration of comparative cost-outcome metrics as well as detailed cost components in their analyses. Nonetheless, the positive economic impact of EHR based CDS interventions is highly promising, especially with regard to reducing waste in healthcare.

A systematic literature review on unnecessary diagnostic testing: The role of ICT use

BACKGROUND

The negative impact of unnecessary diagnostic tests on healthcare systems and patients has been widely recognized. Medical researchers in various countries have been devoting effort to reduce unnecessary diagnostic tests by using different types of interventions, including information and communications technology-based (ICT-based) intervention, educational intervention, audit and feedback, the introduction of guidelines or protocols, and the reward and punishment of staff. We conducted a review of ICT based interventions and a comparative analysis of their relative effectiveness in reducing unnecessary tests.

METHOD

A systematic Boolean search in PubMed, EMBase and EBSCOhost research databases was performed. Keyword search and citation analysis were also conducted. Empirical studies reporting ICT based interventions, and their implications on relative effectiveness in reducing unnecessary diagnostic tests (pathology tests or medical imaging) were evaluated independently by two reviewers based on a rigorously developed coding protocol.

RESULTS

92 research articles from peer-reviewed journals were identified as eligible. 47 studies involved a single-method intervention and 45 involved multi-method interventions. Regardless of the number of interventions involved in the studies, ICT-based interventions were utilized by 71 studies and 59 of them were shown to be effective in reducing unnecessary testing. A clinical decision support (CDS) tool appeared to be the most adopted ICT approach, with 46 out of 71 studies using CDS tools. The CDS tool showed effectiveness in reducing test volume in 38 studies and reducing cost in 24 studies.

CONCLUSIONS

This review investigated five frequently utilized intervention methods, ICT-based, education, introduction of guidelines or protocols, audit and feedback, and reward and punishment. It provides in-depth analysis of the efficacy of different types of interventions and sheds insights about the benefits of ICT based interventions, especially those utilising CDS tools, to reduce unnecessary diagnostic testing. The replicability of the studies is limited due to the heterogeneity of the studies in terms of context, study design, and targeted types of tests.

Minimum retesting intervals in practice: 10 years experience

Background

Minimum retesting intervals (MRI) are a popular demand management solution for the identification and reduction of over-utilized tests. In 2011 Association of Clinical Biochemistry and Laboratory Medicines (ACB) published evidence-based recommendations for the use of MRI.

Aim

The aim of the paper was to review the use of MRI over the period since the introduction of these recommendations in 2011 to 2020 and compare it to previous published data between 2000-2010.

Methods

A multi-source literature search was performed to identify studies that reported the use of a MRI in the management or identification of inappropriate testing between the years prior to (2000–2010) and after implementation (2011–2020) of these recommendations.

Results

31 studies were identified which met the acceptance criteria (2000–2010 n=4, 2011–2020 n=27). Between 2000 and 2010 4.6% of tests (203,104/4,425,311) were identified as failing a defined MRI which rose to 11.8% of tests (2,691,591/22,777,288) in the 2011–2020 period. For those studies between 2011 and 2020 reporting predicted savings (n=20), 14.3% of tests (1,079,972/750,580) were cancelled, representing a total saving of 2.9 M Euros or 2.77 Euro/test. The most popular rejected test was Haemoglobin A1c which accounted for nearly a quarter of the total number of rejected tests. 13 out 27 studies used the ACB recommendations.

Conclusions

MRI are now an established, safe and sustainable demand management tool for the identification and management of inappropriate testing. Evidence based consensus recommendations have supported the adoption of this demand management tool into practice across multiple healthcare settings globally and harmonizing laboratory practice.

Implementation of a High-Value Care Curriculum for General Surgery Residents

INTRODUCTION

Healthcare expenditures account for more than 3.5 trillion dollars annually with estimates of nearly one-half being wasteful. High-value care (HVC) balances the benefits, harms, and costs of healthcare. Since 2012, the American College of Physicians and Accreditation Council for Graduate Medical Education developed a HVC curriculum and incorporated HVC into milestones for medicine residents. However, currently no HVC curriculum or milestones exist for general surgery residents (GSR). We sought to implement a HVC curriculum for GSR and evaluate awareness and attitudes toward HVC, hypothesizing improved resident awareness and attitudes toward HVC without affecting patient outcomes.

METHODS

A prospective comparison between pre-HVC curriculum (7/1/2017-11/30/2017) and post-HVC curriculum (2/1/2018-6/30/2018) was performed. The curriculum included 6 didactic lectures with group discussions. A 14-question Likert-scale survey evaluating awareness, use of, and attitudes toward HVC was performed on all GSR. Additional patient outcomes were collected for all trauma patients cared for during the study period. Bivariate analysis using Mann-Whitney U test was performed.

RESULTS

There were 38/38 GSR respondents (100% response rate) for the pre-HVC survey and 35/38 (92.1% response rate) for the post-HVC survey. More post-HVC respondents somewhat agreed (34.3% vs 5.3%) and less strongly disagreed (31.4% vs 52.6%) with improved knowledge of where to find costs of labs/imaging/treatment (p = 0.02) compared to the pre-HVC group. More post-HVC respondents strongly agreed they balanced the benefit of clinical care with costs and harm when treating patients (25.7% vs 21.1%; p = 0.01). More post-HVC respondents strongly agreed they customized care plans to incorporate patients' values/concerns after implementation of the curriculum (51.4% vs 23.7%, p = 0.0006). From 3254 trauma patients studied, 1722 (52.9%) were pre-HVC and 1532 (47.1%) post-HVC patients. There was no difference between the pre- and post-HVC-curriculum trauma patients in terms of demographics and outcomes such as mortality (3.6% vs 2.4%, p = 0.07) and median length of stay (2 vs 2 days, p = 0.6).

CONCLUSIONS

Implementation of a HVC curriculum for GSR led to improved awareness regarding healthcare costs and customizing decision plans for patients, with no difference in trauma patient outcomes. Future research incorporating cost data is needed; however, with implementation of the 2020 general surgery milestones (addition of Systems-Based Practice-3), this curriculum could prove beneficial.

Room Costs for Common Pediatric Hospitalizations and Cost-Reducing Quality Initiatives

BACKGROUND

Improvement initiatives promote safe and efficient care for hospitalized children. However, these may be associated with limited cost savings. In this article, we sought to understand the potential financial benefit yielded by improvement initiatives by describing the inpatient allocation of costs for common pediatric diagnoses.

METHODS

This study is a retrospective cross-sectional analysis of pediatric patients aged 0 to 21 years from 48 children's hospitals included in the Pediatric Health Information System database from January 1, 2017, to December 31, 2017. We included hospitalizations for 8 common inpatient pediatric diagnoses (seizure, bronchiolitis, asthma, pneumonia, acute gastroenteritis, upper respiratory tract infection, other gastrointestinal diagnoses, and skin and soft tissue infection) and categorized the distribution of hospitalization costs (room, clinical, laboratory, imaging, pharmacy, supplies, and other). We summarized our findings with mean percentages and percent of total costs and used mixed-effects models to account for disease severity and to describe hospital-level variation.

RESULTS

For 195 436 hospitalizations, room costs accounted for 52.5% to 70.3% of total hospitalization costs. We observed wide hospital-level variation in nonroom costs for the same diagnoses (25%-81% for seizure, 12%-51% for bronchiolitis, 19%-63% for asthma, 19%-62% for pneumonia, 21%-78% for acute gastroenteritis, 21%-63% for upper respiratory tract infection, 28%-69% for other gastrointestinal diagnoses, and 21%-71% for skin and soft tissue infection). However, to achieve a cost reduction equal to 10% of room costs, large, often unattainable reductions (>100%) in nonroom cost categories are needed.

CONCLUSIONS

Inconsistencies in nonroom costs for similar diagnoses suggest hospital-level treatment variation and improvement opportunities. However, individual improvement initiatives may not result in significant cost savings without specifically addressing room costs.

Expert Recommendations on Frequency of Utilization of Common Laboratory Tests in Medical Inpatients: a Canadian Consensus Study

BACKGROUND

Repetitive inpatient laboratory testing in the face of clinical stability is a marker of low-value care. However, for commonly encountered clinical scenarios on medical units, there are no guidelines defining appropriate use criteria for laboratory tests.

OBJECTIVE

This study seeks to establish consensus-based recommendations for the utilization of common laboratory tests in medical inpatients.

DESIGN

This study uses a modified Delphi method. Participants completed two rounds of an online survey to determine appropriate testing frequencies for selected laboratory tests in commonly encountered clinical scenarios. Consensus was defined as agreement by at least 80% of participants.

PARTICIPANTS

Participants were 36 experts in internal medicine across Canada defined as internists in independent practice for ≥ 5 years with experience in medical education, quality improvement, or both. Experts represented 8 of the 10 Canadian provinces and 13 of 17 academic institutions.

MAIN MEASURES

Laboratory tests and clinical scenarios included were those that were considered common on medical units. The final survey contained a total of 45 clinical scenarios looking at the utilization of six laboratory tests (complete blood count, electrolytes, creatinine, urea, international normalized ratio, and partial thromboplastin time). The possible frequency choices were every 2-4 h, 6-8 h, twice a day, daily, every 2-3 days, weekly, or none unless there was specific diagnostic suspicion. These scenarios were reviewed by two internists with training in quality improvement and survey methods.

KEY RESULTS

Of the 45 initial clinical scenarios included, we reached consensus on 17 scenarios. We reached weak consensus on an additional 19 scenarios by combining two adjacent frequency categories.

CONCLUSIONS

A Canadian expert panel of internists has provided frequency recommendations on the utilization of six common laboratory tests in medical inpatients. These recommendations need validation in prospective studies to assess whether restrictive versus liberal laboratory test ordering impacts patient outcomes.

Effectiveness of minimum retesting intervals in managing repetitive laboratory testing: experience from a Croatian university hospital

Introduction

Inappropriate laboratory retesting can be addressed by implementing minimum retesting intervals (MRI). The aim of our study was to assess the effectiveness of the implemented MRI protocol for inpatients.

Materials and methods

Minimum retesting intervals were applied for 53 laboratory tests. The overall reduction of test requests, reduction in charges and reagent cost savings, frequency of MRI alert appearance as well as the rate of MRI acceptance and ignorance were calculated for a one-year period. Reasons for violating the MRI rule, hospital departments that contributed mostly to MRI rule violation, and the frequency of MRI violations between routine and emergency laboratory were evaluated.

Results

During the one-year period, 106,780 requests violated the MRI rule, which corresponds to 14.8% of all requests received. 13,843 requests were cancelled, yielding a 1.9% reduction of requested tests. High-volume tests, namely complete blood count, C-reactive protein, alanine aminotransferase, gamma-glutamyltransferase and total bilirubin, accounted for 65% of all generated alerts and had the highest alert ignorance (>85%). The highest cancellation rate was observed for tumor markers and autoimmunity tests, for most being at least 50%. Annual charge reduction was 62,641 EUR while reagent cost savings were 11,408 EUR. Tests performed in the emergency laboratory had a higher alert appearance than the same routine tests. The most common reason for MRI violation was clinical justification based on the patient's condition. Most frequently ignored MRI alerts were in the intensive care unit.

Conclusion

MRI implementation showed limited effectiveness in reducing testing repetition and achieving financial savings, yet provided the basis for future improvements.

Comparative Impact of C-Reactive Protein Testing in Hospitalized Patients with Acute Respiratory Tract Infection: A Retrospective Cohort Study

INTRODUCTION

Evidence-based data on the usefulness of C-reactive protein (CRP) monitoring in patient outcomes are lacking. CRP testing in patients with acute respiratory tract infections (ARTIs) showed wide variability between internal medicine wards in our hospital network. In this study we aimed to investigate whether repetitive CRP tests might influence the switch of antibiotic therapy from intravenous (IV) to oral (PO) route and whether CRP measurements affect the combined outcome of readmission and in-hospital mortality.

METHODS

This was a retrospective cohort study conducted in two internal medicine wards selected in a network of five teaching hospitals on the basis of their CRP prescription frequency. Clinical and laboratory data of 296 patients with ARTIs and admitted from 1 January to 31 December 2016 were analyzed.

RESULTS

The mean ± SD of CRP tests/patient and the in-hospital length of antibiotic therapy (days) in the low-CRP (L-CRP) vs the high-CRP (H-CRP) wards were 1.14 ± 0.62 vs 3.43 ± 1.54 (p < 0.001) and 7.1 ± 2.6 vs 7.5 ± 3.2 (p = 0.298), respectively. The probability of antibiotic switching was higher in the L-CRP ward (HR 2.90, 95% CI 1.69-4.95, p < 0.001) correlating with the lower number of CRP determinations (HR 1.20, 95% CI 1.01-1.41, p = 0.034). In-hospital readmissions and mortality rates did not significantly differ between the two wards (L-CRP 17.1% vs H-CRP 10.0%, p = 0.133). The number of CRP determinations affected the combined outcome (OR 1.38, 95% CI 1.01-1.90, p = 0.043).

CONCLUSIONS

Repetitive CRP testing in ARTIs offers no added value to either antibiotic switch or patient outcomes in hospitalized patients in internal medicine wards.

Prevalence and Predictability of Low-Yield Inpatient Laboratory Diagnostic Tests

IMPORTANCE

Laboratory testing is an important target for high-value care initiatives, constituting the highest volume of medical procedures. Prior studies have found that up to half of all inpatient laboratory tests may be medically unnecessary, but a systematic method to identify these unnecessary tests in individual cases is lacking.

OBJECTIVE

To systematically identify low-yield inpatient laboratory testing through personalized predictions.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective diagnostic study with multivariable prediction models, 116 637 inpatients treated at Stanford University Hospital from January 1, 2008, to December 31, 2017, a total of 60 929 inpatients treated at University of Michigan from January 1, 2015, to December 31, 2018, and 13 940 inpatients treated at the University of California, San Francisco from January 1 to December 31, 2018, were assessed.

MAIN OUTCOMES AND MEASURES

Diagnostic accuracy measures, including sensitivity, specificity, negative predictive values (NPVs), positive predictive values (PPVs), and area under the receiver operating characteristic curve (AUROC), of machine learning models when predicting whether inpatient laboratory tests yield a normal result as defined by local laboratory reference ranges.

RESULTS

In the recent data sets (July 1, 2014, to June 30, 2017) from Stanford University Hospital (including 22 664 female inpatients with a mean [SD] age of 58.8 [19.0] years and 22 016 male inpatients with a mean [SD] age of 59.0 [18.1] years), among the top 20 highest-volume tests, 792 397 were repeats of orders within 24 hours, including tests that are physiologically unlikely to yield new information that quickly (eg, white blood cell differential, glycated hemoglobin, and serum albumin level). The best-performing machine learning models predicted normal results with an AUROC of 0.90 or greater for 12 stand-alone laboratory tests (eg, sodium AUROC, 0.92 [95% CI, 0.91-0.93]; sensitivity, 98%; specificity, 35%; PPV, 66%; NPV, 93%; lactate dehydrogenase AUROC, 0.93 [95% CI, 0.93-0.94]; sensitivity, 96%; specificity, 65%; PPV, 71%; NPV, 95%; and troponin I AUROC, 0.92 [95% CI, 0.91-0.93]; sensitivity, 88%; specificity, 79%; PPV, 67%; NPV, 93%) and 10 common laboratory test components (eg, hemoglobin AUROC, 0.94 [95% CI, 0.92-0.95]; sensitivity, 99%; specificity, 17%; PPV, 90%; NPV, 81%; creatinine AUROC, 0.96 [95% CI, 0.96-0.97]; sensitivity, 93%; specificity, 83%; PPV, 79%; NPV, 94%; and urea nitrogen AUROC, 0.95 [95% CI, 0.94, 0.96]; sensitivity, 87%; specificity, 89%; PPV, 77%; NPV 94%).

CONCLUSIONS AND RELEVANCE

The findings suggest that low-yield diagnostic testing is common and can be systematically identified through data-driven methods and patient context-aware predictions. Implementing machine learning models appear to be able to quantify the level of uncertainty and expected information gained from diagnostic tests explicitly, with the potential to encourage useful testing and discourage low-value testing that incurs direct costs and indirect harms.

The Choosing Wisely initiative and laboratory test stewardship

The United States Choosing Wisely initiative was started in 2012 by the American Board of Internal Medicine Foundation and focused on reducing medical resource overutilization. Since its inception in the US, similar efforts have arisen in at least a dozen countries. Strongly patient-focused, and in fact started in collaboration with the consumer magazine Consumer Reports, the effort has resulted in a collection of greater than 500 recommendations from over 80 US professional societies intended to inform both patients and doctors about medical practices whose necessity should be questioned or discussed. Targets of recommendations include practices that lack a basis in scientific evidence, practices that may be duplicative of other care already received, practices that may be harmful and practices that are simply unnecessary. While critiques have been levied against the Choosing Wisely initiative over its intent, methods and efficacy, it is clear that many of its recommendations have been adopted by large medical practices, and several positive outcomes, i.e. reductions in perceived waste, have been reported in relation to many of the recommendations, including those specifically targeting laboratory tests. The future success of Choosing Wisely will likely hinge on whether or not significantly positive and durable outcomes can be demonstrated, especially at a time where there is increasing pressure to drive down costs in medical care while concomitantly increasing quality.

Routine Postoperative Cardiac Testing is Unnecessary after Carotid Endarterectomy

BACKGROUND

Routine laboratory testing to rule out myocardial infarction (MI) after carotid endarterectomy (CEA) is common in many centers. Its use in this patient population has not been thoroughly investigated. We hypothesize that routine testing for MI in post-CEA patients is of low yield and not cost-effective.

METHODS

A retrospective review of 291 consecutive CEAs from February 2011 to July 2015 was performed. Two patients were excluded: one for postoperative noncardiac death and one for preoperative MI. Patient demographics, medications, medical history, type of anesthesia, and postoperative laboratory results were reviewed. All patients had troponin-I and creatine kinase-MB levels taken postoperatively. A patient was judged to have an MI if troponin-I was greater than or equal to 0.6 ng/mL or CK-MB is >6.3 ng/mL. The incidence of postoperative MI was recorded, and a cost analysis was performed.

RESULTS

The mean age was 70.2 years (range: 42-92). Of all, 59.5% were male, and 92.4% had a history of hypertension. Preoperatively, 57.4% were on beta-blocker therapy, 86.5% on aspirin, and 52.2% on both. Most (80.6%) were on preoperative statin therapy, 26.9% had a prior history of MI (37.2% within 5 years of surgery), and 56.4% of patients had a prior coronary intervention (27.6% percutaneous, 28.7% coronary artery bypass grafting, and 11% both). All patients received general anesthesia. The mean procedure time was 121.5 min (range: 62-258). The mean postoperative length of stay was 2.6 days. Eight patients (2.7%) were judged to have acute MI, one of which was symptomatic. Three of the 8 (38%) had a prior history of MI. In asymptomatic patients, the peak level of troponin-I ranges from 0.52 to 3.64 ng/mL and that of CK-MB from 11.8 to 24 ng/mL. The symptomatic patient had chest pain and bradycardia. The patient had a peak troponin-I level of 1.59 ng/mL, with a CK-MB level of 11.5 ng/mL. All patients were treated medically. The cost per troponin-I and CK-MB is $27.78 and $31.44, respectively, in our institution. We estimate that eliminating routine postoperative troponin-I and CK-MB testing in patients who underwent CEA would have saved an estimated $51,343 over the course of treatment of the studied population.

CONCLUSIONS

Routine postoperative cardiac laboratory testing in asymptomatic patients after CEA increases the hospital cost. The low overall rate of postoperative MI suggests that cardiac testing is best reserved for symptomatic patients or those with clinical suspicion for MI.

The role of a best practice alert in the electronic medical record in reducing repetitive lab tests

Background

The recommendations of the American Board of Internal Medicine Foundation’s “Choosing Wisely^®” initiative recognize the importance of improving the appropriateness of testing behavior and reducing the number of duplicate laboratory tests.

Objective

To assess the effectiveness of an electronic medical record Best Practice Alert (BPA or “pop up”) intervention aimed at reducing duplicate laboratory tests and hospital costs.

Design

Comparison of the number of duplicated laboratory tests performed on inpatients before and after the intervention.

Setting

University of Florida Health Shands Hospital, Gainesville, FL, USA, during 2014–2017.

Intervention

The electronic medical record intervention was a BPA pop-up alert that informed the ordering physician if a recent identical order already existed along with the “ordering time”, “collecting time”, “resulting time”, and the result itself.

Main outcome measures

Percentage change in the number of inpatient duplicate orders of selected clinical biochemistry tests and cost savings from reduction of the duplicates. Student’s t-test and beta-binomial models were used to analyze the data.

Results

Results from the beta-binomial model indicated that the intervention reduced the overall duplicates by 18% (OR=0.82, standard error=0.016, P-value<0.000). Percent reductions in 9 of the 17 tests were statistically significant: serum hemoglobin A1C level, vitamin B12, serum erythrocyte sedimentation rate, serum folate, serum iron, lipid panel, respiratory viral panel, serum thyroid stimulating hormone level, and Vitamin D. Additionally, important cost savings were realized from the reduction of duplicates for each lab test (with the exception of CRP) with an estimated overall savings of $72,543 over 17 months in the post-intervention period.

Conclusions

The present study included all hospital inpatients and covered 17 clinical laboratory tests. This rather simple and low-cost intervention resulted in significant reductions in percentage duplicates of several tests and resulted in cost savings. The study also highlights the role of hospitalists in quality improvement.

Reducing Test Utilization in Hospital Settings: A Narrative Review

Background

Studies addressing the appropriateness of laboratory testing have revealed approximately 20% overutilization. We conducted a narrative review to (1) describe current interventions aimed at reducing unnecessary laboratory testing, specifically in hospital settings, and (2) provide estimates of their efficacy in reducing test order volume and improving patient-related clinical outcomes.

Methods

The PubMed, Embase, Scopus, Web of Science, and Canadian Agency for Drugs and Technologies in Health-Health Technology Assessment databases were searched for studies describing the effects of interventions aimed at reducing unnecessary laboratory tests. Data on test order volume and clinical outcomes were extracted by one reviewer, while uncertainties were discussed with two other reviewers. Because of the heterogeneity of interventions and outcomes, no meta-analysis was performed.

Results

Eighty-four studies were included. Interventions were categorized into educational, (computerized) provider order entry [(C)POE], audit and feedback, or other interventions. Nearly all studies reported a reduction in test order volume. Only 15 assessed sustainability up to two years. Patient-related clinical outcomes were reported in 45 studies, two of which found negative effects.

Conclusions

Interventions from all categories have the potential to reduce unnecessary laboratory testing, although long-term sustainability is questionable. Owing to the heterogeneity of the interventions studied, it is difficult to conclude which approach was most successful, and for which tests. Most studies had methodological limitations, such as the absence of a control arm. Therefore, well-designed, controlled trials using clearly described interventions and relevant clinical outcomes are needed.

Reduction in Unnecessary Red Blood Cell Folate Testing by Restricting Computerized Physician Order Entry in the Electronic Health Record

PURPOSE

The red blood cell (RBC) folate test is a laboratory test with limited clinical utility. Previous attempts to reduce physician ordering of unnecessary laboratory tests, including folate levels, have resulted in only modest success. The objective of this study was to assess the effectiveness and impacts of restricting RBC folate ordering in the electronic health record (EHR).

METHODS

This was a retrospective observational study that took place from January 2010 to December 2016 at a large academic healthcare network in Toronto, Canada. All inpatients and outpatients who underwent at least 1 RBC folate or vitamin B12 test during the study period were included. Ordering an RBC folate test was restricted to clinicians in gastroenterology and hematology. The option to order the test was removed from other physicians' computerized order entry screens in the EHR in June 2013.

RESULTS

RBC folate testing decreased by 94.4% during the study, from a mean of 493.0 ± 48.0 tests per month prior to intervention to 27.6 ± 10.3 tests per month after intervention (P < .001).

CONCLUSIONS

Restricting RBC folate ordering in the EHR resulted in a large and sustained reduction in RBC folate testing. Significant cost savings, estimated at more than a quarter of a million Canadian dollars over 3 years, were achieved. There was no significant clinical impact of the intervention on the diagnosis of folate deficiency.

Laboratory Tests and X-ray Imaging in a Surgical Intensive Care Unit: Checking the Checklist

Context

Patients in the surgical intensive care unit (ICU) frequently undergo laboratory and imaging testing. These tests can lead to iatrogenic anemia and radiation exposure. Many of these tests may be unnecessary for the management of a patient's illness in the surgical ICU, and their ordering may be a reflex rather than in response to a clinical question. Checklists have been used in critical care to identify and address patient care strategies.

Objective

To examine whether adding a “diagnostic testing” section to a daily checklist used for patient rounds in a surgical ICU would decrease the amount of laboratory tests and chest x-ray imaging ordered.

Methods

An additional section was added to an established ICU daily checklist, which included the following 2 questions: “Is a [chest x-ray] needed for clinical management tomorrow?” and “What laboratory tests are medically necessary for tomorrow?” Comparison was made between 3-month preintervention (control group) and intervention (intervention group) periods. Medical records of hospitalized patients during the preintervention and intervention periods were compared to determine differences in the number of tests ordered per day during each period.

Results

A total of 307 adult patients at a single institution were included in the analysis: 155 in the control group and 152 in the intervention group. The patients in each group were similar in terms of sex, age, Sequential Organ Failure scores, Charlson Comorbidity Index scores, elective admission status, surgical procedures, number of days of mechanical ventilation, ICU length of stay, and in-hospital death. No statistical reductions in laboratory tests or chest x-ray imaging ordered per day from the preintervention to intervention period were found.

Conclusion

The addition of the diagnostic testing section to the daily checklist did not result in a reduction of the amount of tests ordered per day. Further research on test appropriateness and the possible addition of a clinician decision-making tool could be studied in the future to assist with reduction of tests ordered in the surgical ICU.

Sample collection and sample handling errors submitted to the transfusion error surveillance system, 2006 to 2015

BACKGROUND

In Canada, transfusion-related errors are voluntarily reported to a tracking system with the goal to systematically improve transfusion safety. This report provides an analysis of sample collection (SC) and sample handling (SH) errors from this national error-tracking system.

STUDY DESIGN AND METHODS

Errors from 2006 to 2015 from 23 participating sites were extracted. A survey was conducted to obtain information regarding institutional policies. Samples received in the blood bank were used to calculate rates. "Wrong blood in tube" (WBIT) errors are blood taken from wrong patient and labeled with intended patient's information, or blood taken from intended patient but labeled with another patient's information.

RESULTS

A total of 42,363 SC and 14,666 SH errors were reported. Predefined low-severity (low potential for harm) and high-severity errors (potential for fatal outcomes) increased from 2006 to 2015 (low SC, SH: 13-27, 3-12 per 1000; high SC, SH: 1.9-3.7, 0.5-2.0 per 1000). The WBIT rate decreased from 12 to 5.8 per 10,000 between 2006 and 2015 (p < 0.0001). The overall WBIT rate was 6.2 per 10,000, with variability by site (median, 0.3 per 10,000; range, 0-17 per 10,000). Sites with error detection mechanisms, such as regrouping second sample requirements, had lower error rates than sites that did not (SC, SH: 12, 1 per 1000 samples vs. 17, 3 per 1000 samples; p < 0.0001).

CONCLUSION

WBIT rates decreased significantly. Low-severity error rates are climbing likely due to increased ascertainment and reporting. Prevention studies are necessary to inform changes to blood transfusion standards to eliminate these errors.

Evaluation of a Reflex Testing Algorithm for Suspected Heparin-Induced Thrombocytopenia

OBJECTIVES

We implemented a policy of reflex serotonin-release assay (SRA) testing for all patients with a positive heparin-induced thrombocytopenia (HIT) immunoassay.

METHODS

We identified all patients who had SRA testing sent as a consequence of a positive HIT immunoassay test. We reviewed charts of patients to calculate the 4Ts clinical score, determined the effect of testing on clinical management, and documented the change in utilization of direct thrombin inhibitors (DTIs).

RESULTS

The likelihood of a positive SRA varied with the optical density (OD) of the immunoassay. The performance of the immunoglobulin G (IgG)-specific and polytypic enzyme-linked immunosorbent assay was not statistically different. Both OD and 4Ts score correlated with the likelihood of a positive SRA but demonstrated poor specificity. Discontinuation of DTIs in patients with negative SRAs resulted in decreased drug utilization.

CONCLUSIONS

The IgG-specific HIT immunoassay OD correlates with the likelihood of a positive SRA but does not achieve high specificity. The reflex testing algorithm allows for definitive classification of patients, and the cost of such a reflex testing program may be offset by decreased utilization of DTIs.

Organizational Benchmarks for Test Utilization Performance: An Example Based on Positivity Rates for Genetic Tests

OBJECTIVES

Health care organizations are under increasing pressure to deliver value by improving test utilization management. Many factors, including organizational factors, could affect utilization performance. Past research has focused on the impact of specific interventions in single organizations. The impact of organizational factors is unknown. The objective of this study is to determine whether testing patterns are subject to organizational effects, ie, are utilization patterns for individual tests correlated within organizations.

METHODS

Comparative analysis of ordering patterns (positivity rates for three genetic tests) across 659 organizations. Hierarchical regression was used to assess the impact of organizational factors after controlling for test-level factors (mutation prevalence) and hospital bed size.

RESULTS

Test positivity rates were correlated within organizations.

CONCLUSIONS

Organizations have a statistically significant impact on the positivity rate of three genetic tests.