1
|
Yeshoua B, Bowman C, Dullea J, Ditkowsky J, Shyu M, Lam H, Zhao W, Shin JY, Dunn A, Tsega S, S Linker A, Shah M. Interventions to reduce repetitive ordering of low-value inpatient laboratory tests: a systematic review. BMJ Open Qual 2023; 12:bmjoq-2022-002128. [PMID: 36958791 PMCID: PMC10040017 DOI: 10.1136/bmjoq-2022-002128] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/05/2023] [Indexed: 03/25/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Brandon Yeshoua
- Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - Chip Bowman
- Department of Medicine, Mount Sinai, New York, New York, USA
| | - Jonathan Dullea
- Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - Jared Ditkowsky
- Emergency Medicine, Hackensack Meridian Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Margaret Shyu
- Department of Medicine, Mount Sinai, New York, New York, USA
| | - Hansen Lam
- Department of Pathology and Laboratory Medicine, Icahn School of Medicine at Mount Sinai Lillian and Henry M Stratton-Hans Popper, New York, New York, USA
| | - William Zhao
- Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - Joo Yeon Shin
- Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - Andrew Dunn
- Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Surafel Tsega
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anne S Linker
- Department of Medicine, Mount Sinai, New York, New York, USA
| | - Manan Shah
- Department of Medicine, Mount Sinai, New York, New York, USA
| |
Collapse
|
2
|
Tran A, Hudoba M, Markin T, Roland K. Sustainable Laboratory-Driven Method to Decrease Repeat, Same-Day WBC Differentials at a Tertiary Care Center. Am J Clin Pathol 2022; 157:561-565. [PMID: 34617986 DOI: 10.1093/ajcp/aqab146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/28/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES A CBC with WBC differential is often ordered when a CBC alone would be sufficient for patient care. Performing unnecessary WBC differentials adds to costs in the laboratory. Our objective was to implement a laboratory middleware algorithm to cancel repeat, same-day WBC differentials to achieve lasting improvements in laboratory resource allocation. METHODS Repeat same-day WBC differentials were first canceled only on intensive care unit samples; after a successful trial period, the algorithm was applied hospital-wide. We retrospectively reviewed CBC with differential orders from pre- and postimplementation periods to estimate the reduction in WBC differentials and potential cost savings. RESULTS The algorithm led to a monthly WBC differential cancellation rate of 5.40% for a total of 10,195 canceled WBC differentials during the cumulative postimplementation period (September 25, 2019, to December 31, 2020). Nearly all (99.94%) differentials remained canceled. Most patients only had one WBC differential canceled (range, 1-38). Savings estimates showed savings of $0.99 CAD per canceled differential and 1,060 minutes (17.7 hours) of technologist time. CONCLUSIONS A middleware algorithm to cancel repeat, same-day WBC differentials is a simple and sustainable way to achieve lasting improvements in laboratory utilization.
Collapse
Affiliation(s)
- Ann Tran
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Monika Hudoba
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
- Division of Hematopathology, Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, Canada
| | - Todd Markin
- Division of Hematopathology, Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, Canada
| | - Kristine Roland
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
- Division of Hematopathology, Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, Canada
| |
Collapse
|
3
|
McAlister S, Smyth B, Koprivic I, Luca Di Tanna G, McGain F, Charlesworth K, Brown MA, Konecny P. Carbon emissions and hospital pathology stewardship: a retrospective cohort analysis. Intern Med J 2021; 53:584-589. [PMID: 34779562 DOI: 10.1111/imj.15622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/12/2021] [Accepted: 10/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND As healthcare is responsible for 7% of Australia's carbon emissions, it was recognised that a policy implemented at St George Hospital, Sydney to reduce non-urgent pathology testing to two days per week and on other days only if essential, would also result in a reduction in carbon emissions. The aim of the study was to measure the impact of this intervention on pathology collections and associated carbon emissions and pathology costs. METHODS The difference in the number of pathology collections, carbon dioxide equivalents (CO2 e) for five common blood tests, and pathology cost per admission were compared between a 6-month reference period and 6-month intervention period. CO2 e were estimated from published pathology CO2 e impacts. Cost was derived from pathology billing records. Outcomes were modelled using multivariable negative binomial, generalised linear, and logistic regression. RESULTS In total, 24,585 pathology collections in 5,695 patients were identified. In adjusted analysis, the rate of collections was lower during the intervention period (rate ratio 0.90, 95% CI, 0.86 to 0.95; P<0.001). This resulted in a reduction of 53 g CO2 e (95% CI, 24 to 83g; P<0.001) and $22 (95% CI, $9 to $34; P=0.001) in pathology fees per admission. The intervention was estimated to have saved 132kg CO2 e (95% CI, 59 to 205kg) and $53,573 (95% CI, 22,076 to 85,096). CONCLUSIONS Reduction in unnecessary hospital pathology collections was associated with both carbon emission and cost savings. Pathology stewardship warrants further study as a potentially scalable, cost-effective, and incentivising pathway to lowering healthcare associated greenhouse gas emissions. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Scott McAlister
- Department of Integrated Critical Care, The University of Melbourne
| | - Brendan Smyth
- Department of Renal Medicine, St George Hospital, Kogarah.,The George Institute for Global Health and University of New South Wales, Newtown
| | - Ivan Koprivic
- Finance and Performance Department, St George Hospital, Kogarah
| | - Gian Luca Di Tanna
- The George Institute for Global Health and University of New South Wales, Newtown
| | | | | | - Mark A Brown
- Department of Renal Medicine, St George Hospital, Kogarah.,St George and Sutherland Clinical School, Faculty of Medicine, UNSW, Sydney
| | - Pam Konecny
- St George and Sutherland Clinical School, Faculty of Medicine, UNSW, Sydney.,Dept Infectious Diseases & Immunology, St George Hospital, Kogarah, NSW, 2217
| |
Collapse
|
4
|
Del Giorno R, Ottini A, Greco A, Stefanelli K, Kola F, Clivio L, Ceschi A, Gabutti L. Peer-pressure and overuse: The effect of a multimodal approach on variation in benzodiazepine prescriptions in a network of public hospitals. Int J Clin Pract 2020; 74:e13448. [PMID: 31750587 PMCID: PMC7065013 DOI: 10.1111/ijcp.13448] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/05/2019] [Accepted: 11/19/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The epidemic phenomenon leading to a progressive increase in benzodiazepine prescriptions represents a challenge for healthcare systems. In the hospital setting, indicators of prescription variation and potential of overuse are lacking and are rarely monitored. Inter-hospital monitoring/benchmarking, via peer-pressure, can foster the motivation to change. The aim of this investigation was to analyse whether, the reduction in new benzodiazepine prescriptions obtained thanks to a Choosing Wisely campaign, also contributed to reducing inter-hospital variation. METHODS Secondary analysis of a multicentre longitudinal intervention in a network of five teaching hospitals in Switzerland. We set out to explore the effect, on inter-hospital benzodiazepine prescription variation, of a continuous monitoring/benchmarking strategy, which was proven effective in reducing the intra-hospital prescription rate. The variance was used to assess inter-hospital variation. To investigate the impact of the intervention a segmented regression analysis of interrupted time series was performed. RESULTS A total of 36 299 admissions over 42 months were analysed (1 July 2014 to 31 December 2017). Before the intervention a significant constant upward trend in inter-hospital variability was found (+0.901; SE 0.441; P < .05). After the intervention, the variance trend line significantly changed, decreasing by -0.257 (SE 0.005: P < .001) and producing by December 2017, a 27% absolute reduction. CONCLUSIONS Thanks to a multimodal approach based on monitoring-benchmarking, a significant reduction in inter-hospital benzodiazepine prescription variation was obtained. Aligning to peer strategy is a spontaneous consequence of open benchmarking that can be used to convert a variation-based suspicion of overuse, into an occasion to actively review prescription habits.
Collapse
Affiliation(s)
- Rosaria Del Giorno
- Department of Internal Medicine and NephrologyRegional Hospital of Bellinzona and ValliBellinzonaSwitzerland
| | - Andrea Ottini
- Department of Internal Medicine and NephrologyRegional Hospital of Bellinzona and ValliBellinzonaSwitzerland
| | - Angela Greco
- Quality and Patient Safety ServiceLa Carità HospitalLocarnoSwitzerland
| | - Kevyn Stefanelli
- Department of Social Sciences and EconomicsSapienza University of RomeRomeItaly
| | - Florenc Kola
- Department of Internal Medicine and NephrologyRegional Hospital of Bellinzona and ValliBellinzonaSwitzerland
| | - Luca Clivio
- Department of InformaticsEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and ToxicologyInstitute of Pharmacological Sciences of Southern SwitzerlandEnte Ospedaliero CantonaleLuganoSwitzerland
- Department of Clinical Pharmacology and ToxicologyUniversity Hospital ZurichZurichSwitzerland
- Institute of BiomedicineUniversity of Southern SwitzerlandLuganoSwitzerland
| | - Luca Gabutti
- Department of Internal Medicine and NephrologyRegional Hospital of Bellinzona and ValliBellinzonaSwitzerland
- Institute of BiomedicineUniversity of Southern SwitzerlandLuganoSwitzerland
| |
Collapse
|
5
|
Giannini O, Del Giorno R, Zasa A, Gabutti L. Comparative Impact of C-Reactive Protein Testing in Hospitalized Patients with Acute Respiratory Tract Infection: A Retrospective Cohort Study. Adv Ther 2019; 36:3186-3195. [PMID: 31522372 DOI: 10.1007/s12325-019-01090-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Olivier Giannini
- Department of Internal Medicine and Service of Nephrology, Ente Ospedaliero Cantonale (EOC), Ospedale Regionale della Beata Vergine, Mendrisio, Switzerland
| | - Rosaria Del Giorno
- Department of Internal Medicine and Service of Nephrology, Ente Ospedaliero Cantonale (EOC), Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland.
| | - Anna Zasa
- Quality and Patient Safety Service, Ente Ospedaliero Cantonale (EOC), Ospedale La Carità, Locarno, Switzerland
| | - Luca Gabutti
- Department of Internal Medicine and Service of Nephrology, Ente Ospedaliero Cantonale (EOC), Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland
- Institute of Biomedicine, University of Southern Switzerland (USI), Lugano, Switzerland
| |
Collapse
|
6
|
Citrome L. Testing, Testing. 1, 2, 3. Is This Mic On? Int J Clin Pract 2019; 73:e13344. [PMID: 30866158 DOI: 10.1111/ijcp.13344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
This issue of the International Journal of Clinical Practice includes 4 articles regarding testing in medicine. Our Associate Editor for Cardiovascular Disease Prevention and Metabolic Diseases, Anthony Wierzbicki, together with Timothy Reynolds, start us off with a thoughtful extended editorial/perspective with the title (translated) "first, do no harm.". This article is protected by copyright. All rights reserved.
Collapse
|
7
|
Wierzbicki AS, Reynolds TM. Primum non nocere: Demand management in pathology and preventing harm. Int J Clin Pract 2019; 73:e13311. [PMID: 30633836 DOI: 10.1111/ijcp.13311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Anthony S Wierzbicki
- Dept Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Timothy M Reynolds
- Dept Metabolic Medicine/Chemical Pathology, Queen's Hospital, Burton-on-Trent, Staffordshire, UK
| |
Collapse
|
8
|
Erard Y, Del Giorno R, Zasa A, De Gottardi S, Della Bruna R, Keller F, Clivio L, Greco A, Giannini O, Gabutti L. A multi-level strategy for a long lasting reduction in unnecessary laboratory testing: A multicenter before and after study in a teaching hospital network. Int J Clin Pract 2018; 73:e13286. [PMID: 30339303 PMCID: PMC6587855 DOI: 10.1111/ijcp.13286] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 10/14/2018] [Indexed: 12/18/2022] Open
Abstract
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 reduced: -7%, P-value<0.05; -3%, P-value<0.01, and -17%, P-value<0.01, respectively. CONCLUSIONS The obtained reduction in the number of laboratory tests, blood volume withdrawn and related costs, support the idea that an open web-based system, involving all health care providers, coupled with educational interventions, can be helpful in generating awareness of prescriber habits and to catalyze changes in their behaviour. The peer pressure related to the unmasked benchmarking process did probably play a determinant role.
Collapse
Affiliation(s)
- Yannick Erard
- Department of Internal MedicineSan Giovanni HospitalEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Rosaria Del Giorno
- Department of Internal MedicineSan Giovanni HospitalEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Anna Zasa
- Department of Internal MedicineSan Giovanni HospitalEnte Ospedaliero CantonaleBellinzonaSwitzerland
- Quality and Patient Safety ServiceLa Carità HospitalEnte Ospedaliero CantonaleLocarnoSwitzerland
| | - Simone De Gottardi
- Department of InformaticsEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Roberto Della Bruna
- Institute of Laboratory MedicineEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Franco Keller
- Institute of Laboratory MedicineEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Luca Clivio
- Department of InformaticsEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Angela Greco
- Quality and Patient Safety ServiceLa Carità HospitalEnte Ospedaliero CantonaleLocarnoSwitzerland
| | - Olivier Giannini
- Department of Internal MedicineBeata Vergine HospitalEnte Ospedaliero CantonaleMendrisioSwitzerland
| | - Luca Gabutti
- Department of Internal MedicineSan Giovanni HospitalEnte Ospedaliero CantonaleBellinzonaSwitzerland
- Institute of BiomedicineUniversity of Southern SwitzerlandLuganoSwitzerland
| |
Collapse
|