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Tchou MJ, Hall M, Markham JL, Stephens JR, Steiner MJ, McCoy E, Aronson PL, Shah SS, Molloy MJ, Cotter JM. Changing patterns of routine laboratory testing over time at children's hospitals. J Hosp Med 2024. [PMID: 38643414 DOI: 10.1002/jhm.13372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/19/2024] [Accepted: 04/09/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Research into low-value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time. OBJECTIVES To identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes. DESIGN, SETTINGS, AND PARTICIPANTS We performed a multi-center, retrospective cohort study of children aged 0-18 hospitalized with common, lower-severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database. MAIN OUTCOMES AND MEASURES We calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A > 2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30-day readmission or ED revisit, adjusted for demographics and case mix index. RESULTS Our study included 576,572 encounters for common, low-severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital-specific testing rates ranged from -6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all ten years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30-day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction.
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Affiliation(s)
- Michael J Tchou
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City and University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John R Stephens
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael J Steiner
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of General Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew J Molloy
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Jillian M Cotter
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado, USA
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2
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Ostermann M, De Waele JJ, Schefold JC. The environmental impact of laboratory measurements in high-resource ICUs. Intensive Care Med 2024; 50:449-452. [PMID: 38353712 DOI: 10.1007/s00134-023-07318-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/29/2023] [Indexed: 03/21/2024]
Affiliation(s)
- Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St Thomas' Hospital, London, UK.
| | - Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, University of Bern, Bern, Switzerland
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3
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Sznol JA, Becher R, Maung AA, Bhattacharya B, Davis K, Schuster KM. Routine post-operative labs and healthcare system burden in acute appendicitis. Am J Surg 2023; 226:571-577. [PMID: 37291012 DOI: 10.1016/j.amjsurg.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/16/2023] [Accepted: 06/01/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Data from the National Health Expenditure Accounts have shown a steady increase in healthcare cost paralleled by availability of laboratory tests. Resource utilization is a top priority for reducing health care costs. We hypothesized that routine post-operative laboratory utilization unnecessarily increases costs and healthcare system burden in acute appendicitis (AA) management. METHODS A retrospective cohort of patients with uncomplicated AA 2016-2020 were identified. Clinical variables, demographics, lab usage, interventions, and costs were collected. RESULTS A total of 3711 patients with uncomplicated AA were identified. Total costs of labs ($289,505, 99.56%) and repletions ($1287.63, 0.44%) were $290,792.63. Increased LOS was associated with lab utilization in multivariable modeling, increasing costs by $837,602 or 472.12 per patient. CONCLUSIONS In our patient population, post-operative labs resulted in increased costs without discernible impact on clinical course. Routine post-operative laboratory testing should be re-evaluated in patients with minimal comorbidities as this likely increases cost without adding value.
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Affiliation(s)
- Joshua A Sznol
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Robert Becher
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Adrian A Maung
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Bishwajit Bhattacharya
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Kimberly Davis
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Kevin M Schuster
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
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Ambasta A, Omodon O, Herring A, Ferrie L, Pokharel S, Mehta A, Liu L, Hews-Girard J, Tam C, Taylor S, Lonergan K, Faris P, Duncan D, Woodhouse D. Repurposing the Ordering of Routine Laboratory Tests in Hospitalised Medical Patients (RePORT): results of a cluster randomised stepped-wedge quality improvement study. BMJ Qual Saf 2023; 32:517-525. [PMID: 37164639 DOI: 10.1136/bmjqs-2022-015611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 04/19/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Low-value use of laboratory tests is a global challenge. Our objective was to evaluate an intervention bundle to reduce repetitive use of routine laboratory testing in hospitalised patients. METHODS We used a stepped-wedge design to implement an intervention bundle across eight medical units. Our intervention included educational tools and social comparison reports followed by peer-facilitated report discussion sessions. The study spanned October 2020-June 2021, divided into control, feasibility testing, intervention and a follow-up period. The primary outcomes were the number and costs of routine laboratory tests ordered per patient-day. We used generalised linear mixed models, and analyses were by intention to treat. RESULTS We included a total of 125 854 patient-days. Patient groups were similar in age, sex, Charlson Comorbidity Index and length of stay during the control, intervention and follow-up periods. From the control to the follow-up period, there was a 14% (incidence rate ratio (IRR)=0.86, 95% CI 0.79 to 0.92) overall reduction in ordering of routine tests with the intervention, along with a 14% (β coefficient=-0.14, 95% CI -0.07 to -0.21) reduction in costs of routine testing. This amounted to a total cost savings of $C1.15 per patient-day. There was also a 15% (IRR=0.85, 95% CI 0.79, 0.92) reduction in ordering of all common tests with the intervention and a 20% (IRR=1.20, 95% CI 1.10 to 1.30) increase in routine test-free patient-days. No worsening was noted in patient safety endpoints with the intervention. CONCLUSIONS A multifaceted intervention bundle using education and facilitated multilevel social comparison was associated with a safe and effective reduction in use of routine daily laboratory testing in hospitals. Further research is needed to understand how system-level interventions may increase this effect and which intervention elements are necessary to sustain results.
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Affiliation(s)
- Anshula Ambasta
- Medicine, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Onyebuchi Omodon
- Ward of the 21st Century, University of Calgary Cumming School of Medicine, Calgary, Canada
| | | | - Leah Ferrie
- Physician Learning Program, University of Calgary, Calgary, Canada
| | | | - Ashi Mehta
- Health Quality Council of Alberta, Calgary, Canada
| | | | | | - Cheuk Tam
- Medicine, University of Calgary Faculty of Medicine, Calgary, Canada
| | - Simon Taylor
- Medicine, University of Calgary, Calgary, Canada
| | | | - Peter Faris
- Measurement and Analysis; Research Excellence Support Team, Alberta Bone and Joint Health Institute; Alberta Health Services, Calgary, Canada
| | - Diane Duncan
- Physician Learning Program, University of Calgary, Calgary, Canada
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Mathias PC, Khor S, Harris K, Wood SJ, Farjah F. Evaluation of a Multilevel Laboratory Stewardship Intervention Targeted to Cardiac and Thoracic Surgical Services at an Academic Medical Center. Arch Pathol Lab Med 2023; 147:957-963. [PMID: 36287195 DOI: 10.5858/arpa.2021-0593-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 07/28/2023]
Abstract
CONTEXT.— Unnecessary laboratory tests are ordered because of factors such as preselected orders on order sets, clinician habits, and trainee concerns. Excessive use of laboratory testing increases patient discomfort via unnecessary phlebotomy, contributes to iatrogenic anemia, increases risk of bloodstream infections, and increases the cost of care. OBJECTIVE.— To address these concerns, we implemented a multilevel laboratory stewardship intervention to decrease unnecessary laboratory testing, measured by laboratory tests per day attributed to service, across 2 surgical divisions with high laboratory use. DESIGN.— The multilevel intervention included 5 components: stakeholder engagement, provider education, computerized provider order entry modification, performance feedback, and culture change supported by leadership. The primary outcome of the study was laboratory tests ordered per patient-day. Secondary outcomes included the number of blood draws per patient-day, total lab-associated costs, length of stay, discharge to a nursing facility, 30-day readmissions, and deaths. A difference-in-differences analytic approach assessed the outcome measures in the intervention period, with other surgical services as controls. RESULTS.— The primary outcome of laboratory tests per patient-day showed a significant decrease across both thoracic and cardiac surgery services, with between 1.5 and 2 fewer tests ordered per patient-day for both services and an estimated 20 000 fewer tests performed during the intervention period. Blood draws per patient-day were also significantly decreased on the thoracic surgery service but not for cardiac surgery. CONCLUSIONS.— A multilevel laboratory stewardship intervention targeted to 2 surgical services resulted in a significant decrease in laboratory test use without negatively impacting length of stay, readmissions, or mortality.
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Affiliation(s)
- Patrick C Mathias
- From the Departments of Laboratory Medicine and Pathology and Biomedical Informatics and Medical Education (Mathias), University of Washington, Seattle
| | - Sara Khor
- Department of Pharmacy (Khor), University of Washington, Seattle
| | - Kathryn Harris
- Department of Surgery (Harris, Farjah), University of Washington, Seattle
| | - Suzanne J Wood
- Department of Health Systems and Population Health (Wood), University of Washington, Seattle
- The Herbert Business School (Wood), University of Miami, Coral Gables, Florida
| | - Farhood Farjah
- Department of Surgery (Harris, Farjah), University of Washington, Seattle
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Spoyalo K, Lalande A, Rizan C, Park S, Simons J, Dawe P, Brown CJ, Lillywhite R, MacNeill AJ. Patient, hospital and environmental costs of unnecessary bloodwork: capturing the triple bottom line of inappropriate care in general surgery patients. BMJ Open Qual 2023; 12:e002316. [PMID: 37402596 DOI: 10.1136/bmjoq-2023-002316] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/26/2023] [Indexed: 07/06/2023] Open
Abstract
OBJECTIVE To characterise the extent of unnecessary care in general surgery inpatients using a triple bottom line approach. DESIGN Patients with uncomplicated acute surgical conditions were retrospectively evaluated for unnecessary bloodwork according to the triple bottom line, quantifying the impacts on patients, healthcare costs and greenhouse gas emissions. The carbon footprint of common laboratory investigations was estimated using PAS2050 methodology, including emissions generated from the production, transport, processing and disposal of consumable goods and reagents. SETTING Single-centre tertiary care hospital. PARTICIPANTS Patients admitted with acute uncomplicated appendicitis, cholecystitis, choledocholithiasis, gallstone pancreatitis and adhesive small bowel obstruction were included in the study. 304 patients met inclusion criteria and 83 were randomly selected for in-depth chart review. MAIN OUTCOME MEASURES In each patient population, the extent of over-investigation was determined by comparing ordered laboratory investigations against previously developed consensus recommendations. The quantity of unnecessary bloodwork was measured by number of phlebotomies, tests and blood volume in addition to healthcare costs and greenhouse gas emissions. RESULTS 76% (63/83) of evaluated patients underwent unnecessary bloodwork resulting in a mean of 1.84 phlebotomies, 4.4 blood vials, 16.5 tests and 18 mL of blood loss per patient. The hospital and environmental cost of these unnecessary activities was $C5235 and 61 kg CO2e (974 g CO2e per person), respectively. The carbon footprint of a common set of investigations (complete blood count, differential, creatinine, urea, sodium, potassium) was 332 g CO2e. Adding a liver panel (liver enzymes, bilirubin, albumin, international normalised ratio/partial thromboplastin time) resulted in an additional 462 g CO2e. CONCLUSIONS We found considerable overuse of laboratory investigations among general surgery patients admitted with uncomplicated acute surgical conditions resulting in unnecessary burden to patients, hospitals and the environment. This study identifies an opportunity for resource stewardship and exemplifies a comprehensive approach to quality improvement.
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Affiliation(s)
- Karina Spoyalo
- Department of Surgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Annie Lalande
- Department of Surgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Chantelle Rizan
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - Sophia Park
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet Simons
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Philip Dawe
- Department of Surgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Carl J Brown
- Department of Surgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Lillywhite
- School of Life Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Andrea J MacNeill
- Department of Surgery, The University of British Columbia, Vancouver, British Columbia, Canada
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7
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Gujju VR, Khattab M, Kastens V, Saeed G, Chen S, Khattab M. Reducing Unnecessary Complete Blood Count Ordering Through Education and Standardization: A Quality Improvement Initiative. Qual Manag Health Care 2023; 32:197-204. [PMID: 36729860 DOI: 10.1097/qmh.0000000000000387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES The American Board of Internal Medicine's Choosing Wisely campaign recommends against ordering repetitive complete blood counts (CBC) in the face of clinical and laboratory stability. METHODS Consecutive patients admitted to a teaching team were included. Intervention 1 was an educational lecture outlining costs of and indications for CBC ordering. Intervention 2 added a simplified algorithm to help providers determine the need for a daily CBC. The primary outcome measure was the number of CBCs ordered per number of patients per day. The secondary outcome measure was net cost saved. The process measures were lecture/poster and algorithm utilization rates. The balancing measure was emergency department visits/readmissions within 7 days of discharge. A statistical process control chart was generated to assess special cause variation. Using R software version 3.5.2, a 2-sample t test and Fisher exact test differences between groups in the outcome and balancing measures. RESULTS One hundred ten patients were included over a 62-day period. The difference between the pre-intervention group and both interventions combined was significant ( P = .000317). Special cause variation was observed after institution of both interventions in conjunction. Net costs saved totaled $43 482. Emergency department visits/readmissions within 7 days were similar between the groups ( P = .1403). CONCLUSIONS Complete blood count ordering patterns and costs were improved through education and providing a decision support tool in the form of a simplified algorithm, without increasing 7-day emergency department visits/readmissions. The algorithm, far less detailed than that previously published, still resulted in significant improvement without unintended consequences, making for a safe and potentially sustainable intervention.
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Affiliation(s)
- Veena R Gujju
- Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City (Drs Gujju, Mahmood Khattab, Kastens, and Saeed); Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, College of Public Health, Oklahoma City (Dr Chen); and Department of Internal Medicine, Division of Cardiovascular Diseases, University of Oklahoma Health Sciences Center, Oklahoma City (Dr Mohamad Khattab)
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Mathura P, Marini S, Hagtvedt R, Spalding K, Duhn L, Kassam N, Medves J. Factors of a physician quality improvement leadership coalition that influence physician behaviour: a mixed methods study. BMJ Open Qual 2023; 12:e002016. [PMID: 37290908 PMCID: PMC10255283 DOI: 10.1136/bmjoq-2022-002016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 05/25/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND A coalition (Strategic Clinical Improvement Committee), with a mandate to promote physician quality improvement (QI) involvement, identified hospital laboratory test overuse as a priority. The coalition developed and supported the spread of a multicomponent initiative about reducing repetitive laboratory testing and blood urea nitrogen (BUN) ordering across one Canadian province. This study's purpose was to identify coalition factors enabling medicine and emergency department (ED) physicians to lead, participate and influence appropriate BUN test ordering. METHODS Using sequential explanatory mixed methods, intervention components were grouped as person focused or system focused. Quantitative phase/analyses included: monthly total and average of the BUN test for six hospitals (medicine programme and two EDs) were compared pre initiative and post initiative; a cost avoidance calculation and an interrupted time series analysis were performed (participants were divided into two groups: high (>50%) and low (<50%) BUN test reduction based on these findings). Qualitative phase/analyses included: structured virtual interviews with 12 physicians/participants; a content analysis aligned to the Theoretical Domains Framework and the Behaviour Change Wheel. Quotes from participants representing high and low groups were integrated into a joint display. RESULTS Monthly BUN test ordering was significantly reduced in 5 of 6 participating hospital medicine programmes and in both EDs (33% to 76%), resulting in monthly cost avoidance (CAN$900-CAN$7285). Physicians had similar perceptions of the coalition's characteristics enabling their QI involvement and the factors influencing BUN test reduction. CONCLUSIONS To enable physician confidence to lead and participate, the coalition used the following: a simply designed QI initiative, partnership with a coalition physician leader and/or member; credibility and mentorship; support personnel; QI education and hands-on training; minimal physician effort; and no clinical workflow disruption. Implementing person-focused and system-focused intervention components, and communication from a trusted local physician-who shared data, physician QI initiative role/contribution and responsibility, best practices, and past project successes-were factors influencing appropriate BUN test ordering.
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Affiliation(s)
- Pamela Mathura
- Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
- Alberta Health Services, Edmonton Zone Medicine, Edmonton, Alberta, Canada
| | - Sandra Marini
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Reidar Hagtvedt
- Alberta School of Business, University of Alberta, Edmonton, Alberta, Canada
| | - Karen Spalding
- School of Nursing, Queen's University, Kingston, Ontario, Canada
| | - Lenora Duhn
- School of Nursing, Queen's University, Kingston, Ontario, Canada
| | - Narmin Kassam
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Medves
- School of Nursing, Queen's University, Kingston, Ontario, Canada
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9
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Conrad S, Gant Kanegusuku A, Conklin SE. Taking a step back from testing: Preanalytical considerations in molecular infectious disease diagnostics. Clin Biochem 2023; 115:22-32. [PMID: 36495954 PMCID: PMC9729171 DOI: 10.1016/j.clinbiochem.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022]
Abstract
Recent studies evaluating the preanalytical factors that impact the outcome of nucleic-acid based methods for the confirmation of SARS-CoV-2 have illuminated the importance of identifying variables that promoted accurate testing, while using scarce resources efficiently. The majority of laboratory errors occur in the preanalytical phase. While there are many resources identifying and describing mechanisms for main laboratory testing on automated platforms, there are fewer comprehensive resources for understanding important preanalytical and environmental factors that affect accurate molecular diagnostic testing of infectious diseases. This review identifies evidence-based factors that have been documented to impact the outcome of nucleic acid-based molecular techniques for the diagnosis of infectious diseases.
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Affiliation(s)
- Stephanie Conrad
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
| | | | - Steven E Conklin
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA; Department of Anatomic & Clinical Pathology, Tufts University School of Medicine, Boston, MA, USA.
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10
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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.
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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
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François T, Charlier J, Balandier S, Pincivy A, Tucci M, Lacroix J, Du Pont-Thibodeau G. Strategies to Reduce Diagnostic Blood Loss and Anemia in Hospitalized Patients: A Scoping Review. Pediatr Crit Care Med 2023; 24:e44-e53. [PMID: 36269063 DOI: 10.1097/pcc.0000000000003094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Blood sampling is a recognized contributor to hospital-acquired anemia. We aimed to bundle all published neonatal, pediatric, and adult data regarding clinical interventions to reduce diagnostic blood loss. DATA SOURCES Four electronic databases were searched for eligible studies from inception until May 2021. STUDY SELECTION Two reviewers independently selected studies, using predefined criteria. DATA EXTRACTION One author extracted data, including study design, population, period, intervention type and comparator, and outcome variables (diagnostic blood volume and frequency, anemia, and transfusion). DATA SYNTHESIS Of 16,132 articles identified, we included 39 trials; 12 (31%) were randomized controlled trials. Among six types of interventions, 27 (69%) studies were conducted in adult patients, six (15%) in children, and six (15%) in neonates. Overall results were heterogeneous. Most studies targeted a transfusion reduction ( n = 28; 72%), followed by reduced blood loss ( n = 24; 62%) and test frequency ( n = 15; 38%). Small volume blood tubes ( n = 7) and blood conservation devices ( n = 9) lead to a significant reduction of blood loss in adults (8/9) and less transfusion of adults (5/8) and neonates (1/1). Point-of-care testing ( n = 6) effectively reduced blood loss (4/4) and transfusion (4/6) in neonates and adults. Bundles including staff education and protocols reduced blood test frequency and volume in adults (7/7) and children (5/5). CONCLUSIONS Evidence on interventions to reduce diagnostic blood loss and associated complications is highly heterogeneous. Blood conservation devices and smaller tubes appear effective in adults, whereas point-of-care testing and bundled interventions including protocols and teaching seem promising in adults and children.
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Affiliation(s)
- Tine François
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Julien Charlier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Sylvain Balandier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Alix Pincivy
- Medical Library, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Geneviève Du Pont-Thibodeau
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
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12
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Laohavisudhi K, Phinyo P, Wittayachamnankul B, Chenthanakij B, Tangsuwanaruk T, Tianwibool P, Laohakul P, Wongtanasarasin W. Symptoms and comorbidities associated with abnormal levels of serum calcium, magnesium, and phosphate in the emergency department: a prospective observational study. World J Emerg Med 2023; 14:59-61. [PMID: 36713345 PMCID: PMC9842460 DOI: 10.5847/wjem.j.1920-8642.2023.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/20/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Korsin Laohavisudhi
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand,Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Borwon Wittayachamnankul
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Boriboon Chenthanakij
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Theerapon Tangsuwanaruk
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Parinya Tianwibool
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Pavita Laohakul
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Wachira Wongtanasarasin
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand,Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California 95817, USA,Corresponding Author: Wachira Wongtanasarasin,
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13
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Affiliation(s)
- William K Silverstein
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Choosing Wisely Canada, Toronto, ON, Canada
| | - Adina S Weinerman
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, Canada
| | - Karen Born
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University Toronto, Toronto, ON, Canada
| | | | - Christopher P Moriates
- Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, USA
- Costs of Care, Boston, MA, USA
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14
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Caruso S, Szoke D, Panteghini M. 'Penelope test': a practical instrument for checking appropriateness of laboratory tests. Clin Chem Lab Med 2022; 60:1342-1349. [PMID: 35785546 DOI: 10.1515/cclm-2022-0368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/22/2022] [Indexed: 11/15/2022]
Abstract
In medical laboratories, the appropriateness challenge directly revolves around the laboratory test and its proper selection, data analysis, and result reporting. However, laboratories have also a role in the appropriate management of those phases of total testing process (TTP) that traditionally are not under their direct control. So that, the laboratory obligation to act along the entire TTP is now widely accepted in order to achieve better care management. Because of the large number of variables involved in the overall TTP structure, it is difficult to monitor appropriateness in real time. However, it is possible to retrospectively reconstruct the body of the clinical process involved in the management of a specific laboratory test to track key passages that may be defective or incomplete in terms of appropriateness. Here we proposed an appropriateness check-list scheme along the TTP chain to be potentially applied to any laboratory test. This scheme consists of a series of questions that healthcare professionals should answer to achieve laboratory test appropriateness. In the system, even a single lacking answer may compromise the integrity of all appropriateness evaluation process as the inability to answer may involve a significant deviation from the optimal trajectory, which compromise the test appropriateness and the quality of subsequent steps. Using two examples of the check-list application, we showed that the proposed instrument may offer an objective help to avoid inappropriate use of laboratory tests in an integrated way involving both laboratory professionals and user clinicians.
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Affiliation(s)
- Simone Caruso
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Dominika Szoke
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Mauro Panteghini
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
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15
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Gabarin N, Trinkaus M, Selby R, Goldberg N, Hanif H, Sholzberg M. Coagulation test understanding and ordering by medical trainees: Novel teaching approach. Res Pract Thromb Haemost 2022; 6:S2475-0379(22)01240-7. [PMID: 35755855 PMCID: PMC9204395 DOI: 10.1002/rth2.12746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/15/2022] [Accepted: 04/05/2022] [Indexed: 11/09/2022] Open
Abstract
Background Coagulation testing provides a prime opportunity to make an impact on the reduction of unnecessary laboratory test ordering, as there are clear indications for testing. Despite the prothrombin time/international normalized ratio and activated partial thromboplastin time being validated for specific clinical indications, they are frequently ordered as screening tests and often ordered together, suggesting a gap in understanding of coagulation. Methods Based on a needs assessment, we developed an online educational module on coagulation for trainees, incorporating education on testing cost, specificity, and sensitivity. Fifty participating resident physicians and medical students completed a validated premodule quiz, postmodule quiz after completion of the module, and a latent quiz 3 to 6 months after to assess longer‐term knowledge retention. Trainees provided responses regarding their subjective laboratory test‐ordering practices before and after module completion. Results The median premodule quiz score was 67% (n = 50; range, 24%‐86%) with an increase of 24% to a median postmodule quiz score of 91% (n = 50; range, 64%‐100%). There was evidence of sustained knowledge acquisition with a latent quiz median score of 89% (n = 40; range, 67%–100%). Trainees were more likely to consider the sensitivity, specificity, and cost of laboratory investigations before ordering them following completion of the educational module. Conclusions Using the expertise of medical educators and incorporating trainee feedback, we employed a novel approach to the teaching of coagulation to maximize its approachability and clinical relevance. We found sustained knowledge retention regarding coagulation and appropriate coagulation test ordering, and a subjective change to trainee ordering habits following participation in our educational intervention.
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Affiliation(s)
- Nadia Gabarin
- Department of Medicine, Michael G. DeGroote School of Medicine McMaster University Hamilton Ontario Canada
| | - Martina Trinkaus
- Department of Medicine St. Michael's Hospital University of Toronto Toronto Ontario Canada.,Division of Hematology, Department of Medicine, St. Michael's Hospital University of Toronto Toronto Ontario Canada
| | - Rita Selby
- Department of Laboratory Medicine & Pathobiology and Department of Medicine University Health Network and Sunnybrook Health Sciences Centre, University of Toronto Toronto Ontario Canada
| | - Nicola Goldberg
- Department of Medicine St. Michael's Hospital University of Toronto Toronto Ontario Canada
| | - Hina Hanif
- Department of Laboratory Medicine & Pathobiology St. Michael's Hospital University of Toronto Toronto Ontario Canada
| | - Michelle Sholzberg
- Department of Medicine St. Michael's Hospital University of Toronto Toronto Ontario Canada.,Division of Hematology, Department of Medicine, St. Michael's Hospital University of Toronto Toronto Ontario Canada.,Department of Laboratory Medicine & Pathobiology St. Michael's Hospital University of Toronto Toronto Ontario Canada
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16
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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.
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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
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17
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Almenar Bonet L, Blasco Peiró MT, Laiz Marro B, Camafort Babkowski M, Buño Soto A, Crespo-Leiro MG. Specific test panels for patients with heart failure: implementation and use in the Spanish National Health System. ADVANCES IN LABORATORY MEDICINE 2022; 3:65-78. [PMID: 37359437 PMCID: PMC10197348 DOI: 10.1515/almed-2022-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/17/2021] [Indexed: 06/28/2023]
Abstract
Objectives The use of specific test panels (STP) for heart failure (HF) could help improve the management of this condition. The purpose of this study is to gain an insight into the level of implementation of STPs in the management of HF in Spain and gather the opinions of experts, with a special focus on parameters related to iron metabolism. Methods The opinions of experts in HF were gathered in three stages STAGE 1 as follows: level of implementation of STPs (n=40). STAGE 2: advantages and disadvantages of STPs (n=12). STAGE 3: level of agreement with the composition of three specific STPs for HF: initial evaluation panel, monitoring panel, and de novo panel (n=16). Results In total, 62.5% of hospitals used STPs for the clinical management of HF, with no association found between the use of STPs and the level of health care (p=0.132) and location of the center (p=0.486) or the availability of a Heart Failure Unit in the center (p=0.737). According to experts, the use of STPs in clinical practice has more advantages than disadvantages (8 vs. 3), with a notable positive impact on diagnostics. Experts gave three motivations and found three limitations to the implementation of STPs. The composition of the three specific STPs for HF was viewed positively by experts. Conclusions Although the experts interviewed advocate the use of diagnostic and monitoring STPs for HF, efforts are still necessary to achieve the standardization and homogenization of test panels for HF in Spanish hospitals.
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Affiliation(s)
- Luis Almenar Bonet
- Unit of Heart Failure and Transplant, Service of Cardiology, University and Polytechnic La Fe Hospital of Valencia, Valencia, Spain
- University of Valencia, Valencia, Spain
- Spanish Network-Center for Cardiovascular Biomedical Research (CIBERCV), Madrid, Spain
| | - Mᵃ Teresa Blasco Peiró
- Unit of Heart Failure and Transplant, Service of Cardiology, Miguel Servet University Hospital, Zaragoza, Spain
- University of Zaragoza, Zaragoza, Spain
| | - Begoña Laiz Marro
- Laboratory Analysis Service, University and Polytechnic La Fe Hospital of Valencia, Valencia, Spain
| | - Miguel Camafort Babkowski
- Service of Internal Medicine, ICMiD, Hospital Clínic, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Antonio Buño Soto
- Laboratory Analysis Service, La Paz University Hospital, Madrid, Spain
| | - Maria Generosa Crespo-Leiro
- Unit of Heart Failure and Heart Transplant, Service of Cardiology, A Coruña Hospital Complex, CHUAC, A Coruña (UDC), Spain
- Biomedical Research Institute of A Coruña (INIBIC), A Coruña, Spain
- University of A Coruña, A Coruña, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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18
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Sri-Ganeshan M, Walker KP, Lines TJ, Neal-Williams TJ, Sheffield ER, Yeoh MJ, Taylor DM. Evaluation of a calcium, magnesium and phosphate clinical ordering tool in the emergency department. Am J Emerg Med 2022; 53:163-167. [DOI: 10.1016/j.ajem.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/22/2021] [Accepted: 01/07/2022] [Indexed: 10/19/2022] Open
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19
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Hueth KD, Prinzi AM, Timbrook TT. Diagnostic Stewardship as a Team Sport: Interdisciplinary Perspectives on Improved Implementation of Interventions and Effect Measurement. Antibiotics (Basel) 2022; 11:antibiotics11020250. [PMID: 35203852 PMCID: PMC8868553 DOI: 10.3390/antibiotics11020250] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/03/2022] [Accepted: 02/11/2022] [Indexed: 02/06/2023] Open
Abstract
Diagnostic stewardship aims to deliver the right test to the right patient at the right time and is optimally combined with antimicrobial stewardship to allow for the right interpretation to translate into the right antimicrobial at the right time. Laboratorians, physicians, pharmacists, and other healthcare providers have an opportunity to improve the effectiveness of diagnostics through collaborative activities around pre-analytical and post-analytical periods of diagnostic testing. Additionally, special considerations should be given to measuring the effectiveness of diagnostics over time. Herein, we perform a narrative review of the literature on these potential optimization opportunities and the temporal factors that can yield changes in diagnostic effectiveness. Our objective is to inform on these considerations to ensure enhanced value through improved implementation and measurement of effectiveness for local stakeholder metrics and/or clinical outcomes research.
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Affiliation(s)
- Kyle D. Hueth
- BioMérieux, Salt Lake City, UT 84104, USA; (K.D.H.); (A.M.P.)
| | | | - Tristan T. Timbrook
- BioMérieux, Salt Lake City, UT 84104, USA; (K.D.H.); (A.M.P.)
- College of Pharmacy, University of Utah, Salt Lake City, UT 84112, USA
- Correspondence:
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20
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Roland K, Yakimec J, Markin T, Chan G, Hudoba M. Customized middleware experience in a tertiary care hospital hematology laboratory. J Pathol Inform 2022; 13:100143. [PMID: 36268082 PMCID: PMC9577123 DOI: 10.1016/j.jpi.2022.100143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/09/2022] [Accepted: 09/21/2022] [Indexed: 11/29/2022] Open
Abstract
Background In the clinical laboratory, middleware is a software application that sits between the analyzer and the laboratory information system (LIS). One of the more common uses of middleware is to perform more efficient result autoverification than can be achieved by the LIS or analyzer alone. In addition to autoverification, middleware can support highly customized rules to handle samples and results from specific patient locations. The objective of this study was to review the impact of customized middleware rules that were designed and implemented in the hematology laboratory of a 1000-bed tertiary care adult academic center hospital. Methods Three novel initiatives using middleware rules to achieve workflow efficiencies were retrospectively reviewed over different audit periods: preliminary neutrophil resulting for oncology patients, microcytosis interpretive comments, and 1 white blood cell differential (WBCD) reported per day. In addition, autoverification rates for complete blood count and differential (CBCD) and coagulation tests were calculated. Results A preliminary neutrophil count was released from middleware on average 64 min before the final CBCD for Leukemia/Bone Marrow Transplant (L/BMT) outpatients, and on average 59 min earlier for oncology patients. Reflexing interpretive comments for select instances of microcytosis removed on average 500 slides per month from technologist review with an estimated cost savings of approximately $3383.33 CAD per month. The 1 WBCD per day rule resulted in a 5.1% cancelation rate, resulting in an estimated monthly cost savings of $943.46 CAD in reagents and technologist time. Finally, middleware rules achieved very high autoverification rates of 97.2% and 88.3% for CBC and CBCD results, respectively. Conclusions Implementation of customized middleware hematology rules in our institution resulted in multiple positive impacts on workflow, achieving high autoverification rates, reduced slide reviews, cost savings, and improved standardization.
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21
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Sun HH, Prunty M, Isali I, Mahran A, Ginsburg K, Markt S, Ponsky L, Calaway A, Bukavina L. Cost of Care in Open Cystectomy Patients Across Time and Space: Does it matter? Bladder Cancer 2021; 7:439-447. [PMID: 38993992 PMCID: PMC11181807 DOI: 10.3233/blc-211580] [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: 06/24/2021] [Accepted: 09/26/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Many variables may affect the cost of open radical cystectomy (RC) care, including surgical approach, diversion type, patient comorbidities, and postoperative complications. OBJECTIVE To determine factors associated with changes in cost of care following open radical cystectomy (ORC) for bladder cancer using the National Inpatient Sample (NIS). METHODS Patients in the NIS with a diagnosis of bladder cancer who underwent ORC with ileal conduit from 2012-2017 using ICD-9-CM and ICD-10-CM codes were identified. Baseline demographics including age, race, region, postoperative complications, and length of stay were obtained. Univariable and multivariable logistic regression were used to identify factors associated with cost variation including demographics, clinical characteristics, surgical factors, and discharge quarter (Q1-Q4). RESULTS 5,189 patients were included in the analysis, with 4,379 at urban teaching hospitals. On multivariable regression analysis, female sex [$1,734 ($1,024-2,444) p < 0.001)], a greater Elixhauser comorbidity score [$93 ($62-124), p < 0.001], presence of any inpatient complication [$1,531 ($894-2,168), p < 0.001], and greater length of stay [$1,665 ($1,536-1,793), p < 0.001] were associated with a greater cost of hospitalization. Discharge in Q3 (July to September) relative to Q2 (April to June) was associated with a higher cost [$1,113 ($292-1,933), p = 0.008. Trends were similar at urban non-teaching and rural hospitals, except discharge quarter was not associated with a significant change in cost. CONCLUSIONS Significant differences in cost of ORC with ileal conduit exist with respect to patient sex, medical comorbidities, and discharge timing. These differences may relate to greater disease burden in female patients, patient complexity, and variation in postoperative care in academic programs.
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Affiliation(s)
- Helen H. Sun
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, USA
| | - Megan Prunty
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, USA
| | - Ilaha Isali
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, USA
| | - Amr Mahran
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, USA
| | - Kevin Ginsburg
- Fox Chase Cancer Center, Department of Surgical Oncology, Division of Urology and Urologic Oncology, Philadelphia, PA, USA
| | - Sarah Markt
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Lee Ponsky
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Adam Calaway
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, USA
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Laura Bukavina
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, USA
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22
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Bradshaw AB, Bonnecaze AK, Burns CA, Beardsley JR. Impact of an Interprofessional Collaborative Quality Improvement Initiative to Decrease Inappropriate Thyroid Function Testing. Hosp Pharm 2021; 56:481-485. [PMID: 34720149 DOI: 10.1177/0018578720920795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Published data show that thyroid function laboratory tests are often ordered inappropriately in the acute care setting, which leads to unnecessary costs and inappropriate therapy decisions. Pilot data at our institution indicated that approximately two-thirds of the thyroid-stimulating hormone (TSH) laboratories were unnecessary, correlating to a potential cost avoidance of more than $20,000 annually. The purpose of this study was to improve the appropriateness of thyroid function test ordering with a multipronged initiative. Methodology: This controlled, single-center, before and after study included inpatients or emergency department (ED) patients at Wake Forest Baptist Medical Center who were at least 18 years of age and had a TSH level ordered during the study period. Patients with a history of thyroid cancer were excluded. The initiative included an electronic ordering intervention, direct education of providers (medical residents, attendings, and clinical pharmacists), and distribution of pocket information cards with appropriate ordering criteria. The primary outcome was the number and percentage of inappropriate TSH tests ordered before and after implementing the 3 interventions. Secondary outcomes included cost savings, inappropriate changes in thyroid therapy based on improperly ordered tests, and the number of free T4 lab tests ordered on patients with a TSH within the therapeutic range. Results: All 3 interventions were implemented, except for education of ED residents and faculty, who chose to forgo the direct education component. Inappropriate ordering of TSH levels decreased from 63 to 50 (13% reduction, P = .062) after implementation. Inappropriate TSH ordering decreased across all services, except in the ED. Inappropriate Free T4 orders decreased from 191 to 133 (30% reduction, P = .01). There were no therapy changes based on inappropriate TSH orders. Extrapolated annual cost savings were approximately $6,000. Conclusion: This multipronged interprofessional collaborative quality improvement initiative was associated with a nonstatistically significant reduction in inappropriate TSH orders, statistically significant reduction in inappropriate free T4 orders, and cost savings. There was a reduction in inappropriate ordering across all services except the ED, which may have been due the ED not participating in the direct education component of the initiative.
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Affiliation(s)
| | | | | | - James R Beardsley
- Wake Forest Baptist Health, Winston-Salem, NC, USA.,Wake Forest School of Medicine, Winston-Salem, NC, USA
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23
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The role of electronic versus written order sets in inappropriate laboratory testing among hospitalized medical patients. Int J Med Inform 2021; 153:104546. [PMID: 34391017 DOI: 10.1016/j.ijmedinf.2021.104546] [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: 04/23/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 11/22/2022]
Abstract
IMPORTANCE Reducing inappropriate blood tests has been highlighted by Choosing Wisely as a key area of focus. Computer physician order entry is one modifiable contributor, but little is known about how computer ordering compares to paper methods when it comes to low-value laboratory testing. OBJECTIVE To determine which method of order entry is associated with a greater amount of appropriate lab testing. Furthermore, to identify ordering patterns for more targeted interventions in future. DESIGN We conducted a retrospective observational cohort study of inpatients discharged at two hospitals (one site uses paper order sets, while the other uses electronic order sets). SETTING General internal medicine wards at two Canadian teaching hospitals. PARTICIPANTS At site 1 (electronic orders), all general internal medicine discharges from May 2015 and February 2016. At site 2 (paper orders), all general internal medicine discharges from April 15, 2015 to May 26, 2015. MAIN OUTCOME(S) AND MEASURE(S) Main outcome was the percentage of inpatient discharges at each site with orders for daily laboratory tests for three days on admission. Secondary measures include proportion of tests with appropriate indications and rates of discontinuation of daily laboratory tests. RESULTS We reviewed 395 discharges with a mean patient age of 69.5 ± 18.9 years and mean length of stay of 12.1 days. Daily laboratory tests were more common with paper orders (site 2) compared to electronic order sets (site 1) for complete blood count (CBC) (90.8% vs. 68.5%, p < 0.001), electrolytes (93.8% vs 71.5%, p < 0.001), and creatinine (93.8% vs 70.0%, p < 0.001) testing. However, paper orders for daily laboratory tests were more often appropriate, both in CBC (76.3% vs. 38.9%, p < 0.001) and electrolyte/creatinine (80.3% vs 44.2%, p < 0.001) testing. Discontinuation of daily labs occurred more often with paper orders (35.4% vs. 6.7%, p < 0.001). CONCLUSIONS AND RELEVANCE Compared to written orders, daily laboratory testing using electronic ordering was associated with higher rates of inappropriate indications and lower rates of discontinuation. Our results support interventions aimed at ensuring electronic order sets incorporate appropriate indications and a mechanism for discontinuation of daily lab orders. Further studies aimed at understanding how the process of completing paper or electronic orders influence appropriateness of daily laboratory orders are needed to further minimize inappropriate testing.
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24
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Conroy M, Homsy E, Johns J, Patterson K, Singha A, Story R, Finnegan G, Shively K, Faherty K, Gephart M, Cape K, Exline MC, Ali N, Besecker B. Reducing Unnecessary Laboratory Utilization in the Medical ICU: A Fellow-Driven Quality Improvement Initiative. Crit Care Explor 2021; 3:e0499. [PMID: 34345825 PMCID: PMC8322547 DOI: 10.1097/cce.0000000000000499] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES: Overutilization of laboratory services is now recognized as harmful to patients and wasteful. In fact, the American Board of Internal Medicine’s Choosing Wisely campaign recommends against ordering routine testing that does not answer a clinical question. Per peer benchmarking, our institution as a whole occupied an extreme outlier position at the 100th percentile for laboratory utilization. We sought to address this problem starting in our medical ICUs with a quality improvement project. DESIGN: Quality improvement project using the design, measure, analyze, improve, and control process. The primary endpoint was a sustained reduction in laboratory utilization. Counterbalance metrics were also followed, and these included mortality, renal replacement therapy initiation rates, stat laboratory orders, and central catheter–associated blood stream infections. SETTING: The medical ICU at the Ohio State University Medical Center. PATIENTS: All patients admitted to the medical ICU from March 2019 to March 2020. INTERVENTIONS: Root causes were identified and addressed with the implementation of a wide range of interventions involving a multidisciplinary team led by trainee physicians. MEASUREMENTS AND MAIN RESULTS: There was a sustained 20% reduction in the number of tests performed per patient day, with no change in the counterbalance metrics. CONCLUSIONS: Trainees can affect positive change in the culture and processes at their institutions to safely reduce laboratory utilization.
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Affiliation(s)
- Megan Conroy
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Elie Homsy
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jennica Johns
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kevin Patterson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Arindam Singha
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ryan Story
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Geoffrey Finnegan
- Cancer Analytics, James Cancer Center and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kevin Shively
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kathrine Faherty
- Department of Critical Care Nursing, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Matthew Gephart
- Department of Critical Care Nursing, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kari Cape
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Matthew C Exline
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Naeem Ali
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Beth Besecker
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
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Ramazani SN, Gottfried JA, Kaissi M, Lynn J, Leonard MS, Schriefer J, Bayer ND. Improving the Timing of Laboratory Studies in Hospitalized Children: A Quality Improvement Study. Hosp Pediatr 2021; 11:670-678. [PMID: 34158310 DOI: 10.1542/hpeds.2020-005793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES For hospitalized children and their families, laboratory study collection at night and in the early morning interrupts sleep and increases the stress of a hospitalization. To change this practice, our quality improvement (QI) study developed a rounding checklist aimed at increasing the percentage of routine laboratory studies ordered for and collected after 7 am. METHODS Our QI study was conducted on the pediatric hospital medicine service at a single-site urban children's hospital over 28 months. Medical records from 420 randomly selected pediatric inpatients were abstracted, and 5 plan-do-study-act cycles were implemented during the intervention. Outcome measures included the percentage of routine laboratory studies ordered for and collected after 7 am. The process measure was use of the rounding checklist. Run charts were used for analysis. RESULTS The percentage of laboratory studies ordered for after 7 am increased from a baseline median of 25.8% to a postintervention median of 75.0%, exceeding our goal of 50% and revealing special cause variation. In addition, the percentage of laboratory studies collected after 7 am increased from a baseline median of 37.1% to 76.4% post intervention, with special cause variation observed. CONCLUSIONS By implementing a rounding checklist, our QI study successfully increased the percentage of laboratory studies ordered for and collected after 7 am and could serve as a model for other health care systems to impact provider ordering practices and behavior. In future initiatives, investigators should evaluate the effects of similar interventions on caregiver and provider perceptions of patient- and family-centeredness, satisfaction, and the quality of patient care.
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Affiliation(s)
| | | | - Maha Kaissi
- Department of Pediatrics, Golisano Children's Hospital
| | - Justin Lynn
- Department of Pediatrics, Golisano Children's Hospital
| | - Michael S Leonard
- Department of Pediatrics, Golisano Children's Hospital.,Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Jan Schriefer
- Department of Pediatrics, Golisano Children's Hospital
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Adhikari AN, Beck MD, Wykes JJ, Ashford BG. Targeted ordering of investigations reduces costs of treatment for surgical inpatients. Int J Qual Health Care 2021; 33:6275450. [PMID: 33987666 DOI: 10.1093/intqhc/mzab083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 04/25/2021] [Accepted: 05/13/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Laboratory testing forms an important part of diagnostic investigation in modern medicine; however, the overuse of 'routine blood tests' can result in significant potential harm and financial cost to the patient and the healthcare system. In 2018, a new protocol targeting the ordering of investigations was implemented within the General Surgical Teams of Wollongong Hospital in New South Wales, an Australian tertiary referral hospital, to reduce the number of 'routine blood tests' as a quality improvement initiative. OBJECTIVE To identify whether there was a reduction in the number of 'routine blood tests' and associated costs following implementation of the new protocol. METHODS The protocol involved regular review of the laboratory investigations being ordered for the following day with a senior team member. The medical records of all patients admitted under the general surgery service at Wollongong Hospital were retrospectively reviewed over two 10-week periods in 2017 and 2018 (control and study, respectively). The casemix was categorized into Minor, Intermediate, Major or Unscored, depending on case complexity coding. RESULTS A total of 838 patients were identified during the control period (2017) and 805 patients were identified during the study period (2018). Ten thousand and thirty tests were included in the control period, compared to 8610 over the study period, resulting in a 16% (or greater) reduction in 'routine blood tests' per patient, per day of admission and a 6% reduction in costs in the study group (P < 0.001). CONCLUSION Targeted ordering of investigations with personalized education and feedback to junior staff during review of clinical status of each patient as a part of normal workflow can reduce inappropriate ordering of 'routine blood tests' and associated costs to the patient and the healthcare system.
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Affiliation(s)
- Ashim Nath Adhikari
- Department of Surgery, Wollongong Public Hospital, 252 Loftus Street, Wollongong, NSW 2500, Australia
| | - Matthew Dylan Beck
- Department of Surgery, Wollongong Public Hospital, 252 Loftus Street, Wollongong, NSW 2500, Australia
| | - James Justin Wykes
- Department of Surgery, Wollongong Public Hospital, 252 Loftus Street, Wollongong, NSW 2500, Australia
| | - Bruce Graham Ashford
- Department of Surgery, Wollongong Public Hospital, 252 Loftus Street, Wollongong, NSW 2500, Australia.,Department of Surgery, University of Wollongong, Northfields Avenue, Wollongong, NSW 2522, Australia
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Financial Incentives to Enhance Participation of Resident Physicians in Hospital-Based Quality Improvement Projects. Jt Comm J Qual Patient Saf 2021; 47:545-555. [PMID: 34023276 DOI: 10.1016/j.jcjq.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 03/18/2021] [Accepted: 04/15/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Methods to promote successful trainee participation in quality improvement projects are poorly studied. This project studied the effects of a trainee pay-for-performance program and quality improvement education at a safety-net hospital. METHODS In this program, trainees worked with quality improvement faculty, participated in projects aligned with the hospital's priorities, and designed their program-specific project. Each trainee who worked at least 88 days in the institution was eligible to earn $400 for every target achieved for at least six months (maximum of $1,200). RESULTS Among hospitalwide goals, needlestick injuries per quarter decreased from [mean (standard deviation; SD)] 18 (4.6) to 12 (2.6), 95% confidence interval (CI) = -10.1-1.9, p = 0.02; percentage of excellent provider communication improved from 76.8% to [mean (SD)] 80.5% (2.9), 95% CI = 0.8-8.3, p = 0.08; and mean length of stay for discharged emergency department patients requiring specialist consultation decreased from [mean (SD)] 523 (120) to 461 (40) minutes, 95% CI = -162-37.2, p = 0.11. Among resident-initiated projects, the percentage of Family Medicine patients undergoing colorectal screening increased from 65.1% to [mean (SD)] 67.7% (0.4), 95% CI = 1.7-3.5, p = 0.01; percentage of at-risk patients receiving naloxone at hospital discharge increased from 9% to [mean (SD)] 63% (7.2), 95% CI = 36.1-71.9, p = 0.01; percentage of adolescents screened for chlamydia increased from 34% to [mean (SD)] 55.8% (6.4), 95% CI = 5.9-37.6, p = 0.03; and percentage of high-dose opioid prescriptions following cesarean section decreased from 28% to [mean (SD)] 1.7% (2.9), 95% CI = -33.5 to -19.2, p = 0.001. Eleven of 14 programs achieved three goals. All resident-led goals were met. CONCLUSION A pay-for-performance improvement program that aligns educational and hospital priorities can provide meaningful experiential learning for trainees and improve patient care.
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Abstract
Objective To reduce diagnostic blood loss by using small volume tubes for routine laboratory testing throughout the hospital, as blood loss from laboratory testing can be substantial for patients and may lead to hospital-acquired anemia. Patients and Methods Diagnostic blood loss was evaluated in hospitalized patients between April 1, 2017, and June 1, 2018. The preintervention, during intervention, and postintervention mean diagnostic blood loss per hospitalized patient was compared across the floors and for each type of tube for hematology, basic metabolic panel, and coagulation tests. Mean hemoglobin levels, blood transfusions per hospitalized patient, and percent redraws were also compared. Results The total volume of blood drawn for all the 3 tests decreased across each implementation phase; however, only patients admitted to the transplant and critical care (T/CC) units had increased hemoglobin levels. In addition, there was a significant reduction in transfusions across implementation phases. The incidence risk ratio for transfusion reduced even more in patients admitted to the T/CC units. Finally, there was no significant difference in the overall percent redraws across all the units. Conclusion The use of small volume tubes in exchange for standard sized tubes markedly decreased diagnostic blood loss by 25.7% in all the units and 22.9% in the T/CC units. Also, the number of transfusions decreased across units, with the greatest decrease in the T/CC units. An increase in mean hemoglobin levels was observed specifically in patients admitted to the T/CC units, with no corresponding change in percent redraws across all the units.
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Jutras C, Charlier J, François T, Du Pont-Thibodeau G. <p>Anemia in Pediatric Critical Care</p>. INTERNATIONAL JOURNAL OF CLINICAL TRANSFUSION MEDICINE 2020. [DOI: 10.2147/ijctm.s229764] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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Tapaskar N, Kilaru M, Puri TS, Martin SK, Edstrom E, Leung E, Ahmed F, Kondo R, Norenberg A, Poli E, Arora VM. Evaluation of the Order SMARTT: An Initiative to Reduce Phlebotomy and Improve Sleep-Friendly Labs on General Medicine Services. J Hosp Med 2020; 15:479-482. [PMID: 32804609 PMCID: PMC7518135 DOI: 10.12788/jhm.3423] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 03/28/2020] [Indexed: 11/20/2022]
Abstract
We assessed the effectiveness of a quality improvement project to reduce routine labs in clinically stable patients, while also promoting sleep-friendly lab timing. The electronic health record was modified with an "Order Sleep" shortcut to facilitate sleep-friendly lab draws. A "4 AM Labs" column was added to electronic patient lists to signal which patients had early morning labs ordered. Among 7,045 patients over 50,951 total patient-days, on average we observed 26.3% fewer routine lab draws per patient-day per week postintervention (4.68 before vs 3.45 after; difference, 1.23; 95% CI, 0.82-1.63; P < .05). In interrupted time series analysis, the "Order Sleep" tool was associated with a significant increase in sleep-friendly lab orders per encounter per week on resident medicine services (intercept, 1.03; standard error (SE), 0.29; P < .001). The "4 AM Labs" column was associated with a significant increase in sleep-friendly lab orders per patient encounter per week on the hospitalist medical service (intercept, 1.17; SE, 0.50; P = .02). We demonstrate the success of an initiative to simultaneously reduce daily labs and improve sleep-friendly ordering.
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Affiliation(s)
- Natalie Tapaskar
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Megha Kilaru
- Center for Healthcare Delivery Science and Innovation, University of Chicago Medicine, Chicago, Illinois
| | - Tipu S Puri
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Shannon K Martin
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Eve Edstrom
- Center for Healthcare Delivery Science and Innovation, University of Chicago Medicine, Chicago, Illinois
| | - Edward Leung
- Department of Pathology and Laboratory Medicine, Children's Hospital of Los Angeles, Los Angeles, California
| | - Farah Ahmed
- Center for Healthcare Delivery Science and Innovation, University of Chicago Medicine, Chicago, Illinois
| | - Ryuhei Kondo
- Booth School of Business, University of Chicago, Chicago, Illinois
| | | | - Elizabeth Poli
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Vineet M Arora
- Department of Medicine, University of Chicago, Chicago, Illinois
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Ko SQ, Quah P, Lahiri M. The cost of repetitive laboratory testing for chronic disease. Intern Med J 2020; 49:1168-1170. [PMID: 31507043 DOI: 10.1111/imj.14428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/15/2018] [Accepted: 11/20/2018] [Indexed: 11/28/2022]
Abstract
Interval laboratory investigations are necessary for monitoring chronic diseases. However, testing too frequently may not be beneficial clinically and can be considered low-value care. We examined the frequency of glycosylated haemoglobin, lipids, iron panels (serum iron, ferritin, transferrin, iron binding) thyroid function (free T4 and thyroid stimulating hormone) and 25-OH vitamin D tests in a 1290-bed tertiary hospital in Singapore. All tests done over a 20-month period (January 2016 to August 2017) were retrieved from the laboratory database. Of the 275 565 tests done for 115 971 patients, 5.2% were repeat tests done at intervals shorter than the minimum retesting interval, as defined by the Royal College of Pathologist and Irish Guidelines on the Use of the Laboratory. Using the Centers for Medicare and Medicaid Services Clinical Laboratory Fee Schedule, we estimated a cost burden of US$222 096 per year. Strategies to reduce unnecessary repetitive testing can result in significant cost savings.
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Affiliation(s)
- Stephanie Q Ko
- Department of Medicine, National University Health Systems, Singapore
| | - Pipetius Quah
- Department of Medicine, National University Health Systems, Singapore
| | - Manjari Lahiri
- Department of Medicine, National University Health Systems, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Ambasta A, Ma IWY, Woo S, Lonergan K, Mackay E, Williamson T. Impact of an education and multilevel social comparison–based intervention bundle on use of routine blood tests in hospitalised patients at an academic tertiary care hospital: a controlled pre-intervention post-intervention study. BMJ Qual Saf 2020; 29:1-2. [DOI: 10.1136/bmjqs-2019-010118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 01/16/2020] [Accepted: 01/26/2020] [Indexed: 11/03/2022]
Abstract
BackgroundRepetitive inpatient laboratory testing contributes to waste in healthcare. We evaluated an intervention bundle combining education and multilevel social comparison feedback to safely reduce repetitive use of inpatient routine laboratory tests.MethodsThis non-randomised controlled pre-intervention post-intervention study was conducted in four adult hospitals from October 2016 to March 2018. In the medical teaching unit (MTU) of the intervention site, learners received education and aggregate social comparison feedback and attending internists received individual comparison feedback on routine laboratory test utilisation. MTUs of the remaining three sites served as control units. Number and cost of routine laboratory tests ordered per patient-day before and after the intervention was compared with the control units, adjusting for patient factors. Safety endpoints included number of critically abnormal laboratory test results, number of stat laboratory test orders, patient length of stay, transfer rate to the ICU, and 30-day readmission and mortality.ResultsA total of 14 000 patients were included. Pre-intervention and post-intervention groups were similar in age, sex, Charlson Comorbidity Index and length of stay. From the pre-intervention period to the post-intervention period, significantly fewer routine laboratory tests were ordered at the intervention MTU (incidence rate ratio=0.89; 95% CI 0.79 to 1.00; p=0.048) with associated costs savings of $C68 877 (p=0.020) as compared with the control sites. The variability in the ordering pattern of internists at the intervention site also decreased post-intervention. No worsening was noted in the safety endpoints between the pre-intervention and post-intervention period at the intervention unit compared with the controls.ConclusionsCombination of education and multilevel social comparison feedback significantly and safely led to cost savings through reduced use of routine laboratory tests in hospitalised patients.
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Lee B, Hershey D, Patel A, Pierce H, Rhee KE, Fisher E. Reducing Unnecessary Testing in Uncomplicated Skin and Soft Tissue Infections: A Quality Improvement Approach. Hosp Pediatr 2020; 10:129-137. [PMID: 31941651 DOI: 10.1542/hpeds.2019-0179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Skin and soft tissue infections are common pediatric diagnoses with substantial costs. Recent studies suggest blood cultures are not useful in management of uncomplicated skin and soft tissue infections (uSSTIs). Complete blood cell count, erythrocyte sedimentation rate, and C-reactive protein are also of questionable value. We aimed to decrease these tests by 25% for patients with uSSTIs admitted to the pediatric hospital medicine service within 3 months. METHODS An interdisciplinary team led a quality improvement (QI) project. Baseline assessment included review of the literature and 12 months of medical records. Key stakeholders identified drivers that informed the creation of an electronic order set and development of a pediatric hospital medicine-emergency department collaborative QI project. The primary outcome measure was mean number of tests per patient encounter. Balancing measures included unplanned readmissions and missed diagnoses. RESULTS Our baseline-year rate was 3.4 tests per patient encounter (573 tests and 169 patient encounters). During the intervention year, the rate decreased by 35% to 2.2 tests per patient encounter (286 tests and 130 patient encounters) and was sustained for 14 months postintervention. There were no unplanned readmissions or missed diagnoses for the study period. Order set adherence was 80% (83 out of 104) during the intervention period and sustained at 87% postintervention. CONCLUSIONS Our interdisciplinary team achieved our aim, reducing unnecessary laboratory testing in patients with an uSSTI without patient harm. Awareness of local culture, creation of an order set, defining appropriate patient selection and testing indications, and implementation of a collaborative QI project helped us achieve our aim.
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Affiliation(s)
- Begem Lee
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Daniel Hershey
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Aarti Patel
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Heather Pierce
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Kyung E Rhee
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Erin Fisher
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
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Ducatman BS, Ducatman AM, Crawford JM, Laposata M, Sanfilippo F. The Value Proposition for Pathologists: A Population Health Approach. Acad Pathol 2020; 7:2374289519898857. [PMID: 31984223 PMCID: PMC6961144 DOI: 10.1177/2374289519898857] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/11/2019] [Accepted: 12/04/2019] [Indexed: 01/09/2023] Open
Abstract
The transition to a value-based payment system offers pathologists the opportunity to play an increased role in population health by improving outcomes and safety as well as reducing costs. Although laboratory testing itself accounts for a small portion of health-care spending, laboratory data have significant downstream effects in patient management as well as diagnosis. Pathologists currently are heavily engaged in precision medicine, use of laboratory and pathology test results (including autopsy data) to reduce diagnostic errors, and play leading roles in diagnostic management teams. Additionally, pathologists can use aggregate laboratory data to monitor the health of populations and improve health-care outcomes for both individual patients and populations. For the profession to thrive, pathologists will need to focus on extending their roles outside the laboratory beyond the traditional role in the analytic phase of testing. This should include leadership in ensuring correct ordering and interpretation of laboratory testing and leadership in population health programs. Pathologists in training will need to learn key concepts in informatics and data analytics, health-care economics, public health, implementation science, and health systems science. While these changes may reduce reimbursement for the traditional activities of pathologists, new opportunities arise for value creation and new compensation models. This report reviews these opportunities for pathologist leadership in utilization management, precision medicine, reducing diagnostic errors, and improving health-care outcomes.
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Affiliation(s)
- Barbara S. Ducatman
- Department of Pathology, Beaumont Health, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI,
USA
| | - Alan M. Ducatman
- Department of Occupational and Environmental Health Sciences, West Virginia
University School of Public Health, Morgantown, WV, USA
| | - James M. Crawford
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker
School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Michael Laposata
- Department of Pathology, University of Texas Medical Branch, Galveston, TX,
USA
| | - Fred Sanfilippo
- Department of Pathology and Laboratory Medicine, Emory University School of
Medicine, Atlanta, GA, USA
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Boulet L, Vermeulin T, Vasiliu A, Gillibert A, Lottin M, Frébourg N, Boyer S, Merle V. Lack of effect of a poster-based intervention to reduce the number of blood culture samples collected. Med Mal Infect 2019; 50:78-82. [PMID: 31640881 DOI: 10.1016/j.medmal.2019.09.017] [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: 02/16/2019] [Accepted: 09/24/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To reduce the number of blood culture samples collected. PATIENTS AND METHOD We performed a cluster randomized controlled trial in adult acute care, and subacute care and rehabilitation wards in a university hospital in France. A poster associating an image of eyes looking at the reader with a summary of blood culture sampling guidelines was displayed in hospital wards in the intervention group. The incidence rate of blood cultures per 1000 days during pre- and post-intervention periods was calculated. RESULTS Thirty-one wards participated in the study. The median difference in blood cultures/1000 days between periods was -1.863 [-11.941; 1.007] in the intervention group and -5.824 [-14.763; -2.217] in the control group (P=0.27). CONCLUSION The intervention did not show the expected effect, possibly due to the choice of blood cultures as a target of good practice, but also to confounding factors such as the stringent policy of decreasing unnecessary costly testing.
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Affiliation(s)
- L Boulet
- Hospital Infection Control and Epidemiology Department, Rouen University Hospital, 76000 Rouen, France.
| | - T Vermeulin
- Clinique Mathilde, Department of Medical Information, 76000 Rouen, France
| | - A Vasiliu
- Hospital Infection Control and Epidemiology Department, Rouen University Hospital, 76000 Rouen, France
| | - A Gillibert
- Unit of Biostatistics, Rouen University Hospital, 76000 Rouen, France
| | - M Lottin
- Healthcare Associated Risk Department, Rouen University Hospital, 76000 Rouen, France
| | - N Frébourg
- Department of Microbiology, Rouen University Hospital, 76000 Rouen, France
| | - S Boyer
- Department of Microbiology, Rouen University Hospital, 76000 Rouen, France
| | - V Merle
- Hospital Infection Control and Epidemiology Department, Rouen University Hospital, 76000 Rouen, France; Dynamiques et Évènements des Soins et des Parcours research group, Rouen University Hospital, 76000 Rouen, France
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Hermes Tacker D. Clinical Utility and Performance in Test Utilization Interventions for Paraneoplastic Antibody Panel Orders: A Delicate Balance. J Appl Lab Med 2019; 4:4-6. [PMID: 31639701 DOI: 10.1373/jalm.2019.029165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 03/20/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Danyel Hermes Tacker
- Department of Pathology, Anatomy, and Laboratory Medicine (PALM), West Virginia University, Morgantown, WV.
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37
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Harb R, Hajdasz D, Landry ML, Sussman LS. Improving laboratory test utilisation at the multihospital Yale New Haven Health System. BMJ Open Qual 2019; 8:e000689. [PMID: 31637323 PMCID: PMC6768328 DOI: 10.1136/bmjoq-2019-000689] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/26/2019] [Accepted: 08/20/2019] [Indexed: 02/05/2023] Open
Abstract
Background Waste persists in healthcare and negatively impacts patients. Clinicians have direct control over test ordering and ongoing international efforts to improve test utilisation have identified multifaceted approaches as critical to the success of interventions. Prior to 2015, Yale New Haven Health lacked a coherent strategy for laboratory test utilisation management. Methods In 2015, a system-wide laboratory formulary committee was formed at Yale New Haven Health to manage multiple interventions designed to improve test utilisation. We report here on specific interventions conducted between 2015 and 2017 including reduction of (1) obsolete or misused testing, (2) duplicate orders, and (3) daily routine lab testing. These interventions were driven by a combination of modifications to computerised physician order entry, test utilisation dashboards and physician education. Measurements included test order volume, blood savings and cost savings. Results Testing for a number of obsolete/misused analytes was eliminated or significantly decreased depending on alert rule at order entry. Hard stops significantly decreased duplicate testing and educational sessions significantly decreased daily orders of routine labs and increased blood savings but the impact waned over time for select groups. In total, we realised approximately $100 000 of cost savings during the study period. Conclusion Through a multifaceted approach to utilisation management, we show significant reductions in low-value clinical testing that have led to modest but significant savings in both costs and patients’ blood.
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Affiliation(s)
- Roa Harb
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - David Hajdasz
- Clinical Redesign, Office of Strategy Management, Yale New Haven Health System, New Haven, Connecticut, USA
| | - Marie L Landry
- Departments of Laboratory Medicine and Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - L Scott Sussman
- Clinical Redesign, Department of Medicine, Yale New Haven Health System, New Haven, Connecticut, USA
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Meidani Z, Mousavi GA, Kheirkhah D, Benar N, Maleki MR, Sharifi M, Farrokhian A. Going beyond audit and feedback: towards behaviour-based interventions to change physician laboratory test ordering behaviour. J R Coll Physicians Edinb 2019. [PMID: 29537404 DOI: 10.4997/jrcpe.2017.407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Studies indicate there are a variety of contributing factors affecting physician test ordering behaviour. Identifying these behaviours allows development of behaviour-based interventions. Methods Through a pilot study, the list of contributing factors in laboratory tests ordering, and the most ordered tests, were identified, and given to 50 medical students, interns, residents and paediatricians in questionnaire form. The results showed routine tests and peer or supervisor pressure as the most influential factors affecting physician ordering behaviour. An audit and feedback mechanism was selected as an appropriate intervention to improve physician ordering behaviour. The intervention was carried out at two intervals over a three-month period. Findings There was a large reduction in the number of laboratory tests ordered; from 908 before intervention to 389 and 361 after first and second intervention, respectively. There was a significant relationship between audit and feedback and the meaningful reduction of 7 out of 15 laboratory tests including complete blood count (p = 0.002), erythrocyte sedimentation rate (p = 0.01), C-reactive protein (p = 0.01), venous blood gas (p = 0.016), urine analysis (p = 0.005), blood culture (p = 0.045) and stool examination (p = 0.001). Conclusion The audit and feedback intervention, even in short duration, affects physician ordering behaviour. It should be designed in terms of behaviour-based intervention and diagnosis of the contributing factors in physicians' behaviour. Further studies are required to substantiate the effectiveness of such behaviour-based intervention strategies in changing physician behaviour.
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Affiliation(s)
- Z Meidani
- D Kheirkhah, Infectious Diseases Research Centre, Kashan University of Medical Sciences, Kashan, Iran.
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Amin RM, Loeb AE, Hasenboehler EA, Levin AS, Osgood GM, Sterling RS, Stahel PF, Shafiq B. Reducing routine laboratory tests in patients with isolated extremity fractures: a prospective safety and feasibility study in 246 patients. Patient Saf Surg 2019; 13:22. [PMID: 31249624 PMCID: PMC6570870 DOI: 10.1186/s13037-019-0203-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/04/2019] [Indexed: 11/10/2022] Open
Abstract
Background Daily routine laboratory testing is unnecessary in most admitted patients. The opportunity to reduce daily laboratory testing in orthopaedic trauma patients has not been previously investigated. Methods A prospective observational study was performed based on a new laboratory testing reduction protocol for 12 months at two tertiary care trauma centers. Admitted patients with surgically treated isolated upper or lower extremity fractures were included (n = 246). The testing protocol consisted of a complete blood count (CBC) and basic metabolic panel (BMP) on postoperative day 2. Thereafter, tests were obtained at individual providers' discretion. Patients were followed for 30 days postoperatively. The primary outcome was number of laboratory tests reduced. Secondary outcomes included provider protocol compliance, and adverse patient outcomes. Chi-squared tests were used to compare differences in categorical variables among the cohorts. Analysis of variance tests were used for continuous variables. The relative reductions in testing utilization were calculated using our division's standard-of-care before program implementation (1 CBC and 1 BMP per patient per inpatient day). Significance was defined as P < 0.05. Results Of the 246 patients, there were 45 protocol fall outs due to provider deviation (n = 24) or medically justified necessity for additional testing (n = 21). Across all groups, a total of 778 CBC or BMP tests were avoided, amounting to a 69% reduction in testing compared to the pre-implementation baseline. Ninety-five percent of protocol group patients were safely discharged either without laboratory testing or with one set of tests obtained on postoperative day 2. There were no 30-day readmissions or reported complications associated with the new laboratory testing protocol. Conclusions In patients with surgically treated fractures about the elbow and knee, obtaining a single set of laboratory tests on postoperative day 2 is safe and efficacious in terms of reducing inappropriate resource utilization. Trial registration retrospectively registered.
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Affiliation(s)
- Raj M Amin
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
| | - Alexander E Loeb
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
| | - Erik A Hasenboehler
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
| | - Adam S Levin
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
| | - Greg M Osgood
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
| | - Robert S Sterling
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
| | - Philip F Stahel
- 2Department of Specialty Medicine, Rocky Vista University College of Osteopathic Medicine, 777 Bannock St., Denver, CO 80204 Parker USA
| | - Babar Shafiq
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
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Date PA, Smith JL, Spencer WS, de Tonnerre EJ, Yeoh MJ, Taylor DM. Utility of calcium, magnesium and phosphate testing in the emergency department. Emerg Med Australas 2019; 32:39-44. [PMID: 31155837 DOI: 10.1111/1742-6723.13332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/14/2019] [Accepted: 05/15/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine how frequently calcium (Ca), magnesium (Mg) and phosphate (PO4 ) tests change ED patient management. METHODS We undertook a retrospective observational study in an Australian tertiary referral ED. We enrolled adult patients (aged ≥18 years) who presented between 1 January and 30 June 2017 and who had a serum Ca, Mg or PO4 test ordered and completed during their ED stay. Patient symptoms, medical history, electrolyte levels and ED management changes were extracted from the electronic medical record. RESULTS Of the 33 120 adults presented during the study period, 1716 (5.2%, 95% confidence interval [CI] 5.0-5.4) had at least one Ca, Mg or PO4 test completed in the ED. This included 4776 individual electrolyte tests, of which 776 (16.2%, 95% CI 15.2-17.3) were abnormal. Fifty-six (7.2% [95% CI 5.5-9.3] of patients with abnormal tests, 1.2% [95% CI 0.9-1.5] of all tests) tests were associated with a change in ED management. Twenty-six out of 1683 (1.5%) Ca levels were low with six (23.1%) management changes; 203 (12.1%) were high with 10 (4.9%) management changes. One hundred and twenty-eight out of 1579 (8.1%) Mg levels were low with 33 (25.8%) management changes; 30 (1.9%) were high with no management changes. Two hundred and twenty-five out of 1514 (14.9%) PO4 levels were low with six (2.7%) management changes; 164 (10.8%) were high with one (0.6%) management change. Fifty (2.9%) patients had management changes despite normal electrolyte levels. CONCLUSION Ca, Mg and PO4 testing is common. However, the yield of clinically significant abnormal levels is low and patient management is rarely changed. Testing of these electrolytes needs to be rationalised.
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Affiliation(s)
| | | | | | - Erik J de Tonnerre
- Northern Sydney Local Health District, NSW Health, Sydney, New South Wales, Australia
| | - Michael J Yeoh
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia
| | - David McD Taylor
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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Appropriate use of laboratory test requests in the emergency department: a multilevel intervention. Eur J Emerg Med 2019; 26:205-211. [DOI: 10.1097/mej.0000000000000518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Faria DK, Taniguchi LU, Fonseca LAM, Ferreira-Junior M, Aguiar FJB, Lichtenstein A, Sumita NM, Duarte AJS, Sales MM. Improving serum calcium test ordering according to a decision algorithm. Clin Mol Pathol 2019; 72:232-236. [DOI: 10.1136/jclinpath-2018-205026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/09/2018] [Accepted: 03/20/2018] [Indexed: 11/04/2022]
Abstract
AimTo detect differences in the pattern of serum calcium tests ordering before and after the implementation of a decision algorithm.MethodsWe studied patients admitted to an internal medicine ward of a university hospital on April 2013 and April 2016. Patients were classified as critical or non-critical on the day when each test was performed. Adequacy of ordering was defined according to adherence to a decision algorithm implemented in 2014.ResultsTotal and ionised calcium tests per patient-day of hospitalisation significantly decreased after the algorithm implementation; and duplication of tests (total and ionised calcium measured in the same blood sample) was reduced by 49%. Overall adequacy of ionised calcium determinations increased by 23% (P=0.0001) due to the increase in the adequacy of ionised calcium ordering in non-critical conditions.ConclusionsA decision algorithm can be a useful educational tool to improve adequacy of the process of ordering serum calcium tests.
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Effect of Clinical Decision Support on Appropriateness of Advanced Imaging Use Among Physicians-in-Training. AJR Am J Roentgenol 2019; 212:859-866. [PMID: 30779671 DOI: 10.2214/ajr.18.19931] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Clinical decision support (CDS) tools have been shown to reduce inappropriate imaging orders. We hypothesized that CDS may be especially effective for house staff physicians who are prone to overuse of resources. MATERIALS AND METHODS Our hospital implemented CDS for CT and MRI orders in the emergency department with scores based on the American College of Radiology's Appropriateness Criteria (range, 1-9; higher scores represent more-appropriate orders). Data on CT and MRI orders from April 2013 through June 2016 were categorized as pre-CDS or baseline, post-CDS period 1 (i.e., intervention with active feedback for scores of ≤ 4), and post-CDS period 2 (i.e., intervention with active feedback for scores of ≤ 6). Segmented regression analysis with interrupted time series data estimated changes in scores stratified by house staff and non-house staff. Generalized linear models further estimated the modifying effect of the house staff variable. RESULTS Mean scores were 6.2, 6.2, and 6.7 in the pre-CDS, post-CDS 1, and post-CDS 2 periods, respectively (p < 0.05). In the segmented regression analysis, mean scores significantly (p < 0.05) increased when comparing pre-CDS versus post-CDS 2 periods for both house staff (baseline increase, 0.41; 95% CI, 0.17-0.64) and non-house staff (baseline increase, 0.58; 95% CI, 0.34-0.81), showing no differences in effect between the cohorts. The generalized linear model showed significantly higher scores, particularly in the post-CDS 2 period compared with the pre-CDS period (0.44 increase in scores; p < 0.05). The house staff variable did not significantly change estimates in the post-CDS 2 period. CONCLUSION Implementation of active CDS increased overall scores of CT and MRI orders. However, there was no significant difference in effect on scores between house staff and non-house staff.
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AI-Driven Pathology Laboratory Utilization Management via Data- and Knowledge-Based Analytics. Artif Intell Med 2019. [DOI: 10.1007/978-3-030-21642-9_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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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.
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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
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Bindraban RS, Ten Berg MJ, Naaktgeboren CA, Kramer MHH, Van Solinge WW, Nanayakkara PWB. Reducing Test Utilization in Hospital Settings: A Narrative Review. Ann Lab Med 2018; 38:402-412. [PMID: 29797809 PMCID: PMC5973913 DOI: 10.3343/alm.2018.38.5.402] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/23/2018] [Accepted: 05/06/2018] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Renuka S Bindraban
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands.,Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Maarten J Ten Berg
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christiana A Naaktgeboren
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark H H Kramer
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Wouter W Van Solinge
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Prabath W B Nanayakkara
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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Ziemba YC, Lomsadze L, Jacobs Y, Chang TY, Haghi N. Using Heatmaps to Identify Opportunities for Optimization of Test Utilization and Care Delivery. J Pathol Inform 2018; 9:31. [PMID: 30294500 PMCID: PMC6166481 DOI: 10.4103/jpi.jpi_7_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 08/07/2018] [Indexed: 11/21/2022] Open
Abstract
Background: When a provider orders a test in a pattern that is substantially different than their peers, it may indicate confusion in the test name or inappropriate use of the test, which can be elucidated by initiating dialog between clinicians and the laboratory. However, the analysis of ordering patterns can be challenging. We propose a utilization index (UI) as a means to quantify utilization patterns for individual providers and demonstrate the use of heatmaps to identify opportunities for improvement. Materials and Methods: Laboratory test orders by all providers were extracted from the laboratory information system. Providers were grouped into cohorts based on the specialty and patient population. A UI was calculated for each provider's use of each test using the following formula: (UI = [provider volume of specific test/provider volume of all tests]/[cohort volume of specific test/cohort volume of all tests]). A heatmap was generated to compare each provider to their cohort. Results: This method identified several hot spots and was helpful in reducing confusion and overutilization. Conclusion: The UI is a useful measure of test ordering behavior, and heatmaps provide a clear visual illustration of the utilization indices. This information can be used to identify areas for improvement and initiate meaningful dialog with providers, which will ultimately bring improvement and reduction in costs. Our method is simple and uses resources that are widely available, making this method effective convenient for many other laboratories.
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Affiliation(s)
- Yonah C Ziemba
- Department of Pathology and Laboratory Medicine, Northwell Health, Lake Success, NY, USA
| | - Liya Lomsadze
- Department of Pathology and Laboratory Medicine, Northwell Health, Lake Success, NY, USA
| | - Yehuda Jacobs
- Department of Pathology and Laboratory Medicine, Northwell Health, Lake Success, NY, USA
| | - Tylis Y Chang
- Department of Pathology and Laboratory Medicine, Northwell Health, Lake Success, NY, USA
| | - Nina Haghi
- Department of Pathology and Laboratory Medicine, Northwell Health, Lake Success, NY, USA
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Morris TF, Ellison TL, Mutabagani M, Althawadi SI, Heppenheimer M. Demand management and optimization of clinical laboratory services in a tertiary referral center in Saudi Arabia. Ann Saudi Med 2018; 38:299-304. [PMID: 30078029 PMCID: PMC6086671 DOI: 10.5144/0256-4947.2018.299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Demand for clinical laboratory services in our insti.tution has increased by 7% each year in the past 5 years, while the amount budgeted for services has remained fixed. To address the issue, we conducted a pilot study to curb inappropriate demand by implementing a minimum retest interval (time-based restrictions on the ordering certain tests) and thus reduce costs. OBJECTIVE Explore the impact (financial and work volume) of restricting overuse of laboratory tests that add to costs but provide no additional clinical value. DESIGN Pilot study of means to reduce costs and workload. SETTING Clinical laboratory that provides diagnostic support to a tertiary care center specializing in transplantation and oncology. METHODS With the engagement of clinical colleagues, we selected 13 tests characterized by high volume, high cost, or a perception of overuse that adds no clinical value. The selection was also based on established lock-out frequencies identified in a literature review. Data was captured on test numbers before and after initiating computer-based lock-outs along with the reference laboratory cost of these tests for the first 6 months of 2016 and 2017. MAIN OUTCOME MEASURES Alterations in testing patterns (mimimum retest intervals) and frequencies for tests. RESULTS The number of tests ordered during the 6-month period in 2017 were reduced by an average of 6.6% versus the same period for 2016, saving 2.03 million Saudi Arabian Riyals (SAR). Given a 7% annual growth in the preceding 5 years, the volume was reduced by 13% in real terms. The percentage reduction in number of tests ranged from as little as 0.2% for PT to 70.3% for an enzyme immunoassay. Savings were 1.4 million SAR in hematology and 0.36 million SAR in microbiology over the 6-month period. CONCLUSION Minimum retest intervals using computer-based rules are effective in supporting strategies to manage demand. LIMITATIONS This approach may not be applicable to all laboratory tests; however, the success of this pilot study would encourage more widespread use of this approach. CONFLICT OF INTEREST None.
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Affiliation(s)
- Thomas F Morris
- Thomas F. Morris,, MBC 10 Cytogenetics Laboratory,, Department of Pathology and Laboratory Medicine,, King Faisal Specialist Hospital and Research Centre,, PO Box 3354, Riyadh 11211, Saudi Arabia, T: 966-11-4647272 ext. 34269, , ORCID: http://orcid.org/0000-0001-7770-387X
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Hueth KD, Jackson BR, Schmidt RL. An Audit of Repeat Testing at an Academic Medical Center: Consistency of Order Patterns With Recommendations and Potential Cost Savings. Am J Clin Pathol 2018; 150:27-33. [PMID: 29718090 DOI: 10.1093/ajcp/aqy020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To evaluate the prevalence of potentially unnecessary repeat testing (PURT) and the associated economic burden for an inpatient population at a large academic medical facility. METHODS We evaluated all inpatient test orders during 2016 for PURT by comparing the intertest times to published recommendations. Potential cost savings were estimated using the Centers for Medicare & Medicaid Services maximum allowable reimbursement rate. We evaluated result positivity as a determinant of PURT through logistic regression. RESULTS Of the evaluated 4,242 repeated target tests, 1,849 (44%) were identified as PURT, representing an estimated cost-savings opportunity of $37,376. Collectively, the association of result positivity and PURT was statistically significant (relative risk, 1.2; 95% confidence interval, 1.1-1.3; P < .001). CONCLUSIONS PURT contributes to unnecessary health care costs. We found that a small percentage of providers account for the majority of PURT, and PURT is positively associated with result positivity.
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Affiliation(s)
- Kyle D Hueth
- Department of Pathology, Health Sciences Center, University of Utah, Salt Lake City
| | - Brian R Jackson
- Department of Pathology, Health Sciences Center, University of Utah, Salt Lake City
- ARUP Laboratories, Salt Lake City, UT
| | - Robert L Schmidt
- Department of Pathology, Health Sciences Center, University of Utah, Salt Lake City
- ARUP Laboratories, Salt Lake City, UT
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Tchou MJ, Tang Girdwood S, Wormser B, Poole M, Davis-Rodriguez S, Caldwell JT, Shannon L, Hagedorn PA, Biondi E, Simmons J, Anderson J, Brady PW. Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods. Pediatrics 2018; 141:peds.2017-3187. [PMID: 29618583 PMCID: PMC7008632 DOI: 10.1542/peds.2017-3187] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite studies indicating a high rate of overuse, electrolyte testing remains common in pediatric inpatient care. Frequently repeated electrolyte tests often return normal results and can lead to patient harm and increased cost. We aimed to reduce electrolyte testing within a hospital medicine service by >25% within 6 months. METHODS We conducted an improvement project in which we targeted 6 hospital medicine teams at a large academic children's hospital system by using the Model for Improvement. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. Our primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. We tracked medical emergency team calls and readmission rates as balancing measures. RESULTS The mean baseline rate of electrolyte testing was 2.0 laboratory draws per 10 patient days, and this rate decreased by 35% after 1 month of initial educational interventions to 1.3 electrolyte laboratory draws per 10 patient days. This change has been sustained for 9 months and could save an estimated $292 000 in patient-level charges over the course of a year. Use of our highest-charge electrolyte panel decreased from 67% to 22% of testing. No change in rates of medical emergency team calls or readmission were found. CONCLUSIONS Our improvement intervention was associated with significant and rapid reduction in electrolyte testing and has not been associated with unintended adverse events.
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Affiliation(s)
- Michael J. Tchou
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio;,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
| | | | | | - Meifawn Poole
- Pediatric Residency Training Program, Cincinnati, Ohio
| | | | | | - Lauren Shannon
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio
| | - Philip A. Hagedorn
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio
| | - Eric Biondi
- Department of Pediatrics, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Jeffrey Simmons
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio;,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
| | - Jeffrey Anderson
- James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio;,Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick W. Brady
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio;,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
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