Promoting improved utilization of laboratory testing through changes in an electronic medical record: experience at an academic medical center

Laboratory Test Names Matter: A Survey on What Works and What Doesn't Work for Orders and Results

CONTEXT.—

Health care providers were surveyed to determine their ability to correctly decipher laboratory test names and their preferences for laboratory test names and result displays.

OBJECTIVE.—

To confirm principles for laboratory test nomenclature and display and to compare and contrast the abilities and preferences of different provider groups for laboratory test names.

DESIGN.—

Health care providers across different specialties and perspectives completed a survey of 38 questions, which included participant demographics, real-life examples of poorly named laboratory orders that they were asked to decipher, an assessment of vitamin D test name knowledge, their preferences for ideal names for tests, and their preferred display for test results. Participants were grouped and compared by profession, level of training, and the presence or absence of specialization in informatics and/or laboratory medicine.

RESULTS.—

Participants struggled with poorly named tests, especially with less commonly ordered tests. Participants' knowledge of vitamin D analyte names was poor and consistent with prior published studies. The most commonly selected ideal names correlated positively with the percentage of the authors' previously developed naming rules (R = 0.54, P < .001). There was strong consensus across groups for the best result display.

CONCLUSIONS.—

Poorly named laboratory tests are a significant source of provider confusion, and tests that are named according to the authors' naming rules as outlined in this article have the potential to improve test ordering and correct interpretation of results. Consensus among provider groups indicates that a single yet clear naming strategy for laboratory tests is achievable.

Reducing duplicate genetic testing in inpatient and outpatient settings across a large safety-net system

OBJECTIVES

To develop a system-wide electronic health record (EHR) intervention at a large safety-net hospital system to reduce wasteful duplicate genetic testing.

METHODS

This project was initiated at a large urban public health care system. An EHR alert was designed to be triggered when a clinician attempted to order any of 16 specified genetic tests for which a previous result existed within the EHR system. Measurements included the proportion of completed genetic tests that were duplicates and alerts per 1,000 tests. Data were stratified by clinician type, specialty, and inpatient vs ambulatory setting.

RESULTS

Across all settings, the rate of duplicate genetic testing decreased from 2.35% (1,050 of 44,592 tests) to 0.09% (21 of 22,323 tests) (96% relative reduction, P < .001). The alert rate per 1,000 tests was 277 for inpatient orders and 64 for ambulatory orders. Among clinician types, residents had the highest alert rate per 1,000 tests at 166 and midwives the lowest at 51 (P < .01). Among clinician specialties, internal medicine had the highest alert rate per 1,000 tests at 245 and obstetrics and gynecology the lowest at 56 (P < .01).

CONCLUSIONS

The EHR intervention successfully reduced duplicate genetic testing by 96% across a large safety-net setting.

Evaluation of a Multilevel Laboratory Stewardship Intervention Targeted to Cardiac and Thoracic Surgical Services at an Academic Medical Center

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.

Targeting repetitive laboratory testing with electronic health records-embedded predictive decision support: A pre-implementation study

INTRODUCTION

Unnecessary laboratory testing contributes to patient morbidity and healthcare waste. Despite prior attempts at curbing such overutilization, there remains opportunity for improvement using novel data-driven approaches. This study presents the development and early evaluation of a clinical decision support tool that uses a predictive model to help providers reduce low-yield, repetitive laboratory testing in hospitalized patients.

METHODS

We developed an EHR-embedded SMART on FHIR application that utilizes a laboratory test result prediction model based on historical laboratory data. A combination of semi-structured physician interviews, usability testing, and quantitative analysis on retrospective laboratory data were used to inform the tool's development and evaluate its acceptability and potential clinical impact.

KEY RESULTS

Physicians identified culture and lack of awareness of repeat orders as key drivers for overuse of inpatient blood testing. Users expressed an openness to a lab prediction model and 13/15 physicians believed the tool would alter their ordering practices. The application received a median System Usability Scale score of 75, corresponding to the 75th percentile of software tools. On average, physicians desired a prediction certainty of 85% before discontinuing a routine recurring laboratory order and a higher certainty of 90% before being alerted. Simulation on historical lab data indicates that filtering based on accepted thresholds could have reduced ∼22% of repeat chemistry panels.

CONCLUSIONS

The use of a predictive algorithm as a means to calculate the utility of a diagnostic test is a promising paradigm for curbing laboratory test overutilization. An EHR-embedded clinical decision support tool employing such a model is a novel and acceptable intervention with the potential to reduce low-yield, repetitive laboratory testing.

Impact of computerised provider order entry on the quality and quantity of clinical information included with investigation requests: an interrupted time series analysis

INTRODUCTION

Relevant clinical information is vital to inform the analytical and interpretative phases of most investigations. The aim of this study is to evaluate the impact of implementation of computerised provider order entry (CPOE), featuring order-specific electronic order entry forms (eOEFs), on the quality and quantity of clinical information included with investigation requests.

METHODS

The CPOE module of a commercially available electronic health record (Cerner Millennium) was implemented at a large, tertiary care centre. The laboratory information management system was interrogated to collect data on specimens sent for microbiological culture 1 year before implementation of CPOE (2018), immediately post implementation (2019) and 6 months post implementation (2020). An interrupted time series analysis was performed, using text mining, to evaluate the quality and quantity of free-text clinical information.

RESULTS

In total, 39 919 specimens were collected from 16 458 patients. eOEFs were used to place 10 071 out of 13 735 orders in 2019 (73.3%), and 9155 out of 12 229 orders in 2020 (74.9%). No clinical details were included with 653 out of 39 919 specimens (1.6%), of which 22 (3.4%) were ordered using eOEFs. The median character count increased from 14 in 2018, to 41 in 2019, and 38 in 2020. An anti-infective agent was specified in 581 out of 13 955 requests (4.2%) in 2018; 5545 out of 13 735 requests (40.4%) in 2019; and 5215 out of 12 229 requests (42.6%) in 2020. Ciprofloxacin or piperacillin-tazobactam (Tazocin) were mentioned in the clinical details included with 421 out of 15 335 urine culture requests (2.7%), of which 406 (96.3%) were ordered using eOEFs. Subsequent detection of in vitro non-susceptibility led to a change in anti-infective therapy for five patients.

CONCLUSIONS

Implementation of CPOE, featuring order-specific eOEFs, significantly and sustainably improves the quality and quantity of clinical information included with investigation requests, resulting in changes to patient management that would not otherwise have occurred.

Displaying Cost and Completion Time for Reference Laboratory Test Orders-A Randomized Controlled Trial

OBJECTIVES

Reduction in unnecessary services is one strategy for increasing the value of health care. Reference laboratory, or send-out, tests are associated with considerable costs. We investigated whether displaying cost and turnaround time (TAT), or time-to-result, for reference laboratory tests at the time of order entry in the electronic health record (EHR) system would impact provider ordering practices.

METHODS

Reference laboratory test cost and TAT data were randomized prior to the study and only displayed for the intervention group. A 24-month dataset composed of 12 months each for baseline and study periods was extracted from the clinical data mart. A difference-in-differences (DID) analysis was conducted using a linear mixed-effects model to estimate the association between the intervention and changes in test-ordering patterns.

RESULTS

In the inpatient setting, the DIDs of aggregate test-order costs and volume were not different among the control and intervention groups (p = 0.31 and p = 0.26, respectively). In the ambulatory setting, the DIDs of aggregate test-order costs and volume were not different among the control and intervention groups (p = 0.82 and p = 0.51, respectively). For both inpatient and ambulatory settings, no significant difference was observed in the DID of aggregate test-order costs and volumes calculated in respect to stratified relative cost and TAT groups (p > 0.05).

CONCLUSION

Lack of alternative tests, test orders placed at a late step in patient management, and orders facilitated by trainees or mid-level providers may have limited the efficacy of the intervention. Our randomized study demonstrated no significant association between the display of cost or TAT display and ordering frequency.

Specific test panels for patients with heart failure: implementation and use in the Spanish National Health System

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.

Clinical Decision Support for Laboratory Testing

BACKGROUND

As technology enables new and increasingly complex laboratory tests, test utilization presents a growing challenge for healthcare systems. Clinical decision support (CDS) refers to digital tools that present providers with clinically relevant information and recommendations, which have been shown to improve test utilization. Nevertheless, individual CDS applications often fail, and implementation remains challenging.

CONTENT

We review common classes of CDS tools grounded in examples from the literature as well as our own institutional experience. In addition, we present a practical framework and specific recommendations for effective CDS implementation.

SUMMARY

CDS encompasses a rich set of tools that have the potential to drive significant improvements in laboratory testing, especially with respect to test utilization. Deploying CDS effectively requires thoughtful design and careful maintenance, and structured processes focused on quality improvement and change management play an important role in achieving these goals.

Educational cost-effective intervention to reduce pathologist's peripheral blood smears reviews with non-contributory findings: an academic institution experience

Peripheral blood smear (PBS) review by a pathologist is a necessary and invaluable diagnostic tool. However, innovative highly sophisticated haematology analysers that flag peripheral blood abnormalities have decreased the need for a PBS review. Ordering practices including PBS reviews lumped as part of an 'order set' or with complete blood count (CBC) constituted most PBS requests at our institution. A retrospective review of all PBS review orders from 1 April 2016 to 31 January 2017 was performed to investigate the ordering practices at our institution. A total of 2864 PBS were ordered during the above study period. In many cases, the PBS report did not add any significant clinical information beyond that acquired by the CBC and differential count. These findings inspired policy changes within our institution for pathologist PBS reviews. Within the electronic order system, all PBS orders for inpatients were linked to a pop-up window with criteria for peripheral smear review and instructions on the approval policy. Outpatient orders required clinicians to request pathology approval. This implementation reduced total number of PBS orders by 42.5% with no adverse effect on patient management. Empowering pathologists and clinicians with guidelines on PBS review orders is a beneficial educational exercise of resource utilisation. Discussion with physicians regarding clinical indications reduces non-contributory PBS reviews, provides guidance to appropriate testing, and aptly allocates pathologist and laboratory staff time and resources.

Time-of-day changes in physician clinical decision making: A retrospective study

Background

Time of day has been associated with variations in certain clinical practices such as cancer screening rates. In this study, we assessed how more general process measures of physician activity, particularly rates of diagnostic test ordering and diagnostic assessments, might be affected by time of day.

Methods

We conducted a retrospective chart review of 3,342 appointments by 20 attending physicians at five outpatient clinics, matching appointments by physician and comparing the average diagnostic tests ordered and average diagnoses assessed per appointment in the first hour of the day versus the last hour of the day. Statistical analyses used sign tests, two-sample t-tests, Wilcoxon tests, Kruskal Wallis tests, and multivariate linear regression.

Results

Examining physicians individually, four and six physicians, respectively, had statistically significant first- versus last-hour differences in the number of diagnostic tests ordered and number of diagnoses assessed per patient visit (p ≤ 0.04). As a group, 16 of 20 physicians ordered more tests on average in the first versus last hour (p = 0.012 for equal chance to order more in each time period). Substantial intra-clinic heterogeneity was found in both outcomes for four of five clinics (p < 0.01).

Conclusions

There is some statistical evidence on an individual and group level to support the presence of time-of-day effects on the number of diagnostic tests ordered per patient visit. These findings suggest that time of day may be a factor influencing fundamental physician behavior and processes. Notably, many physicians exhibited significant variation in the primary outcomes compared to same-specialty peers. Additional work is necessary to clarify temporal and inter-physician variation in the outcomes of interest.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Adoption of a laboratory EMR system and inappropriate laboratory testing in Ontario: a cross-sectional observational study

Background

Electronic medical record (EMR) systems have the potential to facilitate appropriate laboratory testing. We examined three common medical tests in primary care—hemoglobin A1c (HbA1c), lipid, and thyroid stimulating hormone (TSH)— to assess whether adoption of a laboratory EMR system in Ontario had an impact on the rate of inappropriate testing among primary care physicians.

Methods

We used FY2016–17 population-level laboratory data to estimate the association between adoption of a laboratory EMR system and the rate of inappropriate testing. Inappropriate testing was assessed based on recommendations for screening, monitoring, and follow-up that take into account risk factors related to patient age and certain clinical conditions. To overcome the problem of potential endogeneity of physician choice to use the EMR, the EMR penetration rate in the physician’s geographical area of practice was used as an instrumental variable in an ordinary least squares (OLS) regression. We then simulated the change in the rate of inappropriate testing, by physician payment model, as the EMR penetration rate increased from the baseline percentage.

Results

The simulation models showed that an increase in the rate of EMR penetration from a baseline average was associated with a statistically significant decrease in inappropriate hbA1c and lipid testing, but a statistically insignificant increase in inappropriate TSH testing. The impact of EMR penetration also varied by payment model.

Conclusions

This study demonstrated a positive association between availability of an EMR system and appropriate service utilization. Varying impacts of the EMR system availability by primary care payment model may be reflective of different incentives or attributes inherent in payment models. Policies to encourage physicians to increase their use of laboratory EMR systems could improve the quality and continuity of patient care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06296-5.

Use of machine learning to predict clinical decision support compliance, reduce alert burden, and evaluate duplicate laboratory test ordering alerts

Objectives

While well-designed clinical decision support (CDS) alerts can improve patient care, utilization management, and population health, excessive alerting may be counterproductive, leading to clinician burden and alert fatigue. We sought to develop machine learning models to predict whether a clinician will accept the advice provided by a CDS alert. Such models could reduce alert burden by targeting CDS alerts to specific cases where they are most likely to be effective.

Materials and Methods

We focused on a set of laboratory test ordering alerts, deployed at 8 hospitals within the Partners Healthcare System. The alerts notified clinicians of duplicate laboratory test orders and advised discontinuation. We captured key attributes surrounding 60 399 alert firings, including clinician and patient variables, and whether the clinician complied with the alert. Using these data, we developed logistic regression models to predict alert compliance.

Results

We identified key factors that predicted alert compliance; for example, clinicians were less likely to comply with duplicate test alerts triggered in patients with a prior abnormal result for the test or in the context of a nonvisit-based encounter (eg, phone call). Likewise, differences in practice patterns between clinicians appeared to impact alert compliance. Our best-performing predictive model achieved an area under the receiver operating characteristic curve (AUC) of 0.82. Incorporating this model into the alerting logic could have averted more than 1900 alerts at a cost of fewer than 200 additional duplicate tests.

Conclusions

Deploying predictive models to target CDS alerts may substantially reduce clinician alert burden while maintaining most or all the CDS benefit.

A compulsory pop-up form reduces the number of vitamin D requests from general practitioners by 25 percent

OBJECTIVE

Healthcare costs, including costs for laboratory tests, are increasing worldwide. One example is the measurement of vitamin D. General practitioners in the Capital Region of Denmark include a vitamin D status in approximately 20% of all laboratory requisitions. This study intended to examine the effect of a compulsory pop-up form in the electronic request system on the number of vitamin D tests and to monitor the indications.

DESIGN

From 1 January 2017, we introduced a compulsory pop-up form in which the general practitioners had to state the indication for measuring vitamin D, choosing from a predefined set of indications. Intervention practitioners were compared with control practitioners before and after the intervention.

SETTING

General practices in the Capital Region of Denmark.

SUBJECTS

In total, 572 general practitioners and 383,964 patients were included in the period from 1 January 2016 to 31 December 2018.

MAIN OUTCOME MEASURES

Number of vitamin D tests and distribution of indications.

RESULTS

We observed a drop in number of vitamin D requisitions to 70% (in 2017) and 75% (in 2018) relative to 2016. During the same period, the number of requisitions increased by 33% in a non-intervention group of practitioners. The indication 'Monitoring of treatment with vitamin D' was the most frequently used indication, recorded in 121,475 patients.

CONCLUSION

A compulsory pop-up form reduces the number of vitamin D requests from general practitioners by 25%. The implication is that pop-up forms can be used to decrease healthcare costs.

Reference Laboratory Testing for Neurologic Disorders

Laboratory testing plays a critical role in the diagnosis and monitoring of patients with neurologic disorders. Although common tests are often performed in a central hospital laboratory, an increasing number of essential but esoteric tests are performed at reference laboratories or other outside health care facilities. In this article, we analyze recent trends in neurologic disease testing within the overall context of reference laboratory testing and discuss strategies to facilitate the provision of high-quality, cost-effective laboratory services.

Utilization of Laboratory Testing Algorithms for Celiac Disease in a Pediatric Hospital

BACKGROUND

At Texas Children's Hospital in Houston, numerous celiac tests are ordered from a wide range of nonspecialty healthcare providers.

OBJECTIVE

To retrospectively examine the ordering of celiac tests before and after a test ordering initiative at our institution, to determine whether the initiative impacted appropriate usage of those tests and affected costs.

METHODS

We carefully scrutinized all orders for comprehensive celiac testing from July 2016 through September 2017, implemented an in-house celiac-disease screening cascade, and reflexed it to the comprehensive celiac testing panel if an abnormal screening result was obtained.

RESULTS

A total of 60 celiac test orders were issued during the 14-month study period. The ordering physician was a gastroenterologist in 6 cases and a nongastroenterologist in 54 cases. Of the 60 orders, only 4 were approved for sending out for comprehensive celiac testing; in 52 of the 60 cases, the order was altered to celiac screening. In the remaining 4 cases, the tests were canceled as a result of incorrect orders. Only 1 of the 52 celiac screenings yielded a positive result and thus was reflexed to the comprehensive panel.

CONCLUSIONS

We were able to induce appropriate celiac test usage by implementing a celiac-reflexive cascade. Also, our strategy proved to be extremely cost effective.

Noninterruptive Clinical Decision Support Decreases Ordering of Respiratory Viral Panels during Influenza Season

OBJECTIVE

A growing body of evidence suggests that testing for influenza virus alone is more appropriate than multiplex respiratory viral panel (RVP) testing for general populations of patients with respiratory tract infections. We aimed to decrease the proportion of RVPs out of total respiratory viral testing ordered during influenza season.

METHODS

We implemented two consecutive interventions: reflex testing for RVPs only after a negative influenza test, and noninterruptive clinical decision support (CDS) including modifications of the computerized physician order entry search behavior and cost display. We conducted an interrupted time series of RVPs and influenza polymerase chain reaction tests pre- and postintervention, and performed a mixed-effects logistic regression analysis with a primary outcome of proportion of RVPs out of total respiratory viral tests. The primary predictor was the intervention period, and covariates included the provider, clinical setting, associated diagnoses, and influenza incidence.

RESULTS

From March 2013 to April 2019, there were 24,294 RVPs and 26,012 influenza tests (n = 50,306). Odds of ordering an RVP decreased during the reflex testing period (odds ratio: 0.432, 95% confidence interval: 0.397-0.469), and decreased more dramatically during the noninterruptive CDS period (odds ratio: 0.291, 95% confidence interval: 0.259-0.327).

DISCUSSION

The odds of ordering an RVP were 71% less with the noninterruptive CDS intervention, which projected 4,773 fewer RVPs compared with baseline. Assuming a cost equal to Medicare reimbursement rates for RVPs and influenza tests, this would generate an estimated averted cost of $1,259,474 per year.

CONCLUSION

Noninterruptive CDS interventions are effective in reducing unnecessary and expensive testing, and avoid typical pitfalls such as alert fatigue.

Operational Aspects of a Clinical Decision Support Program

Clinical decision support tools that involve improving test utilization should be jointly overseen by a laboratory stewardship committee and the hospital informatics team. The roles of these groups vary by institution and may overlap. This is a team effort and collaboration is a must. The effectiveness of these efforts in an institution depends on the receptiveness of leadership and providers, as well as the effectiveness of the associated committees. Examples of the challenges and successes of laboratory stewardship interventions that have been operationalized at the Cleveland Clinic that use clinical decision support tools, as well as associated literature, are reviewed.

Data on interference indices in body fluid specimens submitted for clinical laboratory analysis

Clinical chemistry analysis of body fluids from non-blood or urine sources presents a technical challenge for clinical laboratories. Examples of body fluids include biliary secretions, cerebrospinal fluid, cyst contents, dialysate, gastric aspirates, peritoneal fluid, pleural fluid, stool, surgical drain fluid, synovial fluid, and wound exudates. The heterogeneous nature of these body fluids presents technical difficulties for analysis. For example, body fluid specimens may have presence of hemolysis, icterus, or lipemia (‘interference indices’) that can interfere with clinical chemistry analysis. In the related research article, we analyzed the distribution of these interference indices and body fluid samples submitted for analysis at an academic medical center central clinical laboratory and compared this to data from serum/plasma specimens. The data in this article provide the body fluid type, clinical chemistry testing ordered, interference indices, and whether the indices exceeded the manufacturer's recommendations in the package insert for serum/blood specimens. The analyzed data are provided in the supplementary tables included in this article. The dataset reported is related to the research article entitled “Review of interference indices in body fluids specimens admitted for clinical chemistry analyses” [1].

A minimalist electronic health record-based intervention to reduce standing lab utilisation

BACKGROUND

Repetitive laboratory testing in stable patients is low-value care. Electronic health record (EHR)-based interventions are easy to disseminate but can be restrictive.

OBJECTIVE

To evaluate the effect of a minimally restrictive EHR-based intervention on utilisation.

SETTING

One year before and after intervention at a 600-bed tertiary care hospital. 18 000 patients admitted to General Medicine, General Surgery and the Intensive Care Unit (ICU).

INTERVENTION

Providers were required to specify the number of times each test should occur instead of being able to order them indefinitely.

MEASUREMENTS

For eight tests, utilisation (number of labs performed per patient day) and number of associated orders were measured.

RESULTS

Utilisation decreased for some tests on all services. Notably, complete blood count with differential decreased 9% (p<0.001) on General Medicine and 21% (p<0.001) in the ICU.

CONCLUSIONS

Requiring providers to specify the number of occurrences of labs changes significantly reduces utilisation in some cases.

Review of interference indices in body fluid specimens submitted for clinical chemistry analyses

Objectives

The aims of this study were to retrospectively investigate interference indices in a wide range of body fluid specimens and compare these indices to those found in serum/plasma.

Design and Methods

This retrospective study evaluated interference indices for hemolysis, icterus, and lipemia in 2752 body fluid specimens submitted for clinical chemistry testing.

Results

The distribution of interference indices for body fluid samples was generally similar to that of serum/plasma interference indices. Hemolysis of specimens submitted for lactate dehydrogenase (LD) represented the most common interference for body fluid chemistries. Body fluids collected from postsurgical drain sites had a higher proportion of tests exceeding both icterus and lipemic limits compared to serum/plasma specimens.

Conclusions

Overall, degrees of hemolysis, icterus, and lipemia observed in body fluid specimens were in large part similar to serum/plasma specimens, with a few notable differences. Body fluids exhibited a higher proportion of samples with severe icterus or lipemia. Severely lipemic body fluid samples were significantly less likely to also be hemolyzed relative to severely lipemic serum/plasma specimens. LD was the test most commonly affected by interference across all body fluid types. False elevations in pleural fluid LD induced by hemolysis can lead to mis-classification of transudative effusions as exudative using Light’s criteria. The possible impact of interferences on clinical chemistry testing in body fluids is an important post-analytical consideration.

•

Hemolysis, icterus, and lipemia were evaluated in 2752 body fluid specimens.

•

Distributions of interference indices in body fluids generally mimicked those of serum/plasma.

•

Pancreatic and pericardial fluids had the highest proportion of tests exceeding the hemolysis index.

•

Compared to serum/plasma, drain fluids had relatively more tests exceeding both icterus and lipemic limits.

An Electronic Strategy for Eliminating Unnecessary Duplicate Genetic Testing

OBJECTIVES

To determine the impact of an electronic intervention designed to block duplicate constitutional genetic tests.

METHODS

We constructed, implemented, and studied an electronic intervention that stopped duplicate genetic tests. The activation frequency, types of tests affected, and cost savings achieved with this intervention were determined. The frequency and justification of override requests were also studied.

RESULTS

This intervention stopped 710 unnecessary duplicate genetic tests over a 3-year period and saved $98,596. The tests with the highest numbers of alerts were those used for screening presurgical or transplant patients and were commonly part of an order set or test panel. Most override requests were justified because of the lack of exclusion codes in the initial programming.

CONCLUSIONS

Electronic interventions that stop duplicate genetic testing, if properly constructed, can reduce waste, save health care dollars, and facilitate patient care by directing the provider to a test that has already been performed.

Clinicians' and laboratory medicine specialists' views on laboratory demand management: a survey in nine European countries

BACKGROUND

Laboratory tests are an essential aspect of current medical practice and their use has grown exponentially. Several studies however have demonstrated inappropriate use of laboratory testing. This inappropriateness can lead to delayed or wrong diagnosis, negatively impacting patient safety and an increase in health care expenditure. The aim of the present small-scale survey was to obtain information on the current status of demand management in European laboratories, as well as the opinions of laboratory and clinical professionals in this regard.

METHODS

Two surveys were developed, one for laboratory specialists and one for clinicians, covering information on current use, knowledge and opinions on the possible impact of different demand management strategies on patient outcome and health care costs. Additionally, we asked for the current state and willingness on collaboration of laboratory specialists and clinicians.

RESULTS

One hundred and fifty responses, 72 laboratory specialists and 78 clinicians, from nine countries were received. Developing local ordering protocols/profiles in collaboration with clinicians was the most used strategy (80.3% of laboratories). Of clinicians, 85.6% considered measures to ensure appropriate use of tests necessary and 100% were interested in advice/information about their indication. Of the laboratory specialists 97.2% were either already participating or willing to participate in multidisciplinary groups on the appropriateness of test demand as were 60.3% of clinicians, and 85.9% of clinicians were interested in attending activities about laboratory test demand management.

CONCLUSIONS

The results of our survey show that tools to improve the appropriate use of laboratory tests are already regularly used today. Laboratory medicine specialists as well as clinicians are willing to undertake additional shared activities aimed at improving patient-centered laboratory diagnostic workup.

The Value Proposition for Pathologists: A Population Health Approach

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.

Improving laboratory test utilisation at the multihospital Yale New Haven Health System

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.

Prevalence and Predictability of Low-Yield Inpatient Laboratory Diagnostic Tests

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Interventions to prevent iatrogenic anemia: a Laboratory Medicine Best Practices systematic review

BACKGROUND

As many as 90% of patients develop anemia by their third day in an intensive care unit (ICU). We evaluated the efficacy of interventions to reduce phlebotomy-related blood loss on the volume of blood lost, hemoglobin levels, transfusions, and incidence of anemia.

METHODS

We conducted a systematic review and meta-analysis using the Laboratory Medicine Best Practices (LMBP) systematic review methods for rating study quality and assessing the body of evidence. Searches of PubMed, Embase, Cochrane, Web of Science, PsychINFO, and CINAHL identified 2564 published references. We included studies of the impact of interventions to reduce phlebotomy-related blood loss on blood loss, hemoglobin levels, transfusions, or anemia among hospital inpatients. We excluded studies not published in English and studies that did not have a comparison group, did not report an outcome of interest, or were rated as poor quality. Twenty-one studies met these criteria. We conducted a meta-analysis if > 2 homogenous studies reported sufficient information for analysis.

RESULTS

We found moderate, consistent evidence that devices that return blood from flushing venous or arterial lines to the patient reduced blood loss by approximately 25% in both neonatal ICU (NICU) and adult ICU patients [pooled estimate in adults, 24.7 (95% CI = 12.1-37.3)]. Bundled interventions that included blood conservation devices appeared to reduce blood loss by at least 25% (suggestive evidence). The evidence was insufficient to determine if these devices reduced hemoglobin decline or risk of anemia. The evidence suggested that small volume tubes reduced the risk of anemia, but was insufficient to determine if they affected the volume of blood loss or the rate of hemoglobin decline.

CONCLUSIONS

Moderate, consistent evidence indicated that devices that return blood from testing or flushing lines to the patient reduce the volume of blood loss by approximately 25% among ICU patients. The results of this systematic review support the use of blood conservation systems with arterial or venous catheters to eliminate blood waste when drawing blood for testing. The evidence was insufficient to conclude the devices impacted hemoglobin levels or transfusion rates. The use of small volume tubes may reduce the risk of anemia.

Going beyond audit and feedback: towards behaviour-based interventions to change physician laboratory test ordering behaviour

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.

The Use of an Electronic Health Record Patient Portal to Access Diagnostic Test Results by Emergency Patients at an Academic Medical Center: Retrospective Study

BACKGROUND

Electronic health record (EHR) patient portals provide a means by which patients can access their health information, including diagnostic test results. Little is known about portal usage by emergency department (ED) patients.

OBJECTIVE

The study aimed to assess patient portal utilization by ED patients at an academic medical center using account activation rates along with the rates of access of diagnostic test results (laboratory results and radiology reports), analyzing the impact of age, gender, and self-reported patient race.

METHODS

This institutional review board-approved retrospective study was performed at a 60,000-visits-per-year university-based ED. We utilized EHR data reporting tools to examine EHR portal activation and utilization for all patients who had at least one ED encounter with one or more diagnostic tests performed between October 1, 2016, and October 1, 2017. The total dataset for laboratory testing included 208,635 laboratory tests on 25,361 unique patients, of which 9482 (37.39%) had active portal accounts. The total dataset for radiologic imaging included 23,504 radiology studies on 14,455 unique patients, of which 5439 (37.63%) had an active portal account.

RESULTS

Overall, 8.90% (18,573/208,635) of laboratory tests and 8.97% (2019/22,504) of radiology reports ordered in the ED were viewed in the patient portal. The highest rates of viewing of laboratory and radiology results were seen for those who were female, were aged 0 to 11 years (parent or guardian viewing by proxy) and 18 to 60 years, and self-reported their race as Caucasian or Asian. The lowest rates were for those who were teenagers, aged older than 81 years, African American/black, and Hispanic/Latino. Infectious disease, urinalysis, and pregnancy testing constituted the highest number of laboratory tests viewed. Magnetic resonance imaging reports were viewed at higher rates than computed tomography or x-ray studies (P<.001). Approximately half of all the diagnostic test results accessed by patients were reviewed within 72 hours of availability in the patient portal (laboratory results: 9904/18,573, 53.32% and radiology reports: 971/2019, 48.1%). On the other extreme, 19.9% (3701/18,573) of laboratory results and 31.6% (639/2019) of radiology reports were viewed more than 2 weeks after availability in the portal.

CONCLUSIONS

The data highlight the relatively low use of a patient portal by ED patients and existing disparities between patient groups. There can be wide lag time (months) between result/report availability and access by patients. Opportunities for improvement exist for both activation and more robust utilization of patient portals by ED patients.

Decreasing daily blood work in hospitals: What works and what doesn't

Recurrent, inappropriate laboratory testing is a costly and wasteful use of healthcare resources. Recognizing this problem, the American Board of Internal Medicine, Canadian Society of Internal Medicine, and the Canadian Association of Pathologist all supported the Choosing Wisely campaign to reduce laboratory investigations in patients who demonstrate clinical and laboratory stability. In this narrative, we review studies looking at a variety of approaches to reduce excessive testing including education, audit and feedback, computerized physician order entry system changes, and forcing functions. Each type of intervention has its own unique advantages and disadvantages, varying in complexity, disruptiveness, effectiveness, and sustainability. Before implementing any quality improvement project, it is important to analyze the local context to identify the root causes for the practice behavior and aim to use the minimal amount of intervention to achieve the desired result. Change is often incremental and will seldom occur with a single intervention or Plan-Do-Study-Act cycle. Garnering the support of opinion leaders and a quality improvement team will help make the process and intervention a success.

Change in HbA1c concentration as decision parameter for frequency of HbA1c measurement

Hemoglobin A_1c (HbA_1c) is a long-term measure for glucose concentration in plasma. Since its introduction as a diabetes monitoring tool, and its more recent application as a diagnostic tool, the number of measurements of HbA_1c have risen dramatically. However, HbA_1c change is slow, so repeating measurements should not be done too often. We use a large, unfiltered dataset from 52,017 patients to determine the possible rate of change in HbA_1c concentration. In our laboratory, the critical difference between HbA_1c measurements is 8.5%. Our data show that a 1-unit HbA_1c rise takes 4 weeks to occur, hence, at a HbA_1c concentration around 50 mmol/mol Hgb, a critically increased HbA_1c concentration cannot be determined until after 16 weeks. Conversely a critically lower HbA1c can manifest itself after 2 weeks, but after 7 weeks the dropping tendency stops. The amount of measurements that can be cancelled because they were taken sooner than 16 weeks is 23 percent.

A Machine Learning Approach to Predicting the Stability of Inpatient Lab Test Results

A primary focus for reducing waste in healthcare expenditure is identifying and discouraging unnecessary repeat lab tests. A machine learning model which could reliably predict low information lab tests could provide personalized, real-time predictions to discourage over-testing. To this end, we apply six standard machine learning algorithms to six years (2008-2014) of inpatient data from a tertiary academic center, to predict when the next measurement of a lab test is likely to be the "same" as the previous one. Out of 13 common inpatient lab tests selected for this analysis, several are predictably stable in many cases. This points to potential areas where machine learning approaches may identify and prevent unneeded testing before it occurs, and a methodological framework for how these tasks can be accomplished.

Hardwiring diagnostic stewardship using electronic ordering restrictions for gastrointestinal pathogen testing

OBJECTIVE

To evaluate the impact of a hard stop in the electronic health record (EHR) on inappropriate gastrointestinal pathogen panel testing (GIPP).

DESIGN

We used a quasi-experimental study to evaluate testing before and after the implementation of an EHR alert to stop inappropriate GIPP ordering.

SETTING

Midwest academic medical center.

PARTICIPANTS

Hospitalized patients with diarrhea for which GIPP testing was ordered, between January 2016 through March 2017 (period 1) and April 2017 through June 2018 (period 2).

INTERVENTION

A hard stop in the EHR prevented clinicians from ordering a GIPP more than once per admission or in patients hospitalized for &gt;72 hours.

RESULTS

During period 1, 1,587 GIPP tests were ordered over 212,212 patient days, at a rate of 7.48 per 1,000 patient days. In period 2, 1,165 GIPP tests were ordered over 222,343 patient days, at a rate of 5.24 per 1,000 patient days. The Poisson model estimated a 30% reduction in total GIPP ordering rates between the 2 periods (relative risk, 0.70; 95% confidence interval [CI], 0.63-0.78; P 72 hours.

Using the EPIDEM Model of Quality Improvement to Increase Value of BCR-ABL1 Tests

Objectives

As pathologists and laboratorians, we can enhance patient care by promoting the appropriate ordering of diagnostic tests. Our goal was to improve the ordering of BCR-ABL1 tests by using the EPIDEM model of quality improvement.

Methods

We applied the EPIDEM model, which emphasizes understanding local context, culture, and resources, to explore inappropriate BCR-ABL1 ordering, promote and implement a new reflexive testing strategy in-house, document and evaluate effectiveness, and make stepwise modifications.

Results

Multiple quality improvement interventions correlated with cost savings and decreased total errors and incorrect orders for both BCR-ABL1 major and minor positive patients. Furthermore, our laboratory built stronger collaborative relationships with colleagues within and outside of pathology.

Conclusions

Our molecular pathology laboratory successfully used the EPIDEM model of quality improvement to improve the ordering of BCR-ABL1 tests and promote better patient care by focusing on educational efforts and modification of laboratory workflow.

A Q-Probes Study Involving Utilization of Free Prostate-Specific Antigen, Factor V Leiden, and Hepatitis A Serology Tests

Context.—

Managing the utilization of laboratory tests is an important quality improvement activity that adds value to health care.

Objective.—

To examine utilization of 3 laboratory tests and identify factors that impact performance.

Design.—

Test utilization performance was evaluated by determining the frequency with which appropriate preconditions for testing were met. This included 30 testing episodes each involving (1) free prostate-specific antigen (PSA) when total PSA was within an appropriate interpretable range, (2) total anti–hepatitis A virus antibody when previous anti–hepatitis A virus antibody results were either negative or not done, and (3) factor V Leiden mutation when a previous result was not already available. Participants also provided information regarding some of their utilization policies and procedures for these 3 tests.

Results.—

The overall frequency with which testing criteria were met was 20.6% (163 of 790), 91.5% (649 of 709), and 95.2% (799 of 839) for free PSA, anti–hepatitis A virus antibody, and factor V Leiden, respectively. Utilization review was infrequent and done by 20.7% (6 of 29) of participants for factor V Leiden, 3.6% (1 of 28) for anti–hepatitis A virus antibody, and 3.6% (1 of 28) for free PSA. No practice or demographic characteristics were significantly associated with utilization performance for any test.

Conclusions.—

Utilization review was infrequent for the 3 tests examined. Variable amounts of unnecessary testing were observed for all tests, most frequently for free PSA, for which reporting results carried the added risk of diagnostic error from misinterpretation of results.

A New Era in Pathology Consultation: The MyPathologist Electronic Consultation Tool

Pathologists and laboratory scientists provide valuable guidance on laboratory utilization, test ordering, interpretation, and quality control provided that clinical staff can easily access the laboratory team. To encourage consultation between clinicians with laboratory scientists and pathologists, we developed an easily accessible electronic tool termed "MyPathologist," placed on the homepage of our electronic health record system. Over its 2-year pilot, utilization of this consultation tool climbed as we continued to publicize it and incorporated education into housestaff onboarding and electronic health record training. Physician satisfaction with the tool was high. Additionally, this became the primary source of consults to our residency call service. Evaluation of MyPathologist questions received during its pilot period showed that more than half the questions were of significant educational value to the residents, often focusing on results interpretation, appropriate test ordering, and quality control. MyPathologist is a novel electronic tool for pathology consultation within our electronic health record and also represents an avenue for educating residents, improving utilization of the laboratory, and improving patient care.

Impact of Daylight Saving Time on the Clinical Laboratory

Daylight saving time is a practice in some countries and local regions to set clocks forward (typically 1 hour) during the longer days of summer and back again in autumn. Time changes resulting from daylight saving time have the potential to impact clinical laboratory instruments, computer interfaces, and information systems. We analyzed turnaround time data for an academic medical center clinical laboratories (chemistry, hematology, blood gas analyzer, and transfusion medicine), examining how turnaround time was impacted by the daylight saving time shifts in 2017. We also determined whether the daylight saving time shift on November 5, 2017 (“fall back” by 1 hour) resulted in any “absurd” time combinations such as a receipt time occurring “before” a normally later time such as final result. We also describe challenges resulting from daylight saving time changes over a 5-year period. The only significant impact on turnaround time was for clinical chemistry samples during the autumn daylight saving time change, but the overall impact was low. Four instances of absurd time combinations occurred in the autumn time change with only a transfusion medicine example resulting in an interface error (a Type and Screen resulted “before” receipt in laboratory). Over a 5-year period, other daylight saving time impacts included problems of reestablishing interface to instruments, inadvertent discrepancies in manual time changes at different points of the core laboratory automation line, and time change errors in instruments with older operating systems lacking patches that updated daylight saving time rules after 2007. Clinical laboratories should be aware that rare problems may occur due to issues with daylight saving time changes.

Impact of nonintrusive clinical decision support systems on laboratory test utilization in a large academic centre

BACKGROUND

The near-universal prevalence of electronic health records (EHRs) has made the utilization of clinical decision support systems (CDSS) an integral strategy for improving the value of laboratory ordering. Few studies have examined the effectiveness of nonintrusive CDSS on inpatient laboratory utilization in large academic centres.

METHODS

Red blood cell folate, hepatitis C virus viral loads and genotypes, and type and screens were selected for study. We incorporated the appropriate indications for these labs into text that accompanied the laboratory orders in our hospital's EHR. Providers could proceed with the order without additional clicks. An interrupted time-series analysis was performed, and the primary outcome was the rate of tests ordered on all inpatient medicine floors.

RESULTS

The rate of folate tests ordered per monthly admissions showed no significant level change at the time of the intervention with only a slight decrease in rate of 0.0109 (P = .07). There was a 43% decrease in the rate of hepatitis C virus tests per monthly admissions immediately after the intervention with a decrease of 0.0135 tests per monthly admissions (P = .02). The rate of type and screens orders per patient days each month had a significant downward trend by 0.114 before the intervention (P = .04) but no significant level change at the time of the intervention or significant change in rate after the intervention.

DISCUSSION

Our study suggests that nonintrusive CDSS should be evaluated for individual laboratory tests to ensure only effective alerts continue to be used so as to avoid increasing EHR fatigue.

An Audit of Repeat Testing at an Academic Medical Center: Consistency of Order Patterns With Recommendations and Potential Cost Savings

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.

Strategies to Reduce Inappropriate Laboratory Blood Test Orders in Intensive Care Are Effective and Safe: A Before-And-After Quality Improvement Study

Unnecessary pathology tests performed in intensive care units (ICU) might lead to increased costs of care and potential patient harm due to unnecessary phlebotomy. We hypothesised that a multimodal intervention program could result in a safe and effective reduction in the pathology tests ordered in our ICU. We conducted a single-centre pre- and post-study using multimodal interventions to address commonly ordered routine tests. The study was performed during the same six month period (August to February) over three years: 2012 to 2013 (pre-intervention), 2013 to 2014 (intervention) and 2014 to 2015 (post-intervention). Interventions consisted of staff education, designing new pathology forms, consultant-led pathology test ordering and intensive monitoring for a six-month period. The results of the study showed that there was a net savings of over A$213,000 in the intervention period and A$175,000 in the post-intervention period compared to the pre-intervention period. There was a 28% reduction in the tests performed in the intervention period (P <0.0001 compared to pre-intervention period) and 26% in the post-intervention period (P <0.0001 compared to pre-intervention period). There were no ICU or hospital mortality differences between the groups. There were no significant haemoglobin differences between the groups. A multimodal intervention safely reduced pathology test ordering in the ICU, resulting in substantial cost savings.

Analysis of current thyroid function test ordering practices

RATIONALE

Current guidelines recommend thyroid stimulating hormone (TSH) alone as the best test to detect and monitor thyroid dysfunction, yet free thyroxine (FT4) and free triiodothyronine (FT3) are commonly ordered when not clinically indicated. Excessive testing can lead to added economic burden in an era of rising healthcare costs, while rarely contributing to the evaluation or management of thyroid disease.

OBJECTIVE

To evaluate our institution's practice in ordering thyroid function tests (TFTs) and to identify strategies to reduce inappropriate FT4 and FT3 testing.

METHODS

A record of all TFTs obtained in the San Antonio Military Health System during a 3-month period was extracted from the electronic medical record. The TFTs of interest were TSH, FT4, thyroid panel (TSH + FT4), FT3, total thyroxine (T4), and total triiodothyronine (T3). These were categorized based on the presence or absence of hypothyroidism.

RESULTS

Between August 1 and October 31, 2016, there were 38 214 individual TFTs ordered via 28 597 total laboratory requests; 11 486 of these requests were in patients with a history of hypothyroidism. The number (percent) of laboratory requests fell into these patterns: TSH alone 14 919 (52.14%), TSH + FT4 7641 (26.72%), FT3 alone 3039 (10.63%), FT4 alone 1219 (4.26%), TSH + FT4 + FT3 783 (2.74%), and others 996 (3.48%); 36.0% of TFTs ordered were free thyroid hormones. Projected out to a year, using Department of Defense laboratory costs, $317 429 worth of TFTs would be ordered, with free thyroid hormone testing accounting for $107 720.

CONCLUSION

Inappropriate ordering of free thyroid hormone tests is common. In an era of rising healthcare costs, inappropriate thyroid function testing is an ideal target for efforts to reduce laboratory overutilization, which in our system, could save up to $120 000 per year. Further evaluation is needed to determine strategies that can reduce excessive thyroid hormone testing.

Patterns and trends of potentially inappropriate high-density lipoprotein cholesterol testing in Australian adults at high risk of cardiovascular disease from 2008 to 2014: analysis of linked individual patient data from the Australian Medicare Benefits Schedule and Pharmaceutical Benefits Scheme

OBJECTIVES

We examine the extent to which the adult Australian population on lipid-lowering medications receives the level of high-density lipoprotein cholesterol (HDL-C) testing recommended by national guidelines.

DATA

We analysed records from 7 years (2008-2014) of the 10% publicly available sample of deidentified, individual level, linked Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) electronic databases of Australia.

METHODS

The PBS data were used to identify individuals on stable prescriptions of lipid-lowering treatment. The MBS data were used to estimate the annual frequency of HDL-C testing. We developed a methodology to address the issue of 'episode coning' in the MBS data, which causes an undercounting of pathology tests. We used a published figure on the proportion of unreported HDL-C tests to correct for the undercounting and estimate the probability that an HDL-C test was performed. We judged appropriateness of testing frequency by comparing the HDL-C testing rate to guidelines' recommendations of annual testing for people at high risk for cardiovascular disease.

RESULTS

We estimated that approximately 49% of the population on stable lipid-lowering treatment did not receive any HDL-C test in a given year. We also found that approximately 19% of the same population received two or more HDL-C tests within the year. These levels of underutilisation and overutilisation have been changing at an average rate of 2% and -4% a year, respectively, since 2009. The yearly expenditure associated with test overutilisation was approximately $A4.3 million during the study period, while the cost averted because of test underutilisation was approximately $A11.3 million a year.

CONCLUSIONS

We found that approximately half of Australians on stable lipid-lowering treatment may be having fewer HDL-C testing than recommended by national guidelines, while nearly one-fifth are having more tests than recommended.

What's to Be Done About Laboratory Quality? Process Indicators, Laboratory Stewardship, the Outcomes Problem, Risk Assessment, and Economic Value: Responding to Contemporary Global Challenges

OBJECTIVES

For 50 years, structure, process, and outcomes measures have assessed health care quality. For clinical laboratories, structural quality has generally been assessed by inspection. For assessing process, quality indicators (QIs), statistical monitors of steps in the clinical laboratory total testing, have proliferated across the globe. Connections between structural and process laboratory measures and patient outcomes, however, have rarely been demonstrated.

METHODS

To inform further development of clinical laboratory quality systems, we conducted a selective but worldwide review of publications on clinical laboratory quality assessment.

RESULTS

Some QIs, like seven generic College of American Pathologists Q-Tracks monitors, have demonstrated significant process improvement; other measures have uncovered critical opportunities to improve test selection and result management. The College of Pathologists of Australasia Key Indicator Monitoring and Management System has deployed risk calculations, introduced from failure mode effects analysis, as surrogate measures for outcomes. Showing economic value from clinical laboratory testing quality is a challenge.

CONCLUSIONS

Clinical laboratories should converge on fewer (7-14) rather than more (21-35) process monitors; monitors should cover all steps of the testing process under laboratory control and include especially high-risk specimen-quality QIs. Clinical laboratory stewardship, the combination of education interventions among clinician test orderers and report consumers with revision of test order formats and result reporting schemes, improves test ordering, but improving result reception is more difficult. Risk calculation reorders the importance of quality monitors by balancing three probabilities: defect frequency, weight of potential harm, and detection difficulty. The triple approach of (1) a more focused suite of generic consensus quality indicators, (2) more active clinical laboratory testing stewardship, and (3) integration of formal risk assessment, rather than competing with economic value, enhances it.

Reducing Inappropriate Testing for the Evaluation of Diarrhea Among Hospitalized Patients

BACKGROUND

Diarrhea is one of the most common illnesses in the United States. Evaluation frequently does not follow established guidelines. The objective of this study was to evaluate the effectiveness of a computerized physician order entry-based test guidance algorithm with regard to the clinical, financial, and operational impacts.

METHODS

Our population was patients with diarrheal illness at a tertiary academic medical center. The intervention was a computerized physician order entry-based test guidance algorithm that restricted the use of stool cultures and ova and parasites testing of diarrhea in the adult inpatient location vs nonintervention sites, which were the emergency department, pediatric inpatient and adult and pediatric outpatient locations. We measured stool culture, ova and parasites, and Clostridium difficile testing rates from July 1, 2012 to January 31, 2016. Additionally, we calculated advisor usage, consults generated, accuracy of information, and cost savings.

RESULTS

There was a significant decrease in stool culture and ova and parasites testing rates at the adult inpatient (P = .001 for both), pediatric (P < .001 for both), and adult emergency department (P < .001; P = .009) locations. The decrease at the intervention site was immediate, whereas the other locations showed a delayed but sustained decrease that suggests a collateral impact. A significant increase in the rate of stool culture and ova and parasites testing was observed in the outpatient setting (P = .02 and P = .001). We estimate that $21,931 was saved annually.

CONCLUSIONS

A point-of-order test restriction algorithm for hospitalized adults with diarrhea reduced stool testing. Similar programs should be considered at other institutions and for the evaluation of other conditions.