Bedside Assessment of the Necessity of Daily Lab Testing for Patients Nearing Discharge

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

PROSPERO REGISTRATION NUMBER

CRD42021254076.

Developing an Institute for Health Care Delivery Science: successes, challenges, and solutions in the first five years

Medical knowledge is increasing at an exponential rate. At the same time, unexplained variations in practice and patient outcomes and unacceptable rates of medical errors and inefficiencies in health care delivery have emerged. Our Institute for Health Care Delivery Science (I-HDS) began in 2014 as a novel platform to conduct multidisciplinary healthcare delivery research. We followed ten strategies to develop a successful institute with excellence in methodology and strong understanding of the value of team science. Our work was organized around five hubs: 1) Quality/Process Improvement and Systematic Review, 2) Comparative Effectiveness Research, Pragmatic Clinical Trials, and Predictive Analytics, 3) Health Economics and Decision Modeling, 4) Qualitative, Survey, and Mixed Methods, and 5) Training and Mentoring. In the first 5 years of the I-HDS, we have identified opportunities for change in clinical practice through research using our health system's electronic health record (EHR) data, and designed programs to educate clinicians in the value of research to improve patient care and recognize efficiencies in processes. Testing the value of several model interventions has guided prioritization of evidence-based quality improvements. Some of the changes in practice have already been embedded in the EHR workflow successfully. Development and sustainability of the I-HDS has been fostered by a mix of internal and external funding, including philanthropic foundations. Challenges remain due to the highly competitive funding environment and changes needed to adapt the EHR to healthcare delivery research. Further stakeholder engagement and culture change working with hospital leadership and I-HDS core and affiliate members continues.

"THINK" Before You Order: Multidisciplinary Initiative to Reduce Unnecessary Lab Testing

Inappropriate daily lab testing can have adverse effects on patients, including anemia, pain, and interruption of sleep. We implemented a student-led, multifaceted intervention featuring clinician education, publicity campaign, gamification, and system changes, including a novel nurse-driven protocol to reduce unnecessary daily lab testing in a teaching hospital. We applied a quasi-experimental interrupted time series design with a segmented regression analysis to estimate changes before and after our 14-month intervention with a comparison to a control surgical unit. There was an increasing trend in the baseline period, which was mitigated by the intervention (postintervention effect estimate -0.04 labs per patient day/month, p < .05), which was not seen in the control unit. Estimated cost savings was $94,269 ($6,734/month). A student-led, multidisciplinary campaign involving nurse-driven pathway, education, publicity, gamification, and system changes was effective in reducing daily lab testing.

Signage as an intervention on a general medicine ward to reduce unnecessary testing

BACKGROUND

Up to 30% of medical spending in developed countries is unnecessary. Unnecessary testing is not only wasteful economically, but can be injurious to patients. Studies have shown that interventions such as education, auditing, and restrictive ordering can reduce unnecessary testing. However, these interventions are time- and resource-intensive. We conducted a study to determine if the passive intervention of placing signs on clinicians' computers was effective in reducing unnecessary testing.

AIMS

To determine the effectiveness of signage on physicians' computers to limit unnecessary testing.

METHODS

We identified two acute medicine wards on which all orders are placed via computer. On one ward (Ward A), we placed signs outlining recommendations regarding responsible test-ordering. Ward B acted as a control. Data was collected during a 6-month study period to determine whether test-ordering practices differed.

RESULTS

A total of 1645 patients accounting for 17 786 patient-days were included in the study. Fewer tests were ordered on Ward A than Ward B (7.38 vs 8.20 tests/patient-day; P < 0.01). Additionally, significantly fewer patients on Ward B received ≥1 complete blood count/day (36.1% vs 42.5%, P = 0.04). This effect was most pronounced among patients admitted for 7-30 days.

CONCLUSION

The passive intervention of placing signs on clinicians' computers significantly reduced unnecessary testing.