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Li H, Chen J, Hu Y, Cai X, Tang D, Zhang P. Clinical value of serum calcium in elderly patients with sepsis. Am J Emerg Med 2021; 52:208-211. [PMID: 34959023 DOI: 10.1016/j.ajem.2021.12.019] [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: 08/31/2021] [Revised: 12/03/2021] [Accepted: 12/10/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To explore the clinical value of serum calcium (Ca) in elderly patients with sepsis. MATERIALS AND METHODS The clinical data and laboratory data of elderly patients with sepsis (n = 165) and elderly population for physical examination (n = 67) in a tertiary hospital from January 2020 to November 2020 were collected. We analyzed serum Ca levels in sepsis and septic shock firstly, and then continued to investigate them in the survival group and the death group. Meanwhile, we also assessed the correlation between serum Ca and PCT. RESULTS The serum Ca levels of the elderly patients with sepsis were lower than that of the control group (median 1.98 vs 2.31 mmol/L, P < 0.001), and the more severe the sepsis, the lower the serum Ca levels. Sepsis patients with decreased serum Ca had higher shock rate and mortality. There was a negative correlation between serum Ca and PCT (r = -0.2957, P < 0.001). CONCLUSION Serum Ca has a certain value for the early recognition of elderly patients with sepsis and the judgment of the severity of the disease.
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Affiliation(s)
- Huan Li
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, China
| | - Juanjuan Chen
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, China
| | - Yuanhui Hu
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, China
| | - Xin Cai
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, China
| | - Dongling Tang
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, China
| | - Pingan Zhang
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, China.
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2
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Hughes AEO, Jackups R. Clinical Decision Support for Laboratory Testing. Clin Chem 2021; 68:402-412. [PMID: 34871351 DOI: 10.1093/clinchem/hvab201] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/24/2021] [Indexed: 01/16/2023]
Abstract
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.
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Affiliation(s)
- Andrew E O Hughes
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ronald Jackups
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
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3
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Mrazek C, Haschke-Becher E, Felder TK, Keppel MH, Oberkofler H, Cadamuro J. Laboratory Demand Management Strategies-An Overview. Diagnostics (Basel) 2021; 11:1141. [PMID: 34201549 PMCID: PMC8305334 DOI: 10.3390/diagnostics11071141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 01/07/2023] Open
Abstract
Inappropriate laboratory test selection in the form of overutilization as well as underutilization frequently occurs despite available guidelines. There is broad approval among laboratory specialists as well as clinicians that demand management strategies are useful tools to avoid this issue. Most of these tools are based on automated algorithms or other types of machine learning. This review summarizes the available demand management strategies that may be adopted to local settings. We believe that artificial intelligence may help to further improve these available tools.
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Affiliation(s)
- Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University Salzburg, A-5020 Salzburg, Austria; (E.H.-B.); (T.K.F.); (M.H.K.); (H.O.); (J.C.)
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Katzman BM, Bryant SC, Karon BS. Is It Time to Remove Total Calcium from the Basic and Comprehensive Metabolic Panels? Assessing the Effects of American Medical Association-Approved Chemical Test Panels on Laboratory Utilization. Clin Chem 2021; 66:1444-1449. [PMID: 33141903 DOI: 10.1093/clinchem/hvaa203] [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: 04/23/2020] [Accepted: 08/10/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND The necessity of individual tests within the most commonly used disease-oriented test panels has not been well established. We evaluated test-ordering practices for total calcium, both before and after implementation of American Medical Association (AMA)-approved panels (basic metabolic panel [BMP] and comprehensive metabolic panel [CMP]) in our electronic ordering system. METHODS We performed a retrospective review of all total calcium orders placed during April and June 2018, before and after implementation of the panels. Orders from inpatient, outpatient, and emergency department (ED) care units were totaled, and the percentage of abnormal test results was calculated. We then queried institutional databases to determine the number of unique patients with calcium-related diagnoses and compared the rates from a 5-month period both before and after implementation of the panels. RESULTS Total test volumes and tests per unique patient increased by more than 3-fold after implementation of calcium-containing AMA-approved panels, with the majority of those orders coming from BMPs and CMPs. The rate of low calcium values increased because of the shift toward more inpatient testing; however, the percentage of abnormal results within each patient population (inpatient, outpatient, ED) decreased. The prevalence of hypo- and hypercalcemia-related diagnoses among patients in the 5 months after implementation did not change significantly (1.29% before implementation vs 1.27% after implementation). CONCLUSIONS Implementation of BMPs and CMPs dramatically increased total calcium testing volumes without changing the rate of calcium-related diagnoses. The results suggest that the increase in total calcium orders associated with panel-based testing largely constitutes excess or unnecessary testing.
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Affiliation(s)
- Brooke M Katzman
- Division of Core Clinical Laboratory Services Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Sandra C Bryant
- Division of Biostatistics Department of Health Sciences Research Mayo Clinic College of Medicine Rochester, MN
| | - Brad S Karon
- Division of Core Clinical Laboratory Services Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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Keppel MH, Kolbitsch T, Hoppe UC, Auer S, Felder TK, Oberkofler H, Mrazek C, Haschke-Becher E, Cadamuro J. The clinically effective use of cardiac markers by restructuring laboratory profiles at Cardiology wards. Clin Chem Lab Med 2020; 58:1565-1571. [PMID: 32305953 DOI: 10.1515/cclm-2019-1229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/04/2020] [Indexed: 12/20/2022]
Abstract
Background Laboratory overutilization is associated with diagnostic error and potential patient risk. We applied a demand management strategy in collaboration with the local Department of Cardiology to reduce the cardiac markers high-sensitive troponin T (hsTropT) and N-terminal pro brain natriuretic peptide (NTproBNP) in laboratory ordering profiles (LOPs). The present study aimed to retrospectively evaluate the implemented strategies. Methods Strategies included educational measures and evidence-guided, active test de-selection from all cardiology ward LOPs, and/or permanent removal from LOPs. Tests remained available at all times. We evaluated overutilization by reductions in monthly orders, and assessed differences in 30-day all-cause readmission rate and length of patients' hospital stay. Results Overall, we observed a mean reduction of 66.1% ± 7.6% (n = 277 ± 31) in hsTropT tests. Educational measures effectively reduced NTproBNP orders by 52.8% ± 17.7% (n = 60 ± 20). Permanent removal of tests from LOPs additionally decreased orders to a final extent of 75.8% ± 8.0% (n = 322 ± 31) in NTproBNP tests. The 30-day readmission rate and overall length of hospital stay did not increase. Conclusions Our results indicate that cardiac markers in routine care are subject to extensive overutilization when used within LOPs. Educational measures are an effective strategy to overcome the overutilization of cardiac markers but may be more effective when combined with the removal of cardiac markers from LOPs.
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Affiliation(s)
- Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Tobias Kolbitsch
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Uta C Hoppe
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Simon Auer
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Thomas K Felder
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Hannes Oberkofler
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
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Uljon SN, Simmons DP, Rudolf JW, Baron JM, Dutta S, McEvoy DS, Murali M, Dighe AS. Validation and Implementation of an Ordering Alert to Improve the Efficiency of Monoclonal Gammopathy Evaluation. Am J Clin Pathol 2020; 153:396-406. [PMID: 31776551 DOI: 10.1093/ajcp/aqz180] [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: 01/09/2023] Open
Abstract
OBJECTIVES To evaluate the use of a provider ordering alert to improve laboratory efficiency and reduce costs. METHODS We conducted a retrospective study to assess the use of an institutional reflex panel for monoclonal gammopathy evaluation. We then created a clinical decision support (CDS) alert to educate and encourage providers to change their less-efficient orders to the reflex panel. RESULTS Our retrospective analysis demonstrated that an institutional reflex panel could be safely substituted for a less-efficient and higher-cost panel. The implemented CDS alert resulted in 79% of providers changing their high-cost order panel to an order panel based on the reflex algorithm. CONCLUSIONS The validated decision support alert demonstrated high levels of provider acceptance and directly led to operational and cost savings within the laboratory. Furthermore, these studies highlight the value of laboratory involvement with CDS efforts to provide agile and targeted provider ordering assistance.
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Affiliation(s)
- Sacha N Uljon
- Departments of Pathology, Massachusetts General Hospital, Boston
| | - Daimon P Simmons
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA
| | - Joseph W Rudolf
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis
| | - Jason M Baron
- Departments of Pathology, Massachusetts General Hospital, Boston
| | - Sayon Dutta
- Departments of Pathology, Massachusetts General Hospital, Boston
- Emergency Medicine, Massachusetts General Hospital, Boston
| | | | | | - Anand S Dighe
- Departments of Pathology, Massachusetts General Hospital, Boston
- Partners HealthCare, Somerville, MA
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7
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Kandalam V, Lau CK, Guo M, Ma I, Naugler C. Inappropriate repeat testing of complete blood count (CBC) and electrolyte panels in inpatients from Alberta, Canada. Clin Biochem 2019; 77:32-35. [PMID: 31891680 DOI: 10.1016/j.clinbiochem.2019.12.011] [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] [Received: 09/17/2019] [Revised: 12/19/2019] [Accepted: 12/21/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The avoidance of repeat chemistry testing such as Complete Blood Count (CBC) and Electrolyte Panel (EP) on clinically stable patients was identified as important utilization goals by Choosing Wisely Canada. The purpose of this study was to assess the volume of overutilization of CBC and EP in an inpatient setting in Alberta, Canada, and provide an estimated cost assessment of unnecessary testing. METHODS The total laboratory testing volumes of two common test panels were collected retrospectively for one-year from January to December 2018. Data was collected on test panels performed in an emergency room (ER) and inpatient setting from three separate Laboratory Information Systems covering the provincial population in Alberta, Canada. Total initial test panel instances, total repeated panels, repeated panels that were previously normal or abnormal, and estimated costs were examined. Cost assessment was completed based on Reference Median Cost (RMC) analysis for each of these two common test panels. RESULTS During the study period, 2,020,467 (CBC) and 1,455,983 (EP) initial test panel instances were recorded, of which 67.7% and 73.5% were repeated for the CBC and EP, respectively. There was a higher proportion of EP repeated inappropriately (previously normal; 35.6%) compared to CBCs (5.4%). The cost to the province for inappropriately repeating CBC and EP were estimated to be RMC $0.52 million and RMC $1.90 million CAD, respectively. CONCLUSION Results from this study can assist policy makers in implementing utilization management initiatives and update clinical practice guidelines to reduce costs to healthcare without compromising patient care.
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Affiliation(s)
- Vijay Kandalam
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cheryl K Lau
- Alberta Public Laboratories (formerly Calgary Laboratory Services), Calgary, Alberta, Canada
| | - Maggie Guo
- Alberta Public Laboratories (formerly Calgary Laboratory Services), Calgary, Alberta, Canada
| | - Irene Ma
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Naugler
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Public Laboratories (formerly Calgary Laboratory Services), Calgary, Alberta, Canada.
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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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Abstract
Laboratory tests are an integral part of the electronic health record (EHR). Providing clinical decision support (CDS) for the ordering, collection, reporting, viewing, and interpretation of laboratory testing is a fundamental function of the EHR. The implementation of a sustainable, effective laboratory CDS program requires a commitment to standardization and harmonization of the laboratory dictionaries that are the foundation of laboratory-based CDS. In this review, the authors provide an overview of the tools available within the EHR to improve decision making throughout the entire laboratory testing process, from test order to clinical action.
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Affiliation(s)
- Joseph W Rudolf
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, 420 Delaware Street Southeast, MMC 609 Mayo, Minneapolis, MN 55455, USA
| | - Anand S Dighe
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, USA.
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10
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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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Corré J, Douard H. [Rationalization of biological tests in cardiology department]. SANTE PUBLIQUE (VANDOEUVRE-LES-NANCY, FRANCE) 2018; 30:689-695. [PMID: 30767484 DOI: 10.3917/spub.186.0689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Laboratory tests usually complete clinical examinations for diagnostic, prognostic and even therapeutical care. However, French doctors might too easily prescribe such examinations without knowing their cost. As a matter of fact, the prescription is sometimes excessive or unjustified. Cardiology is not an exception, with costly laboratory tests. OBJECTIVE To show that the relevance of each additional test prescription, in a cardiology department, allows a significant reduction of the examination volumes and costs, with no prejudicial effect on patients' care. METHODS Two consecutive 2-year periods, between November 1st 2011 and October 31st 2015, - before and after the development of a policy of rationalization of additional tests - were compared. All the patients admitted in our cardiology department during these periods were prospectively included.During 4 years, the volume and the cost of prescription of the most frequent laboratory tests were studied, considering successive half-year periods. RESULTS After rationalizing, there was a significant reduction of prescription of the laboratory tests (CBC -72%, BNP -92%, troponin -82%, CRP -89%, liver test -87%, lipid status -80%, TSH -80%, p<0.01).No serious adverse events were reported and no death rate increase was noticed. CONCLUSION Rationalizing allows a significant reduction of complementary examinations, with no additional risk for the patient.
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Rodriguez-Borja E, Corchon-Peyrallo A, Barba-Serrano E, Villalba Martínez C, Carratala Calvo A. “Send & hold” clinical decision support rules improvement to reduce unnecessary testing of vitamins A, E, K, B1, B2, B3, B6 and C. ACTA ACUST UNITED AC 2018; 56:1063-1070. [DOI: 10.1515/cclm-2017-1031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 12/28/2017] [Indexed: 11/15/2022]
Abstract
Abstract
Background:
We assessed the impact of several “send & hold” clinical decision support rules (CDSRs) within the electronical request system for vitamins A, E, K, B1, B2, B3, B6 and C for all outpatients at a large health department.
Methods:
When ordered through electronical request, providers (except for all our primary care physicians who worked as a non-intervention control group) were always asked to answer several compulsory questions regarding main indication, symptomatology, suspected diagnosis, vitamin active treatments, etc., for each vitamin test using a drop-down list format. After samples arrival, tests were later put on hold internally by our laboratory information system (LIS) until review for their appropriateness was made by two staff pathologists according to the provided answers and LIS records (i.e. “send & hold”). The number of tests for each analyte was compared between the 10-month period before and after CDSRs implementation in both groups.
Results:
After implementation, vitamins test volumes decreased by 40% for vitamin A, 29% for vitamin E, 42% for vitamin K, 37% for vitamin B1, 85% for vitamin B2, 68% for vitamin B3, 65% for vitamin B6 and 59% for vitamin C (all p values 0.03 or lower except for vitamin B3), whereas in control group, the majority increased or remained stable. In patients with rejected vitamins, no new requests and/or adverse clinical outcome comments due to this fact were identified.
Conclusions:
“Send & hold” CDSRs are a promising informatics tool that can support in utilization management and enhance the pathologist’s leadership role as tests specialist.
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Eaton KP, Chida N, Apfel A, Feldman L, Greenbaum A, Tuddenham S, Kendall EA, Pahwa A. Impact of nonintrusive clinical decision support systems on laboratory test utilization in a large academic centre. J Eval Clin Pract 2018; 24:474-479. [PMID: 29446193 PMCID: PMC6050580 DOI: 10.1111/jep.12890] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 01/15/2018] [Accepted: 01/22/2018] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Kevin P Eaton
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Natasha Chida
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ariella Apfel
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Leonard Feldman
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adena Greenbaum
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan Tuddenham
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily A Kendall
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amit Pahwa
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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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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Rudolf JW, Dighe AS, Coley CM, Kamis IK, Wertheim BM, Wright DE, Lewandrowski KB, Baron JM. Analysis of Daily Laboratory Orders at a Large Urban Academic Center: A Multifaceted Approach to Changing Test Ordering Patterns. Am J Clin Pathol 2017; 148:128-135. [PMID: 28898984 DOI: 10.1093/ajcp/aqx054] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We sought to address concerns regarding recurring inpatient laboratory test order practices (daily laboratory tests) through a multifaceted approach to changing ordering patterns. METHODS We engaged in an interdepartmental collaboration to foster mindful test ordering through clinical policy creation, electronic clinical decision support, and continuous auditing and feedback. RESULTS Annualized daily order volumes decreased from approximately 25,000 to 10,000 during a 33-month postintervention review. This represented a significant change from preintervention order volumes (95% confidence interval, 0.61-0.64; P < 10-16). Total inpatient test volumes were not affected. CONCLUSIONS Durable changes to inpatient order practices can be achieved through a collaborative approach to utilization management that includes shared responsibility for establishing clinical guidelines and electronic decision support. Our experience suggests auditing and continued feedback are additional crucial components to changing ordering behavior. Curtailing daily orders alone may not be a sufficient strategy to reduce in-laboratory costs.
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Affiliation(s)
| | - Anand S Dighe
- Departments of Pathology
- Harvard Medical School, Boston, MA
| | - Christopher M Coley
- Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
| | - Irina K Kamis
- Information Systems, Partners HealthCare, Boston, MA
| | - Bradley M Wertheim
- Harvard Medical School, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Douglas E Wright
- Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
| | | | - Jason M Baron
- Departments of Pathology
- Harvard Medical School, Boston, MA
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16
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Rudolf J, Jackson BR, Wilson AR, Smock KJ, Schmidt RL. Organizational Benchmarks for Test Utilization Performance: An Example Based on Positivity Rates for Genetic Tests. Am J Clin Pathol 2017; 147:382-389. [PMID: 28340161 DOI: 10.1093/ajcp/aqx019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Health care organizations are under increasing pressure to deliver value by improving test utilization management. Many factors, including organizational factors, could affect utilization performance. Past research has focused on the impact of specific interventions in single organizations. The impact of organizational factors is unknown. The objective of this study is to determine whether testing patterns are subject to organizational effects, ie, are utilization patterns for individual tests correlated within organizations. METHODS Comparative analysis of ordering patterns (positivity rates for three genetic tests) across 659 organizations. Hierarchical regression was used to assess the impact of organizational factors after controlling for test-level factors (mutation prevalence) and hospital bed size. RESULTS Test positivity rates were correlated within organizations. CONCLUSIONS Organizations have a statistically significant impact on the positivity rate of three genetic tests.
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Affiliation(s)
- Joseph Rudolf
- From the Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston
| | - Brian R Jackson
- Center for Effective Medical Testing, Department of Pathology, University of Utah, Salt Lake City
| | - Andrew R Wilson
- School of Nursing, University of Utah Health Sciences Center, Salt Lake City
| | - Kristi J Smock
- Center for Effective Medical Testing, Department of Pathology, University of Utah, Salt Lake City
| | - Robert L Schmidt
- Center for Effective Medical Testing, Department of Pathology, University of Utah, Salt Lake City
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Venkatesh AK, Hajdasz D, Rothenberg C, Dashevsky M, Parwani V, Sevilla M, Shapiro M, Schwartz I. Reducing Unnecessary Blood Chemistry Testing in the Emergency Department: Implementation of Choosing Wisely. Am J Med Qual 2017; 33:81-85. [DOI: 10.1177/1062860617691842] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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18
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Jackups R. The Promise-and Pitfalls-of Computerized Provider Alerts for Laboratory Test Ordering. Clin Chem 2016; 62:791-2. [PMID: 27127182 DOI: 10.1373/clinchem.2016.256776] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 03/28/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Ronald Jackups
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO.
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