The usefulness of implementing minimum retest intervals in reducing inappropriate laboratory test requests in a Dutch hospital

OBJECTIVES

Inappropriate use of laboratory testing remains a challenging problem worldwide. Minimum retest intervals (MRI) are used to reduce inappropriate laboratory testing. However, their effectiveness and the usefulness in reducing inappropriate laboratory testing is still a matter of debate. The aim of this study was to evaluate the effectiveness of broadly implemented MRIs as a means of reducing inappropriate laboratory test requests.

METHODS

We performed a retrospective study in a general care and teaching hospital in the Netherlands, where MRI alerts have been implemented as standard care since June 7th 2017. Clinical chemistry test orders in adult internal medicine patients placed between July 13th 2017 and December 31st 2019 were included. The primary outcome was the effectiveness of MRIs, expressed as percentages of tests ordered and barred as a result of MRIs.

RESULTS

Of a total of 218,511 test requests, 4,159 (1.90%) got an MRI alert. These MRIs were overruled by physicians in 21.76% of the cases. As a result of implementing MRIs, 3,254 (1.49%) tests were barred. The financial savings for the department of internal medicine directly related to the included barred laboratory tests during this period were 11,880 euros on a total amount of 636,598 euros for all performed tests.

CONCLUSIONS

Only a small proportion of laboratory tests are barred after implementation of MRIs, with a limited impact on the annual costs. However, MRIs provide a continuous reminder to focus on appropriate testing and the effectiveness of MRIs is potentially higher than described in this study.

A Multimodal Intervention for Reducing Unnecessary Repeat Glycated Hemoglobin Testing

OBJECTIVES

Reducing unnecessary tests that do not enhance quality can promote health-care value. Glycated hemoglobin (A1C) is often ordered at a frequency exceeding the recommendation of once every 3 months. We conducted a quality improvement (QI) initiative aimed to reduce unnecessary repeat testing by 75% at a tertiary care academic hospital.

METHODS

A retrospective baseline analysis was conducted on laboratory data from 2019 that enumerated unnecessary A1C tests, defined as repeat tests ordered within 60 days. A multifaceted change intervention with iterative plan-do-study-act cycles was introduced in March 2019 to educate providers and to automatically cancel A1C tests requested within 60 days. Monthly totals of A1C testing processed were plotted on statistical process control charts.

RESULTS

In 2019, 11% of all A1C tests ordered were unnecessary. Between March 2020 and January 2021, 11% of the tests (N=14,247 tests) were unnecessary, of which 84% were cancelled with our intervention. Providers in cardiology and nephrology accounted for over half (55%) of the unnecessary tests ordered.

CONCLUSIONS

A 2-pronged approach informed by root-cause analysis, and comprised of gatekeeping and provider education, can effectively promote resource stewardship for reducing unnecessary A1C testing.

Overutilization in laboratory medicine: tackling the problem with quality improvement science

Overutilization of tests and treatments is a widespread problem in contemporary heath care, and laboratory medicine is no exception. It is estimated that 10-70% of laboratory tests may be unnecessary, with estimates in the literature varying depending on the situation and the laboratory test. Inappropriate use of laboratory tests can lead to further unnecessary testing, adverse events, inaccurate diagnoses, and inappropriate treatments. Altogether, this increases the risk of harm to a patient, which can be physical, psychological, or financial in nature. Overutilization in healthcare is driven by complex factors including care delivery models, litigious practice environments, and medical and patient culture. Quality improvement (QI) methods can help to tackle overutilization. In this review, we outline the global healthcare problem of laboratory overutilization, particularly in the developed world, and describe how an understanding of and application of quality improvement principles can help to address this challenge.

Minimum retesting intervals in practice: 10 years experience

Background

Minimum retesting intervals (MRI) are a popular demand management solution for the identification and reduction of over-utilized tests. In 2011 Association of Clinical Biochemistry and Laboratory Medicines (ACB) published evidence-based recommendations for the use of MRI.

Aim

The aim of the paper was to review the use of MRI over the period since the introduction of these recommendations in 2011 to 2020 and compare it to previous published data between 2000-2010.

Methods

A multi-source literature search was performed to identify studies that reported the use of a MRI in the management or identification of inappropriate testing between the years prior to (2000–2010) and after implementation (2011–2020) of these recommendations.

Results

31 studies were identified which met the acceptance criteria (2000–2010 n=4, 2011–2020 n=27). Between 2000 and 2010 4.6% of tests (203,104/4,425,311) were identified as failing a defined MRI which rose to 11.8% of tests (2,691,591/22,777,288) in the 2011–2020 period. For those studies between 2011 and 2020 reporting predicted savings (n=20), 14.3% of tests (1,079,972/750,580) were cancelled, representing a total saving of 2.9 M Euros or 2.77 Euro/test. The most popular rejected test was Haemoglobin A1c which accounted for nearly a quarter of the total number of rejected tests. 13 out 27 studies used the ACB recommendations.

Conclusions

MRI are now an established, safe and sustainable demand management tool for the identification and management of inappropriate testing. Evidence based consensus recommendations have supported the adoption of this demand management tool into practice across multiple healthcare settings globally and harmonizing laboratory practice.

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.

The cost of repetitive laboratory testing for chronic disease

Interval laboratory investigations are necessary for monitoring chronic diseases. However, testing too frequently may not be beneficial clinically and can be considered low-value care. We examined the frequency of glycosylated haemoglobin, lipids, iron panels (serum iron, ferritin, transferrin, iron binding) thyroid function (free T4 and thyroid stimulating hormone) and 25-OH vitamin D tests in a 1290-bed tertiary hospital in Singapore. All tests done over a 20-month period (January 2016 to August 2017) were retrieved from the laboratory database. Of the 275 565 tests done for 115 971 patients, 5.2% were repeat tests done at intervals shorter than the minimum retesting interval, as defined by the Royal College of Pathologist and Irish Guidelines on the Use of the Laboratory. Using the Centers for Medicare and Medicaid Services Clinical Laboratory Fee Schedule, we estimated a cost burden of US$222 096 per year. Strategies to reduce unnecessary repetitive testing can result in significant cost savings.

Effectiveness of minimum retesting intervals in managing repetitive laboratory testing: experience from a Croatian university hospital

Introduction

Inappropriate laboratory retesting can be addressed by implementing minimum retesting intervals (MRI). The aim of our study was to assess the effectiveness of the implemented MRI protocol for inpatients.

Materials and methods

Minimum retesting intervals were applied for 53 laboratory tests. The overall reduction of test requests, reduction in charges and reagent cost savings, frequency of MRI alert appearance as well as the rate of MRI acceptance and ignorance were calculated for a one-year period. Reasons for violating the MRI rule, hospital departments that contributed mostly to MRI rule violation, and the frequency of MRI violations between routine and emergency laboratory were evaluated.

Results

During the one-year period, 106,780 requests violated the MRI rule, which corresponds to 14.8% of all requests received. 13,843 requests were cancelled, yielding a 1.9% reduction of requested tests. High-volume tests, namely complete blood count, C-reactive protein, alanine aminotransferase, gamma-glutamyltransferase and total bilirubin, accounted for 65% of all generated alerts and had the highest alert ignorance (>85%). The highest cancellation rate was observed for tumor markers and autoimmunity tests, for most being at least 50%. Annual charge reduction was 62,641 EUR while reagent cost savings were 11,408 EUR. Tests performed in the emergency laboratory had a higher alert appearance than the same routine tests. The most common reason for MRI violation was clinical justification based on the patient's condition. Most frequently ignored MRI alerts were in the intensive care unit.

Conclusion

MRI implementation showed limited effectiveness in reducing testing repetition and achieving financial savings, yet provided the basis for future improvements.

Once-Per-Visit Alerts: A Means to Study Alert Compliance and Reduce Repeat Laboratory Testing

BACKGROUND

Clinical decision support alerts for laboratory testing have poor compliance. Once-per-visit alerts, triggered by reorder of a test within the same admission, are highly specific for unnecessary orders and provide a means to study alert compliance.

METHODS

Once-per-visit alerts for 18 laboratory orderables were analyzed over a 60-month period from September 2012 to October 2016 at a 1200-bed academic medical center. To determine correlates of alert compliance, we compared alerts by test and provider characteristics.

RESULTS

Overall alert compliance was 54.5%. In multivariate regression, compliance correlated with length of stay at time of alert, provider type, previous alerts in a patient visit, test ordered, total alerts experienced by ordering provider, and previous order status.

CONCLUSIONS

A diverse set of provider and test characteristics influences compliance with once-per-visit laboratory alerts. Future alerts should incorporate these characteristics into alert design to minimize alert overrides.

The role of a best practice alert in the electronic medical record in reducing repetitive lab tests

Background

The recommendations of the American Board of Internal Medicine Foundation’s “Choosing Wisely^®” initiative recognize the importance of improving the appropriateness of testing behavior and reducing the number of duplicate laboratory tests.

Objective

To assess the effectiveness of an electronic medical record Best Practice Alert (BPA or “pop up”) intervention aimed at reducing duplicate laboratory tests and hospital costs.

Design

Comparison of the number of duplicated laboratory tests performed on inpatients before and after the intervention.

Setting

University of Florida Health Shands Hospital, Gainesville, FL, USA, during 2014–2017.

Intervention

The electronic medical record intervention was a BPA pop-up alert that informed the ordering physician if a recent identical order already existed along with the “ordering time”, “collecting time”, “resulting time”, and the result itself.

Main outcome measures

Percentage change in the number of inpatient duplicate orders of selected clinical biochemistry tests and cost savings from reduction of the duplicates. Student’s t-test and beta-binomial models were used to analyze the data.

Results

Results from the beta-binomial model indicated that the intervention reduced the overall duplicates by 18% (OR=0.82, standard error=0.016, P-value<0.000). Percent reductions in 9 of the 17 tests were statistically significant: serum hemoglobin A1C level, vitamin B12, serum erythrocyte sedimentation rate, serum folate, serum iron, lipid panel, respiratory viral panel, serum thyroid stimulating hormone level, and Vitamin D. Additionally, important cost savings were realized from the reduction of duplicates for each lab test (with the exception of CRP) with an estimated overall savings of $72,543 over 17 months in the post-intervention period.

Conclusions

The present study included all hospital inpatients and covered 17 clinical laboratory tests. This rather simple and low-cost intervention resulted in significant reductions in percentage duplicates of several tests and resulted in cost savings. The study also highlights the role of hospitalists in quality improvement.

Reducing Test Utilization in Hospital Settings: A Narrative Review

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.

Relevance or performance: potential savings associated with verification of prior results before performing microbiology analysis

OBJECTIVE

In an era of rising healthcare expenditures, it is critical to find ways to decrease cost. The objective of this study is to evaluate the number of repeated tests and the associated cost savings in a university-affiliated hospital.

METHODS

The following 7 microbiology analysis were assessed for nonrepeat testing: HCV antibody, HBV core antibody, CMV IgG, rubella IgG, Treponema pallidum antibodies, Clostridioides difficile toxin detection, and vancomycin-resistant enterococci PCR. Presence of a prior positive result leads to the cancellation of subsequent orders.

RESULTS

Percentages of not repeated test ranged from 0.1% to 21.4%. Rubella IgG had the highest proportion of unnecessary repeat testing. Total cost savings were estimated at $33,627 for 2016.

CONCLUSION

Unnecessary repeated microbiologic test can account for a non-negligible part of total volume test. Use of an automated software to detect unnecessary repeated microbiologic test through laboratory information system can generate important savings.

Demand management and optimization of clinical laboratory services in a tertiary referral center in Saudi Arabia

BACKGROUND

Demand for clinical laboratory services in our insti.tution has increased by 7% each year in the past 5 years, while the amount budgeted for services has remained fixed. To address the issue, we conducted a pilot study to curb inappropriate demand by implementing a minimum retest interval (time-based restrictions on the ordering certain tests) and thus reduce costs.

OBJECTIVE

Explore the impact (financial and work volume) of restricting overuse of laboratory tests that add to costs but provide no additional clinical value.

DESIGN

Pilot study of means to reduce costs and workload.

SETTING

Clinical laboratory that provides diagnostic support to a tertiary care center specializing in transplantation and oncology.

METHODS

With the engagement of clinical colleagues, we selected 13 tests characterized by high volume, high cost, or a perception of overuse that adds no clinical value. The selection was also based on established lock-out frequencies identified in a literature review. Data was captured on test numbers before and after initiating computer-based lock-outs along with the reference laboratory cost of these tests for the first 6 months of 2016 and 2017.

MAIN OUTCOME MEASURES

Alterations in testing patterns (mimimum retest intervals) and frequencies for tests.

RESULTS

The number of tests ordered during the 6-month period in 2017 were reduced by an average of 6.6% versus the same period for 2016, saving 2.03 million Saudi Arabian Riyals (SAR). Given a 7% annual growth in the preceding 5 years, the volume was reduced by 13% in real terms. The percentage reduction in number of tests ranged from as little as 0.2% for PT to 70.3% for an enzyme immunoassay. Savings were 1.4 million SAR in hematology and 0.36 million SAR in microbiology over the 6-month period.

CONCLUSION

Minimum retest intervals using computer-based rules are effective in supporting strategies to manage demand.

LIMITATIONS

This approach may not be applicable to all laboratory tests; however, the success of this pilot study would encourage more widespread use of this approach.

CONFLICT OF INTEREST

None.

Demand management by electronic gatekeeping of test requests does not influence requesting behaviour or save costs dramatically

Background

Healthcare budgets face constraints, and laboratories have developed strategies to adapt to the concomitant increase in workload. Some of the tests (7.4%) may be attributed to unnecessary repeat testing. Electronic gatekeeping has been implemented at selected laboratories in South Africa to limit unnecessary repeat testing. We performed a study of chemistry tests subjected to electronic gatekeeping to determine its effectiveness as a sustainable demand management tool.

Methods

A 22-month retrospective study of chemistry test requests at a Pretoria hospital was performed. Tests violating electronic gatekeeping rules were rejected upon registration before analysis, and cost-savings were estimated from electronic gatekeeping-held tests. The impact of electronic gatekeeping on the test requesting pattern of clinicians was derived from the percentage cost of electronic gatekeeping-held tests.

Results

The total savings generated from electronic gatekeeping test rejections amounted to $84,380. Greatest savings were generated from high-cost tests: glycated haemoglobin ($14,139), urea ($8661) and thyroid-stimulating hormone ($7514). The average number of electronic gatekeeping-held tests as a percentage of their total requested number over 22 months was 3.18%.

Discussion

The savings from electronic gatekeeping-held tests were not as dramatic as anticipated, but were modest and may have some impact in a cost-constrained setting. Electronic gatekeeping was concluded not to have a substantial effect on the clinician test requesting pattern, demonstrated by the largely unchanged monthly percentage of electronic gatekeeping-held tests. As a solitary demand management strategy, electronic gatekeeping does not appear to be as effective as anticipated or as demonstrated in other studies.

Reduction in Unnecessary Clinical Laboratory Testing Through Utilization Management at a US Government Veterans Affairs Hospital

OBJECTIVES

To implement an electronic laboratory utilization management system (laboratory expert system [LES]) to provide safe and effective reductions in unnecessary clinical laboratory testing.

METHODS

The LES is a set of frequency filter subroutines within the Veterans Affairs hospital and laboratory information system that was formulated by an interdisciplinary medical team.

RESULTS

Since implementing the LES, total test volume has decreased by a mean of 11.18% per year compared with our pre-LES test volume. This change was not attributable to fluctuations in outpatient visits or inpatient days of care. Laboratory cost savings were estimated at $151,184 and $163,751 for 2012 and 2013, respectively. A significant portion of these cost savings was attributable to reductions in high-volume, large panel testing. No adverse effects on patient care were reported, and mean length of stay for patients remained unchanged.

CONCLUSIONS

Electronic laboratory utilization systems can effectively reduce unnecessary laboratory testing without compromising patient care.

Interventions at the laboratory level to reduce laboratory test ordering by family physicians: Systematic review

OBJECTIVES

To assess the effectiveness of interventions by laboratories and to increase rational and reduce unnecessary family physician test ordering.

DESIGN AND METHODS

MEDLINE [1946-present], EMBASE [1980-present], EBM Reviews [1991-present](Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, - Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Health Technology Assessment, NHS Economic Evaluation Database), PubMed [1966-present], PubMed Central [1900-present], Scopus [1960-present], Web of Science [1900-present] and CINAHL [1982-present] were searched with no language or publication limits. Non-randomised studies were assessed with the Newcastle-Ottawa scale.

RESULTS

The search identified 9282 titles and abstracts, 238 were read in full-text and 3 cohort and 7 before- and after-studies were included. Most focused on changing a few tests and evaluated the interventions over several months. Seven changed laboratory forms (the two largest involved 5.2 million and 3.2 million tests), one negotiated a test ordering protocol with family physicians, and two required laboratory approval. They achieved an average 35% reduction in the 19 targeted tests, with a wide range (0%-100% reduction).

CONCLUSIONS

Ten studies were identified which tested interventions by laboratories to reduce test ordering by family physicians, and achieved an average 35% reduction in the 19 targeted tests. The rationale for choosing specific tests for intervention was often not explained, most studies targeted a few tests for several months, the tests and test volumes differed widely across studies, no author improved the results of previous interventions or asked participants their opinions about the intervention or assessed factors impeding change.

Effectiveness of a computerized alert system based on re-testing intervals for limiting the inappropriateness of laboratory test requests

OBJECTIVES

There is consolidated evidence that the burden of inappropriate laboratory test requests is very high, up to 70%. We describe here the function of a computerized alert system linked to the order entry, designed to limit the number of potentially inappropriate laboratory test requests.

DESIGN AND METHODS

A computerized alert system based on re-testing intervals and entailing the generation of pop-up alerts when preset criteria of appropriateness for 15 laboratory tests were violated was implemented in two clinical wards of the University Hospital of Parma. The effectiveness of the system for limiting potentially inappropriate tests was monitored for 6months.

RESULTS

Overall, 765/3539 (22%) test requests violated the preset criteria of appropriateness and generated the appearance of electronic alert. After alert appearance, 591 requests were annulled (17% of total tests requested and 77% of tests alerted, respectively). The total number of test requests violating the preset criteria of inappropriateness constantly decreased over time (26% in the first three months of implementation versus 17% in the following period; p<0.001). The total financial saving of test withdrawn was 3387 Euros (12.8% of the total test cost) throughout the study period.

CONCLUSIONS

The results of this study suggest that a computerized alert system may be effective to limit the inappropriateness of laboratory test requests, generating significant economic saving and educating physicians to a more efficient use of laboratory resources.

Demand management: an audit of chemical pathology test rejections by an electronic gate-keeping system at an academic hospital in Cape Town

Background

Demand management is an area of laboratory activity, which is becoming increasingly important. Within the health-care system, demand management can be defined as the use of health resources to maximise its utility. Tygerberg Hospital has introduced an electronic gate-keeping system. Chemistry tests which generate the highest cost are subjected to this system and may be automatically rejected according to a set of rules. This study aimed: (1) to identify the number of chemistry tests rejected by the eGK; (2) to identify which of these rejected tests were subsequently restored and (3) to assess the impact of rejections on clinical outcome and cost-saving.

Methods

A retrospective audit was conducted to determine the number of chemistry tests rejected and subsequently restored over a 6-month period. The case-notes of patients for whom requested tests previously rejected had been restored were randomly selected and investigated to assess clinical impact. Any cost-saving was calculated.

Results

A total of 68,480 tests were subjected to gate-keeping, and 4605 tests (6.7%) were rejected while 679 (14.7%) of these were restored by the requestor phoning the laboratory after obtaining authorisation. After examining a subset of clinical notes it was found that in most cases (80%), patient care was unaffected. The total cost saved was £25,387.

Conclusions

The majority of the rejected tests were unnecessary and following rejection, real savings were made. Electronic gate-keeping is a simple, effective and sustainable method of demand management.

An automated minimum retest interval rejection rule reduces repeat CRP workload and expenditure, and influences clinician-requesting behaviour

AIMS

Repeat serum C-reactive protein (CRP) measurements on the same day or on consecutive days are of limited clinical value. Minimum retesting intervals are recommended for managing unnecessary repeat testing. As not previously reported, we studied the effect of minimum retesting interval test rejection on laboratory workload and expenditure and on clinician-requesting behaviour.

METHODS

In a prospective study, we evaluated the effect of an automated 48 h CRP minimum retesting interval rule on inpatient and outpatient CRP workload and costs. Control data on inpatient and outpatient serum urea and electrolytes (UE) workload were collected during the study.

RESULTS

Over 1 year, there was a 7.0% and 12.3% decrease in CRP requests and CRP tests analysed, respectively, following the introduction of the minimum retesting interval rule when compared to the 1 year baseline period. This equated to an estimated annual reduction in revenue costs of £10 500, but cash savings in consumable costs of £3000. There was no significant change in UE requests.

CONCLUSIONS

We report, for the first time, that automated minimum retesting interval rejection rules as a stand-alone strategy are a cheap and sustainable method for reducing unnecessary repeat CRP tests, resulting in small laboratory cash savings, more efficient use of laboratory resources and standardisation of patient care pathways. The minimum retesting interval rejection rule also altered clinician test-requesting behaviour towards more appropriate requesting.