Canned Comments in the Hospital Laboratory Information System Can Decrease Microbiology Requests

OBJECTIVES

Phone calls to the microbiology laboratory can be to clarify culture results and provide education, but those calls also interrupt laboratory workflow. We characterized calls that the laboratory received and developed targeted comments to educate providers.

METHODS

Calls were logged and characterized, and we developed comments to address common call subjects. We applied the new comments to cultures and logged calls over the same interval the subsequent year. Data before and after implementation were analyzed.

RESULTS

Call volume decreased from 496 calls to 419 calls after implementation. There was a significant difference in level of training among callers (P < .005), but the nature of the calls did not change. Laboratory response showed an increase in release of previously generated data (eg, suppressed susceptibility results). Comments specifically developed to address intrinsic antibiotic resistance and common susceptibility patterns did not decrease call volume.

CONCLUSIONS

Implementation of comments in the laboratory information system decreased call volume, but targeted comments were less effective than anticipated.

The impact of education and clinical decision support on the quality of positive antinuclear antibody referrals

To implement and evaluate an intervention using education and clinical decision support (CDS) to improve the quality of positive ANA referrals. We retrospectively reviewed "positive ANA" referrals from April 2017 to May 2019. Demographic data and referring provider's location were recorded. Final diagnoses were categorized into two groups: rheumatic disease (RD) or no RD. We compared pre- and post-intervention groups for each type of referral. The positive predictive value (PPV) of an ANA referral leading to an RD for each referral group was calculated. Our intervention consisted of an educational poster and CDS which included a hard-stop prompt embedded into the electronic ANA order. All internal subgroups received CDS; only the main campus primary care providers (IPCP) received the educational poster. The external (EXT) referral subgroup did not receive either intervention. We found a significant increase in the number of RDs diagnosed post-intervention (p = 0.007). The PPV for all referrals increased from 16% to 26% during this project. All groups demonstrated improvement in PPV except the EXT group, which showed no change. Subgroups which demonstrated significant increase in the diagnosis of RD included total internal (p = 0.0005), internal PCP (p = 0.002), and affiliated primary care providers (p = 0.0002). The IPCP subgroup additionally received the educational intervention and did not demonstrate significant improvement. Implementing an intervention with a CDS component helps improve the quality of positive ANA referrals to rheumatology. Key Points • Clinical decision support improves the quality of positive ANA referrals. • Incorporating clinical decision support within the ANA order of an EHR is an effective way to deliver information to impact ordering at the "point of care."

A systematic literature review on unnecessary diagnostic testing: The role of ICT use

BACKGROUND

The negative impact of unnecessary diagnostic tests on healthcare systems and patients has been widely recognized. Medical researchers in various countries have been devoting effort to reduce unnecessary diagnostic tests by using different types of interventions, including information and communications technology-based (ICT-based) intervention, educational intervention, audit and feedback, the introduction of guidelines or protocols, and the reward and punishment of staff. We conducted a review of ICT based interventions and a comparative analysis of their relative effectiveness in reducing unnecessary tests.

METHOD

A systematic Boolean search in PubMed, EMBase and EBSCOhost research databases was performed. Keyword search and citation analysis were also conducted. Empirical studies reporting ICT based interventions, and their implications on relative effectiveness in reducing unnecessary diagnostic tests (pathology tests or medical imaging) were evaluated independently by two reviewers based on a rigorously developed coding protocol.

RESULTS

92 research articles from peer-reviewed journals were identified as eligible. 47 studies involved a single-method intervention and 45 involved multi-method interventions. Regardless of the number of interventions involved in the studies, ICT-based interventions were utilized by 71 studies and 59 of them were shown to be effective in reducing unnecessary testing. A clinical decision support (CDS) tool appeared to be the most adopted ICT approach, with 46 out of 71 studies using CDS tools. The CDS tool showed effectiveness in reducing test volume in 38 studies and reducing cost in 24 studies.

CONCLUSIONS

This review investigated five frequently utilized intervention methods, ICT-based, education, introduction of guidelines or protocols, audit and feedback, and reward and punishment. It provides in-depth analysis of the efficacy of different types of interventions and sheds insights about the benefits of ICT based interventions, especially those utilising CDS tools, to reduce unnecessary diagnostic testing. The replicability of the studies is limited due to the heterogeneity of the studies in terms of context, study design, and targeted types of tests.

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.

Reducing unnecessary vitamin testing in general practice: barriers and facilitators according to general practitioners and patients

OBJECTIVE

There has been an increase in testing of vitamins in patients in general practice, often based on irrational indications or for non-specific symptoms, causing increasing healthcare expenditures and medicalisation of patients. So far, there is little evidence of effective strategies to reduce this overtesting in general practice. Therefore, the aim of this qualitative study was to explore the barriers and facilitators for reducing the number of (unnecessary) vitamin D and B12 laboratory tests ordered.

DESIGN AND SETTING

This qualitative study, based on a grounded theory design, used semistructured interviews among general practitioners (GPs) and patients from two primary care networks (147 GPs, 195 000 patients). These networks participated in the Reducing Vitamin Testing in Primary Care Practice (REVERT) study, a clustered randomized trial comparing two de-implementation strategies to reduce test ordering in primary care in the Netherlands.

PARTICIPANTS

Twenty-one GPs, with a maximum of 1 GP per practice who took part in the REVERT study, and 22 patients (who were invited by their GP during vitamin-related consultations) were recruited, from which 20 GPs and 19 patients agreed to participate in this study.

RESULTS

The most important factor hampering vitamin-test reduction programmes is the mismatch between patients and medical professionals regarding the presumed appropriate indications for testing for vitamin D and B12. In contrast, the most important facilitator for vitamin-test reduction may be updating GPs' knowledge about test indications and their awareness of their own testing behaviour.

CONCLUSION

To achieve a sustainable reduction in vitamin testing, guidelines with clear and uniform recommendations on evidence-based indications for vitamin testing, combined with regular (individual) feedback on test-ordering behaviour, are needed. Moreover, the general public needs access to clear and reliable information on vitamin testing. Further research is required to measure the effect of these strategies on the number of vitamin test requests.

TRIAL REGISTRATION NUMBER

WAG/mb/16/039555.

Cost per Case Mix Index-Adjusted Hospital Day as a Measure of Effective Laboratory Utilization Efforts in a Growing Academic Medical Center

OBJECTIVES

Traditional laboratory utilization measures are unable to detect the results of small-scale utilization improvement efforts in a background of rising patient volumes and acuity. However, accurate assessment is necessary to document effectiveness of these efforts.

METHODS

Test menu changes, physician education, and laboratory utilization feedback were used to address costs and overused tests. Effectiveness was evaluated using cost/case mix index (CMI)-adjusted hospital day and inpatient tests/CMI-adjusted discharge. These metrics were compared with the more traditional measures of cost/test and inpatient tests/discharge.

RESULTS

Cost/CMI-adjusted hospital day and inpatient tests/CMI-adjusted discharge better demonstrated the impact of utilization improvement efforts compared with more traditional measures because they account for changes in patient volume and acuity.

CONCLUSIONS

Cost/CMI-adjusted hospital day and tests/CMI-adjusted discharge show the effectiveness of laboratory utilization efforts despite increasing patient volume and acuity.