A simple, focused, computerized query to detect overutilization of laboratory tests

Does an electronic pathology ordering system change the volume and pattern of routine testing in hospital? An interrupted time series analysis

AIMS

Identifying and reducing low-value care is a vital issue in Australia, with pathology test ordering a common focus in this field. This study builds on previous research and aimed to quantify the impact of the implementation of an electronic ordering (e-ordering) system on the volume of pathology testing, compared with manual (paper based) ordering.

METHODS

An audit and analysis of pathology test data were conducted, using an interrupted time series design to investigate the impact of the e-ordering system on pathology ordering patterns. All medical and surgical adult inpatients at a tertiary referral hospital in Newcastle, Australia, were included over a 3-year period.

RESULTS

Overall, there were no statistically significant differences in the volume of orders due to the implementation of the e-ordering system. There was a slight increase in the aggregated volume (tests per admission and tests per bed day) of tests ordered across the entire study period, reflecting a secular trend.

CONCLUSIONS

Despite providing greater visibility and tracking of orders, we conclude that the implementation of an e-ordering system does not, in and of itself, reduce ordering volume. Efforts to identify and reduce low-value care will require intentional effort and specifically designed educational programmes or hard-wired algorithms.

Deep into Laboratory: An Artificial Intelligence Approach to Recommend Laboratory Tests

Laboratory tests are performed to make effective clinical decisions. However, inappropriate laboratory test ordering hampers patient care and increases financial burden for healthcare. An automated laboratory test recommendation system can provide rapid and appropriate test selection, potentially improving the workflow to help physicians spend more time treating patients. The main objective of this study was to develop a deep learning-based automated system to recommend appropriate laboratory tests. A retrospective data collection was performed at the National Health Insurance database between 1 January 2013, and 31 December 2013. We included all prescriptions that had at least one laboratory test. A total of 1,463,837 prescriptions from 530,050 unique patients was included in our study. Of these patients, 296,541 were women (55.95%), the range of age was between 1 and 107 years. The deep learning (DL) model achieved a higher area under the receiver operating characteristics curve (AUROC micro = 0.98, and AUROC macro = 0.94). The findings of this study show that the DL model can accurately and efficiently identify laboratory tests. This model can be integrated into existing workflows to reduce under- and over-utilization problems.

Inappropriate repeat testing of complete blood count (CBC) and electrolyte panels in inpatients from Alberta, Canada

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.

Primary care use of laboratory tests in Northern Ireland's Western Health and Social Care Trust: a cross-sectional study

OBJECTIVES

To describe the laboratory test ordering patterns by general practitioners (GPs) in Northern Ireland Western Health and Social Care Trust (WHSCT) and explore demographic and socioeconomic associations with test requesting.

DESIGN

Cross-sectional study.

SETTING

WHSCT, Northern Ireland. : Particip ANTS: 55 WHSCT primary care medical practices that remained open throughout the study period 1 April 2011-31 March 2016.

OUTCOMES

To identify the temporal patterns of laboratory test ordering behaviour for eight commonly requested clinical biochemistry tests/test groups in WHSCT. To analyse the extent of variations in laboratory test requests by GPs and to explore whether these variations can be accounted for by clinical outcomes or geographical, demographic and socioeconomic characteristics.

RESULTS

The median number of adjusted test request rates over 5 consecutive years of the study period decreased by 45.7% for urine albumin/creatinine ratio (p<0.000001) and 19.4% for lipid profiles (p<0.000001) while a 60.6%, 36.6% and 29.5% increase was observed for HbA_1c (p<0.000001), immunoglobulins (p=0.000007) and prostate-specific antigen (PSA) (p=0.0003), respectively. The between-practice variation in test ordering rates increased by 272% for immunoglobulins (p=0.008) and 500% for HbA_1c (p=0.0001). No statistically significant relationship between ordering activity and either demographic (age and gender) and socioeconomic factors (deprivation) or Quality and Outcome Framework scores was observed. We found the rural-urban differences in between-practice variability in ordering rates for lipid profiles, thyroid profiles, PSA and immunoglobulins to be statistically significant at the Bonferroni-adjusted significance level p<0.01.

CONCLUSIONS

We explored potential factors of the interpractice variability in the use of laboratory tests and found that differences in requesting activity appear unrelated to either demographic and socioeconomic characteristics of GP practices or clinical outcome indicators.

Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods

BACKGROUND AND OBJECTIVES

Despite studies indicating a high rate of overuse, electrolyte testing remains common in pediatric inpatient care. Frequently repeated electrolyte tests often return normal results and can lead to patient harm and increased cost. We aimed to reduce electrolyte testing within a hospital medicine service by >25% within 6 months.

METHODS

We conducted an improvement project in which we targeted 6 hospital medicine teams at a large academic children's hospital system by using the Model for Improvement. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. Our primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. We tracked medical emergency team calls and readmission rates as balancing measures.

RESULTS

The mean baseline rate of electrolyte testing was 2.0 laboratory draws per 10 patient days, and this rate decreased by 35% after 1 month of initial educational interventions to 1.3 electrolyte laboratory draws per 10 patient days. This change has been sustained for 9 months and could save an estimated $292 000 in patient-level charges over the course of a year. Use of our highest-charge electrolyte panel decreased from 67% to 22% of testing. No change in rates of medical emergency team calls or readmission were found.

CONCLUSIONS

Our improvement intervention was associated with significant and rapid reduction in electrolyte testing and has not been associated with unintended adverse events.

Essential and Nonessential Blood Testing in the Clinical Teaching Unit

OBJECTIVES

The aim of the study was to evaluate the essential and nonessential blood tests ordered on the internal medicine clinical teaching units (CTUs) at Kingston General Hospital. Our aim was to establish a baseline performance measure identifying appropriate use of laboratory tests that could be used to inform improvement over time.

METHODS

For an 8-week period, 14 CTU attending physicians at Kingston General Hospital were surveyed. They were asked for each of their patients, "What blood tests do you consider to be essential for tomorrow morning to maintain appropriate care for this patient?" The following day, blood tests that were ordered were compared with the "essential" list previously given by the attending physicians.

RESULTS

Of 291 processed blood tests, 148 (51%) had not been considered essential by attending physicians; of the 203 tests considered essential, 60 (30%) were not ordered. Total agreement between "essential" and processed tests was poor (κ = 0.51; confidence interval, 0.45-0.56).

CONCLUSIONS

Inadequate use of blood tests for CTU patients is common. Quality improvement initiatives should aim to address the lack of observed consensus between attending physicians' views and the ordered tests and to streamline decision-making and the ordering/communication processes. Clinical standards and guidelines regarding ordering of laboratory tests should be clearly defined.

Duplicated laboratory tests: evaluation of a computerized alert intervention abstract

Redundant testing contributes to reductions in healthcare system efficiency. The purpose of this study was to: (1) determine if the use of a computerized alert would reduce the number and cost of duplicated Acute Hepatitis Profile (AHP) laboratory tests and (2) assess what patient, test, and system factors were associated with duplication. This study used a quasi-experimental pre- and post-test design to determine the proportion of duplication of the AHP test before and after implementation of a computerized alert intervention. The AHP test was duplicated if the test was requested again within 15 days of the initial test being performed and the result present in the medical record. The intervention consisted of a computerized alert (pop-up window) that indicated to the clinician that the test had recently been ordered. A total of 674 AHP tests were performed in the pre-intervention period and 692 in the postintervention group. In the pre-intervention period, 53 (7.9%) were duplicated and in postintervention, 18 (2.6%) were duplicated (p<.001). The implementation of the alert was shown to significantly reduce associated costs of duplicated AHP tests (p≤.001). Implementation of computerized alerts may be useful in reducing duplicate laboratory tests and improving healthcare system efficiency.

The rise of cholesterol testing: how much is unnecessary

BACKGROUND

Laboratory testing has increased dramatically over recent decades, which is a consequence particularly of repeat testing or monitoring, as either a response to treatment or follow-up.

AIM

To assess rates of measurement of lipid levels (total cholesterol, high-density lipoprotein, triglyceride) for diagnosis and monitoring over the last 20 years.

DESIGN OF STUDY

Audit of electronic database.

SETTING

A single region in the UK (Oxfordshire).

METHOD

Specimens from individual patients were matched over time. All tests that were the third or more in a 3-year period were considered to be for monitoring, while the first and second were considered to be for diagnosis. As recent evidence-based recommendations suggest that frequent monitoring of cholesterol may reflect measurement error rather than true changes, between one and three tests in each 3-year period were considered to be 'necessary'.

RESULTS

Over the 20 years from 1987 there has been a more than 15-fold rise in the overall number of lipid tests requested. After a small decline in the early 1990s, testing rose steadily after publication of several large statin trials, particularly tests requested in primary rather than secondary care. Repeat testing (likely to be for monitoring) rose from 24% of tests (1993-1995) to 61% (2005-2007), with between 42% and 79% of tests in 2005-2007 possibly being unnecessary. Mean cholesterol values declined over time from 1996 onwards.

CONCLUSION

In the last decade, the number of cholesterol tests performed in Oxfordshire has risen dramatically. Much of this appears to be for monitoring purposes rather than case finding or risk assessment. The majority of cholesterol tests requested may be unnecessary.

Implementation of computerised physician order entry (CPOE) and picture archiving and communication systems (PACS) in the NHS: quantitative before and after study

OBJECTIVE

To assess the impact of components of the national programme for information technology (NPfIT) on measures of clinical and operational efficiency.

DESIGN

Quasi-experimental controlled before and after study using routinely collected patient level data.

SETTING

Four NHS acute hospital trusts in England.

DATA SOURCES

Inpatient admissions and outpatient appointments, 2000-5.

INTERVENTIONS

A system for ordering pathology tests and browsing results (computerised physician order entry, CPOE) and a system for requesting radiological examinations and displaying images (picture archiving and communications system, PACS).

MAIN OUTCOME MEASURES

Requests per inpatient, outpatient, or day case patient for full blood count, urine culture and urea and electrolytes tests, and plain x ray film, computed tomography, and ultrasonography examinations.

RESULTS

CPOE was associated with a reduction in the proportion of outpatient appointments at which full blood count (odds ratio 0.25, 95% confidence interval 0.16 to 0.40), urea and electrolytes (0.55, 0.39 to 0.77), and urine culture (0.30, 0.17 to 0.51) tests were ordered, and at which full blood count tests were repeated (0.73, 0.53 to 0.99). Conversely, the same system was associated with an almost fourfold increase in the use of urea and electrolytes tests among day case patients (3.63, 1.66 to 7.94). PACS was associated with a reduction in repeat plain x ray films at outpatient appointments (0.62, 0.44 to 0.88) and a reduction in inpatient computed tomography (0.83, 0.70 to 0.98). Conversely, it was associated with increases in computed tomography requested at outpatient appointments (1.89, 1.26 to 2.84) and computed tomography repeated within 48 hours during an inpatient stay (2.18, 1.52 to 3.14).

CONCLUSIONS

CPOE and PACS were associated with both increases and reductions in tests and examinations. The magnitude of the changes is potentially important with respect to the efficiency of provision of health care. Better information about the impact of modern IT is required to enable healthcare organisations to manage implementation optimally.

PROTEMPA: a method for specifying and identifying temporal sequences in retrospective data for patient selection

OBJECTIVE

To specify and identify disease and patient care processes represented by temporal patterns in clinical events and observations, and retrieve patient populations containing those patterns from clinical data repositories, in support of clinical research, outcomes studies, and quality assurance.

DESIGN

A data processing method called PROTEMPA (Process-oriented Temporal Analysis) was developed for defining and detecting clinically relevant temporal and mathematical patterns in retrospective data. PROTEMPA provides for portability across data sources, "pluggable" data processing environments, and the creation of libraries of pattern definitions and data processing algorithms.

MEASUREMENTS

A proof-of-concept implementation of PROTEMPA in Java was evaluated against standard SQL queries for its ability to identify patients from a large clinical data repository who show the features of HELLP syndrome, and categorize those patients by disease severity and progression based on time sequence characteristics in their clinical laboratory test results. RESULTS were verified by manual case review.

RESULTS

The proof-of-concept implementation was more accurate than SQL in identifying patients with HELLP and correctly assigned severity and disease progression categories, which was not possible using SQL only.

CONCLUSIONS

PROTEMPA supports the identification and categorization of patients with complex disease based on the characteristics of and relationships between time sequences in multiple data types. Identifying patient populations who share these types of patterns may be useful when patient features of interest do not have standard codes, are poorly-expressed in coding schemes, may be inaccurately or incompletely coded, or are not represented explicitly as data values.

Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy

AIMS

To identify factors contributing to laboratory overutilisation in an academic medical department, and to assess the effect of an educational feedback strategy on inappropriate test-ordering behaviour.

METHODS

The records of 426 patients admitted during a 6-month period were reviewed. The usefulness of 25 investigations (haematology, basic biochemistry and arterial blood gases) was assessed according to implicit criteria. Trainees' acquaintance with investigation costs was assessed via a multiple-choice questionnaire. The medical staff was informed about their test-ordering behaviour, cost awareness and the factors associated with overuse of diagnostic tests. The test-ordering behaviour of the same doctors was reassessed on 214 patients managed during 6 months after the intervention.

RESULTS

Overall, 24 482 laboratory tests were ordered before the intervention (mean 2.96 tests/patient/day). Among those, 67.9% were not considered to have contributed towards management of patients (mean avoidable 2.01 tests/patient/day). Patient age >/=65 years, hospitalisation beyond 7 days and increased case difficulty (death or inability to establish a diagnosis) were factors independently associated with overuse of laboratory tests. Senior trainees ordered more laboratory examinations, but the percentage of avoidable tests requested by junior trainees was higher. A moderate and disparate level of trainees' awareness about the cost of common laboratory examinations was disclosed. The avoidable tests/patient/day were significantly decreased after the intervention (mean 1.58, p = 0.002), but containment of unnecessary ordering of tests gradually waned during the semester after the intervention.

CONCLUSION

Repeated audit, continuous education and alertness of doctors, on the basis of assessment of factors contributing to laboratory overutilisation, result in restraining the redundant ordering of tests in the hospital setting.

Managing transferability of laboratory data

Considerable attention has been focused on definition and enhancement of the analytical quality in laboratory testing over the past decades. Advances in laboratory technology and computer informatics have allowed a major sense of confidence with the analytical phase and more efforts should now be focused on extra-analytical areas of improvement, that should further strengthen the link between cost effectiveness and clinical outcome. Deduction and implementation of common reference intervals, to be possibly shared by a regional network of clinical laboratories, appear so far a crucial step to increase efficiency and harmonization. With the experience gained from External Quality Control exercises and with the consensus of several contributory laboratories, this process is underway in Italy. Quality performances resulting from widespread implementation of common reference intervals and longitudinal comparison of patient's data, will allow clinical laboratories to accomplish with a major transferability, amplifying health benefits and meeting increasing health systems demand.

Preanalytical variability: the dark side of the moon in laboratory testing

Remarkable advances in instrument technology, automation and computer science have greatly simplified many aspects of previously tedious tasks in laboratory diagnostics, creating a greater volume of routine work, and significantly improving the quality of results of laboratory testing. Following the development and successful implementation of high-quality analytical standards, analytical errors are no longer the main factor influencing the reliability and clinical utilization of laboratory diagnostics. Therefore, additional sources of variation in the entire laboratory testing process should become the focus for further and necessary quality improvements. Errors occurring within the extra-analytical phases are still the prevailing source of concern. Accordingly, lack of standardized procedures for sample collection, including patient preparation, specimen acquisition, handling and storage, account for up to 93% of the errors currently encountered within the entire diagnostic process. The profound awareness that complete elimination of laboratory testing errors is unrealistic, especially those relating to extra-analytical phases that are harder to control, highlights the importance of good laboratory practice and compliance with the new accreditation standards, which encompass the adoption of suitable strategies for error prevention, tracking and reduction, including process redesign, the use of extra-analytical specifications and improved communication among caregivers.