From the University of Toronto (Dr. Basuita, Corey L. Kamen, and Dr. Soong) and Sinai Health System (Corey L. Kamen, Cheryl Ethier, and Dr. Soong), Toronto, Ontario, Canada. Co-first authors are Manpreet Basuita, MD, and Corey L. Kamen, BSc.
Abstract
- Objective: Routine laboratory testing is common among medical inpatients; however, when ordered inappropriately testing can represent low-value care. We examined the impact of an evidence-based intervention bundle on utilization.
- Participants/setting: This prospective cohort study took place at a tertiary academic medical center and included 6424 patients admitted to the general internal medicine service between April 2016 and March 2018.
- Intervention: An intervention bundle, whose first components were implemented in July 2016, included computer order entry restrictions on repetitive laboratory testing, education, and audit-feedback.
- Measures: Data were extracted from the hospital electronic health record. The primary outcome was the number of routine blood tests (complete blood count, creatinine, and electrolytes) ordered per inpatient day.
- Analysis: Descriptive statistics were calculated for demographic variables. We used statistical process control charts to compare the baseline period (April 2016-June 2017) and the intervention period (July 2017-March 2018) for the primary outcome.
- Results: The mean number of combined routine laboratory tests ordered per inpatient day decreased from 1.19 (SD, 0.21) tests to 1.11 (SD, 0.05), a relative reduction of 6.7% (P < 0.0001). Mean cost per case related to laboratory tests decreased from $17.24 in the pre-intervention period to $16.17 in the post-intervention period (relative reduction of 6.2%). This resulted in savings of $26,851 in the intervention year.
- Conclusion: A laboratory intervention bundle was associated with small reductions in testing and costs. A routine test performed less than once per inpatient day may not be clinically appropriate or possible.
Keywords: utilization; clinical costs; quality improvement; QI intervention; internal medicine; inpatient.
Routine laboratory blood testing is a commonly used diagnostic tool that physicians rely on to provide patient care. Although routine blood testing represents less than 5% of most hospital budgets, routine use and over-reliance on testing among physicians makes it a target of cost-reduction efforts.1-3 A variety of interventions have been proposed to reduce inappropriate laboratory tests, with varying results.1,4-6 Successful interventions include providing physicians with fee data associated with ordered laboratory tests, unbundling panels of tests, and multicomponent interventions.6 We conducted a multifaceted quality improvement study to promote and develop interventions to adopt appropriate blood test ordering practices.
Methods
Setting
This prospective cohort study took place at Mount Sinai Hospital, a 443-bed academic hospital affiliated with the University of Toronto, where more than 2400 learners rotate through annually. The study was approved by the Mount Sinai Hospital Research Ethics Board.
Participants
We included all inpatient admissions to the general internal medicine service between April 2016 and March 2018. Exclusion criteria included a length of stay (LOS) longer than 365 days and admission to a critical care unit. Patients with more than 1 admission were counted as separate hospital inpatient visits.