Nephrolithiasis is a disease common in both the Western and non-Western world. Several population based studies have demonstrated a rising prevalence and incidence of the disease over the last several decades. Recurrence occurs frequently after an initial stone event. The influence of diet on the risk of nephrolithiasis is important, particularly dietary calcium and fluid intake. An increasing intake of dietary calcium and fluid are consistently associated with a reduced risk of incident nephrolithiasis in both men and women. Increasing evidence suggests that nephrolithiasis is associated with systemic diseases like obesity, diabetes, and cardiovascular disease. Nephrolithiasis places a significant burden on the health care system, which is likely to increase with time.

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Resident physicians routinely order unnecessary inpatient laboratory tests. As hospitalists face growing pressures to reduce low-value services, understanding the factors that drive residents' laboratory ordering can help steer resident training in high-value care. We conducted a qualitative analysis of internal medicine (IM) and general surgery (GS) residents at a large academic medical center to describe the frequency of perceived unnecessary ordering of inpatient laboratory tests, factors contributing to that behavior, and potential interventions to change it. The sample comprised 57.0% of IM and 54.4% of GS residents. Among respondents, perceived unnecessary inpatient laboratory test ordering was self-reported by 88.2% of IM and 67.7% of GS residents, occurring on a daily basis by 43.5% and 32.3% of responding IM and GS residents, respectively. Across both specialties, residents attributed their behaviors to the health system culture, lack of transparency of the costs associated with health care services, and lack of faculty role models that celebrate restraint. Journal of Hospital Medicine 2016;11:869-872. V C 2016 Society of Hospital MedicineResident physicians routinely order inpatient laboratory tests, 1 and there is evidence to suggest that many of these tests are unnecessary 2 and potentially harmful. 3 The Society of Hospital Medicine has identified reducing the unnecessary ordering of inpatient laboratory testing as part of the Choosing Wisely campaign. 4 Hospitalists at academic medical centers face growing pressures to develop processes to reduce low-value care and train residents to be stewards of healthcare resources. 5 Studies 6-9 have described that institutional and training factors drive residents' resource utilization patterns, but, to our knowledge, none have described what factors contribute to residents' unnecessary laboratory testing. To better understand the factors associated with residents' ordering patterns, we conducted a qualitative analysis of internal medicine (IM) and general surgery (GS) residents at a large academic medical center in order to describe residents' perception of the: (1) frequency of ordering unnecessary inpatient laboratory tests, (2) factors contributing to that behavior, and (3) potential interventions to change it. We also explored differences in responses by specialty and training level. METHODSIn October 2014, we surveyed all IM and GS residents at the Hospital of the University of Pennsylvania. We reviewed the literature and conducted focus groups with residents to formulate items for the survey instrument. A draft of the survey was administered to 8 residents from both specialties, and their feedback was collated and incorporated into the final version of the instrument. The final 15-question survey was comprised of 4 components: (1) training information such as specialty and postgraduate year (PGY), (2) selfreported frequency of perceived unnecessary ordering of inpatient laboratory tests, (3) perception of factors contributing to unnecessary ordering, a...

are considering increasing price transparency at the time of order entry. However, evidence of its impact on clinician ordering behavior is inconsistent and limited to single-site evaluations of shorter duration.OBJECTIVE To test the effect of displaying Medicare allowable fees for inpatient laboratory tests on clinician ordering behavior over 1 year. DESIGN, SETTING, AND PARTICIPANTSThe Pragmatic Randomized Introduction of Cost data through the electronic health record (PRICE) trial was a randomized clinical trial comparing a 1-year intervention to a 1-year preintervention period, and adjusting for time trends and patient characteristics. The trial took place at 3 hospitals in Philadelphia between April 2014 and April 2016 and included 98 529 patients comprising 142 921 hospital admissions.INTERVENTIONS Inpatient laboratory test groups were randomly assigned to display Medicare allowable fees (30 in intervention) or not (30 in control) in the electronic health record. MAIN OUTCOMES AND MEASURESPrimary outcome was the number of tests ordered per patient-day. Secondary outcomes were tests performed per patient-day and Medicare associated fees. RESULTSThe sample included 142 921 hospital admissions representing patients who were 51.9% white (74 165), 38.9% black (55 526), and 56.9% female (81 291) with a mean (SD) age of 54.7 (19.0) years. Preintervention trends of order rates among the intervention and control groups were similar. In adjusted analyses of the intervention group compared with the control group over time, there were no significant changes in overall test ordering behavior (0.