A multifaceted hospitalist quality improvement intervention: Decreased frequency of common labs

Abstract

PURPOSE:Common labs such as a daily complete blood count or a daily basic metabolic panel represent possible waste and have been targeted by professional societies and the Choosing Wisely campaign for critical evaluation. We undertook a multifaceted quality-improvement (QI) intervention in a large community hospitalist group to decrease unnecessary common labs. METHODS:The QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered as daily within the hospitalist group. We performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the 7-month intervention period. Demographic and clinical data were collected from the electronic medical record. The primary endpoint was number of common labs ordered per patient-day as estimated by a clustered multivariable linear regression model clustering by ordering hospitalist. Secondary endpoints included length of stay, hospital mortality, 30-day readmission, blood transfusion, amount of blood transfused, and laboratory cost per patient. RESULTS:The baseline (n 5 7824) and intervention (n 5 5759) cohorts were similar in their demographics, though the distribution of primary discharge diagnosisrelated groups differed. At baseline, a mean of 2.06 (standard deviation 1.40) common labs were ordered per patientday. Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared to baseline (95% confidence interval [CI], 0.34 to 0.11; P < 0.01). There were nonsignificant reductions in hospital mortality in the intervention period compared to baseline (2.2% vs 1.8%, P 5 0.1) as well as volume of blood transfused in patients who received a transfusion (127.2 mL decrease; 95% CI, 2257.9 to 3.6; P 5 0.06). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618).CONCLUSION: Implementation of a multifaceted QI intervention within a community-based hospitalist group was associated with a significant, but modest, decrease in the number of ordered lab tests and hospital costs. No effect was seen on hospital length of stay, mortality, or readmission rate. This intervention suggests that a communitybased hospitalist QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care. Journal

Reducing the number of unnecessary routine laboratory tests through education of internal medicine residents

“…Corson et al 8 used emails to educate hospitalists and ask they reduce the number or routine tests ordered. They tracked the number of tests each hospitalist ordered and provided monthly reports to the group detailing how many tests each hospitalist ordered.…”

A multi‐level strategy for a long lasting reduction in unnecessary laboratory testing: A multicenter before and after study in a teaching hospital network

“…The spectrum of laboratory testing overuse in the hospital setting concerns both, the initial patient evaluation and scheduled checks during the follow‐up . The repetition of untargeted laboratory testing during the hospital stay in clinically stable patients represents an example of low‐value care which potentially can harm patients . Ordering laboratory testing at regular intervals (eg, daily) or on a routine basis, could in fact lead to further unnecessary diagnostic and therapeutic procedures potentially producing stress and side‐effects .…”

“…Several interventions have been targeted at the inadequacy of blood testing in hospitals. The most successful were those that implemented multifaceted approaches involving a combination of 3 strategies: education, audit, and feedback on provider ordering practices, and restrictive ordering options in the electronic prescription tools . In the context of the Choosing Wisely Campaign, an initiative launched by the American Board of Internal Medicine aimed to target unnecessary low value investigations and treatment and to promote conversation between patients and providers, several medical societies have recommended against routine laboratory testing in hospitalised patients .…”

Low Diagnostic Utility of Rechecking Hemoglobins Within 24 Hours in Hospitalized Patients

“…4,5 There are few guidelines that address the appropriateness of blood testing practices in hospitalized patients, and there have been concerns that tests are often over-ordered. 6,7,8,9,10 The objective of this study was to describe the proportion of repeat hemoglobin tests that demonstrated a clinically significant drop of at least 1 g/dL when obtained on the same calendar day.…”