Association Between Health System Factors and Utilization of Routine Laboratory Tests in Clinical Teaching Units: a Cohort Analysis

Abstract

BACKGROUND: Few studies have looked at health system factors associated with laboratory test use. OBJECTIVE: To determine the association between health system factors and routine laboratory test use in medical inpatients. DESIGN: We conducted a retrospective cohort study on adult patients admitted to clinical teaching units over a 3year period (January 2015 to December 2017) at three tertiary care hospitals in Calgary, Alberta. PARTICIPANTS: Patients were assigned to a Case Mix Group+ (CMG+) category based on their clinical characteristics, and patients in the top 10 CMG+ groups were included in the cohort. EXPOSURES: The examined health system factors were (1) number of primary attending physicians seen by a patient, (2) number of attending medical teams seen by a patient, (3) structure of the medical team, and (4) day of the week. MAIN MEASURES: The primary outcome was the total number of routine laboratory tests ordered on a patient during their admission. Statistical models were adjusted for age, sex, length of stay, Charlson comorbidity index, and CMG+ group. RESULTS: The final cohort consisting of 36,667 patientdays in hospital (mean (SD) age 62.5 (18.4) years) represented 5071 unique hospitalizations and 4324 unique patients. Routine laboratory test use was increased when patients saw multiple attending physicians; with an adjusted incidence rate ratio (IRR) of 1.46 (95% CI, 1.37-1.55) for two attending physicians, and 2.50 (95% CI, 2.23-2.79) for three or more attending physicians compared to a single attending physician. The number of routine laboratory tests was slightly lower on weekends (IRR 0.98, 95% CI, 0.96-0.99) and on teams without a senior resident as part of their team structure (IRR 0.89, 95% CI 0.830.96). CONCLUSIONS:The associations observed in this study suggest that breaks in continuity of care, including increased frequency in patient transfer of care, may impact the utilization of routine laboratory tests.

Association between physician continuity of care and patient outcomes in clinical teaching units: a cohort analysis

“…We excluded 74 540 in-hospital patient-days that did not belong in the top 10 CMG+ categories. Our final cohort included 36 667 hospital patient-days with 4324 unique patients over 5071 hospital admissions 11 (Figure 1). The top 10 CMG+ groups were as follows: heart failure without coronary angiogram, other or unspecified sepsis or shock, chronic obstructive pulmonary disease, cirrhosis or alcoholic hepatitis, viral or unspecified pneumonia, diabetes, renal failure, gastrointestinal hemorrhage, respiratory failure and disorders of fluid or electrolyte imbalance.…”

“…20 Related research has shown other impacts of breaks in physician continuity such as increases in redundant use of diagnostic testing. 11,21,22 More research is needed to identify the full spectrum of downstream outcomes of breaks in attending physician continuity of care on CTUs at the patient, provider and health-systems levels.…”

“…10 We used the same cohort that we had employed previously to describe the association between health system factors and use of routine laboratory tests on CTUs. 11 We identified all adult (aged ≥ 18 yr) hospital admissions on the CTUs at the 3 hospitals between January 2015 and December 2017. We selected this study period because the CTU structure had been stable during these years.…”

Repurposing the Ordering of Routine Laboratory Tests in Hospitalised Medical Patients (RePORT): results of a cluster randomised stepped-wedge quality improvement study

“…However, on the CTUs, the changes did not sustain after the study period. Recognising the additional merits of system-focused interventions on effectiveness and sustainability,29 our team has worked with operational and medical team leaders in advance of the launch of a new provincial harmonised EMR system to design system-level changes including modifications of order sets and entry processes 30. We are currently examining the effect of the provincial harmonised EMR deployment on the use of laboratory tests.…”