Failed Attempts to Reduce Inappropriate Laboratory Utilization in an Emergency Department Setting in Cyprus: Lessons Learned

Petrou, Panagiotis

doi:10.1016/j.jemermed.2015.07.025

Cited by 18 publications

(13 citation statements)

References 25 publications

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“…In particular, our ED has electronic test ordering, which may increase the ease of ordering tests. This phenomenon has been observed in other settings . Additionally, our electronic system allows ordering of these electrolytes as a coupled package as well as individual ordering.…”

Section: Discussionsupporting

confidence: 68%

Utility of calcium, magnesium and phosphate testing in the emergency department

Date

Smith²,

Spencer

et al. 2019

Emerg Medicine Australasia

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Objective To determine how frequently calcium (Ca), magnesium (Mg) and phosphate (PO4) tests change ED patient management. Methods We undertook a retrospective observational study in an Australian tertiary referral ED. We enrolled adult patients (aged ≥18 years) who presented between 1 January and 30 June 2017 and who had a serum Ca, Mg or PO4 test ordered and completed during their ED stay. Patient symptoms, medical history, electrolyte levels and ED management changes were extracted from the electronic medical record. Results Of the 33 120 adults presented during the study period, 1716 (5.2%, 95% confidence interval [CI] 5.0–5.4) had at least one Ca, Mg or PO4 test completed in the ED. This included 4776 individual electrolyte tests, of which 776 (16.2%, 95% CI 15.2–17.3) were abnormal. Fifty‐six (7.2% [95% CI 5.5–9.3] of patients with abnormal tests, 1.2% [95% CI 0.9–1.5] of all tests) tests were associated with a change in ED management. Twenty‐six out of 1683 (1.5%) Ca levels were low with six (23.1%) management changes; 203 (12.1%) were high with 10 (4.9%) management changes. One hundred and twenty‐eight out of 1579 (8.1%) Mg levels were low with 33 (25.8%) management changes; 30 (1.9%) were high with no management changes. Two hundred and twenty‐five out of 1514 (14.9%) PO4 levels were low with six (2.7%) management changes; 164 (10.8%) were high with one (0.6%) management change. Fifty (2.9%) patients had management changes despite normal electrolyte levels. Conclusion Ca, Mg and PO4 testing is common. However, the yield of clinically significant abnormal levels is low and patient management is rarely changed. Testing of these electrolytes needs to be rationalised.

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Section: Discussionsupporting

confidence: 68%

Utility of calcium, magnesium and phosphate testing in the emergency department

Date

Smith²,

Spencer

et al. 2019

Emerg Medicine Australasia

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“…T, alkaline phosphate, complete blood count, erythrocyte sedimentation rate, C-reactive protein, urine culture, blood culture, stool examination and VBG. Then, the most expensive and MULTs, as well as contributing factors in inappropriate test ordering behaviour, were developed in Failure to check previous results 6, 26 …”

Section: Study Protocolmentioning

confidence: 99%

“…4,5 Diagnostic laboratory tests impose more fi nancial diffi culties and lead to poor patient satisfaction with services by causing morbidities like polyphlebotomy and hospitalacquired anaemia. 5,6 Despite the unpleasant impact caused by laboratory tests, studies revealed 26.4% and 20.6% of all laboratory tests are over utilised. 7,8 It is both clinically and fi nancially signifi cant to understand physician ordering behaviour in requesting laboratory tests.…”

Section: Introductionmentioning

confidence: 99%

Going beyond Audit and Feedback: Towards Behaviour-Based Interventions to Change Physician Laboratory Test Ordering Behaviour

Meidani

Ga²,

Kheirkhah

et al. 2017

Journal of the Royal College of Physicians of Edinburgh

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Studies indicate there are a variety of contributing factors affecting physician test ordering behaviour. Identifying these behaviours allows development of behaviour-based interventions.Methods Through a pilot study, the list of contributing factors in laboratory tests ordering, and the most ordered tests, were identi ed, and given to 50 medical students, interns, residents and paediatricians in questionnaire form. The results showed routine tests and peer or supervisor pressure as the most in uential factors affecting physician ordering behaviour. An audit and feedback mechanism was selected as an appropriate intervention to improve physician ordering behaviour. The intervention was carried out at two intervals over a three-month period.Findings There was a large reduction in the number of laboratory tests ordered; from 908 before intervention to 389 and 361 after rst and second intervention, respectively. There was a signi cant relationship between audit and feedback and the meaningful reduction of 7 out of 15 laboratory tests including complete blood count (p = 0.002), erythrocyte sedimentation rate (p = 0.01), C-reactive protein (p = 0.01), venous blood gas (p = 0.016), urine analysis (p = 0.005), blood culture (p = 0.045) and stool examination (p = 0.001).Conclusion The audit and feedback intervention, even in short duration, affects physician ordering behaviour. It should be designed in terms of behaviour-based intervention and diagnosis of the contributing factors in physicians' behaviour. Further studies are required to substantiate the effectiveness of such behaviour-based intervention strategies in changing physician behaviour.Keywords: audit and feedback, child, diagnostic tests, laboratory medicine, medical students, physicians, teaching rounds, test ordering, test request, utilisation review Declaration of interests: No confl ict of interests declaredAbstract Introduction

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“…This is particularly applicable to physicians in high‐risk specialties such as Emergency Medicine. This shift in practice has led to resources overutilization, increased economic burden to the health care system, and potentially added patients' discomfort and risk exposure (eg ionizing radiation) . Studies have revealed that, in clinical practice, an increased awareness about the cost of any diagnostic test by the practicing physician yields a change in ordering behavior and a reduction in medical expenses .…”

Section: Introductionmentioning

confidence: 99%

Clinical utility and economic burden of routine serum lipase determination in the Emergency Department

et al. 2019

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Background Serum lipase is a rapid and reliable laboratory test central to diagnosing acute pancreatitis (AP). Routine use in the emergency department (ED) setting for all cases of abdominal pain or as part of a standard laboratory biochemical profile may lead to unnecessary expenses. Aim To examine the utility of serum lipase determination at a tertiary care centre ED. Methods Retrospective cross‐sectional study of ED patients having serum lipase determination over a 12‐month period. Electronic medical records were reviewed for indication and interpretation leading to additional diagnostic imaging, specialist consultation, interventions or hospital admission. Results A total of 24 133 adult patients visited the ED during the study period: 4976 (20.6%) had serum lipase determination, 614 (12.4%) had abnormal lipase, 130 of which (21.1%) were above the diagnostic threshold for acutre pancreatitis (AP) (>3× ULN). A total of 75 patients had confirmed AP (0.3% of all adult ED visits). The positive and negative predictive values of serum lipase (>3× ULN) for AP were 43.6% and 99.6%, respectively. One thousand eight hundred and ninety patients (38.0%) had no abdominal pain on history or physical examination. In this group, the total charge associated with lipase determination was $51 030 with 251 (13.3%) elevated lipase values triggering cross‐sectional abdominal imaging in 61 (24.3%) patients and unwarranted gastroenterology consultation in three (1.2%) for an additional charge of $28 975. Conclusions Serum lipase is widely overutilised in the emergency setting resulting in unnecessary expenses and investigations. Evidence‐based review of clinical guidelines and more restrictive testing can result in substantial cost savings and improved patient care.

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Failed Attempts to Reduce Inappropriate Laboratory Utilization in an Emergency Department Setting in Cyprus: Lessons Learned

Cited by 18 publications

References 25 publications

Utility of calcium, magnesium and phosphate testing in the emergency department

Utility of calcium, magnesium and phosphate testing in the emergency department

Going beyond Audit and Feedback: Towards Behaviour-Based Interventions to Change Physician Laboratory Test Ordering Behaviour

Clinical utility and economic burden of routine serum lipase determination in the Emergency Department

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