Medical stewardship: Pathology evidence based ordering to reduce inappropriate test ordering in a teaching hospital

Abstract

Objective: This study was designed as an educational program aimed at promoting evidence-based pathology ordering with the aim of reducing inappropriate test ordering. Methods: Researchers benchmarked the hospital's pathology tests ordered in 2013-2014 before conducting a multifaceted education program in 2014-2015. The intervention consisted of main priorities including pathology test auditing, in-services and lectures, development and implementation of investigation pathways, and policy and procedure compliance. The main outcome measures was a reduction in commonly inappropriate ordered pathology testing leading to a reduction in the average test per hospital admission, and a reduction in specimen collection errors. Results: Through this educational method the researchers achieved a reduction in the average test per admission in 2014-2015 (M = 12.98) from 2013-2014 (M = 13.83). A two sample t-test indicated that this difference was significant, t(3.3006) = 0.0071, p = .01. The intervention included a focus on specimen collection errors and achieved a reduction in specimen error rates (M = 2,695) from the previous year (M = 3,000). A one sample t-test indicated that this difference was significant, t(3.0804) = 0.0105, p = .05. This intervention decreased commonly inappropriate pathology requests of Full Blood Count (FBC, -4.21%), Liver Function Tests (LFTs, -8.36%), Vitamin B12 (B12, -6.45%) and Coagulation profile (-21.22%). Commonly inappropriate pathology tests decreased (M = 7,120.33) from (M = 7,609.67). A two sample t-test indicated that this difference was significant, t(3.7730) = 0.0031, p = .005. Conclusions: Results confirmed that a multi-faceted education program can reduce inappropriate pathology test ordering, commonly over-ordered pathology test ordering, and pathology specimen error rates while maintaining positive patient outcomes.

Are all after-hours diagnostic imaging appropriate? An Australian Emergency Department pilot study

“…Results from this study, were thought to provide an indication on whether inappropriate requesting was a problem, before conducting an analysis into day-time requesting trends. The inspiration, for this pilot study was amid the growing concerns around unnecessary medical testing [1], [2], [3], [4], [5].…”

“…Diagnostic imaging procedures include: computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), computed tomography (CT), radiographs (X-rays), ultrasounds (US), and nuclear medicine scans. There is interest in the appropriateness of diagnostic imaging [1], and pathology test ordering within Australia [2]. Many radiologists acknowledge that diagnostic imaging is often inappropriately requested by treating clinicians, and that up to a third of all tests are partially or completely unnecessary [3], whereas others have suggested up to 20%–50% are at least in part unnecessary [4], [5].…”

“…Inappropriate medical testing has been defined as ‘applications of testing procedures which are performed at the wrong time or too frequently to be of value in diagnosis, prognosis, or ongoing clinical patient management’ [2]. This study defines inappropriate imaging, as procedures that do not adhere to clinical guidelines, and do not alter the ongoing management of the patient.…”

Audit and feedback to reduce inappropriate Full Blood Count pathology testing

“…This reliance has led to dramatic increases in pathology testing in many countries. [1][2][3] While some of this increase is appropriate, reflecting advances in training and technology, [4] as detailed by Gardiner [5] there is a growing trend of inappropriate/unnecessary pathology ordering. This includes inappropriate pathology requesting which are "performed at the wrong time or too frequently to be of value in diagnosis, prognosis, or ongoing clinical management".…”

“…Much of these FBC tests were deemed inappropriate, such as repeated FBC pathology testing (7.45%). Previous research [5] highlighted that the hospital ward areas had the highest percentage of inappropriate FBC pathology testing repeats, at an average inappropriate rate of 18%. These repeated tests did not contribute to the ongoing management of the patient and could be deemed a low-value pathology test.…”