Quality Improvement Intervention for Reduction of Redundant Testing

Abstract

Laboratory data are critical to analyzing and improving clinical quality. In the setting of residual use of creatine kinase M and B isoenzyme testing for myocardial infarction, we assessed disease outcomes of discordant creatine kinase M and B isoenzyme +/troponin I (−) test pairs in order to address anticipated clinician concerns about potential loss of case-finding sensitivity following proposed discontinuation of routine creatine kinase and creatine kinase M and B isoenzyme testing. Time-sequenced interventions were introduced. The main outcome was the percentage of cardiac marker studies performed within guidelines. Nonguideline orders dominated at baseline. Creatine kinase M and B isoenzyme testing in 7496 order sets failed to detect additional myocardial infarctions but was associated with 42 potentially preventable admissions/quarter. Interruptive computerized soft stops improved guideline compliance from 32.3% to 58% (P < .001) in services not receiving peer leader intervention and to >80% (P < .001) with peer leadership that featured dashboard feedback about test order performance. This successful experience was recapitulated in interrupted time series within 2 additional services within facility 1 and then in 2 external hospitals (including a critical access facility). Improvements have been sustained postintervention. Laboratory cost savings at the academic facility were estimated to be ≥US$635 000 per year. National collaborative data indicated that facility 1 improved its order patterns from fourth to first quartile compared to peer norms and imply that nonguideline orders persist elsewhere. This example illustrates how pathologists can provide leadership in assisting clinicians in changing laboratory ordering practices. We found that clinicians respond to local laboratory data about their own test performance and that evidence suggesting harm is more compelling to clinicians than evidence of cost savings. Our experience indicates that interventions done at an academic facility can be readily instituted by private practitioners at external facilities. The intervention data also supplement existing literature that electronic order interruptions are more successful when combined with modalities that rely on peer education combined with dashboard feedback about laboratory order performance. The findings may have implications for the role of the pathology laboratory in the ongoing pivot from quantity-based to value-based health care.

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

“…Similarly, CK‐MB was once over‐utilised in the Emergency Department and has now become an obsolete test, no longer recommended by the current literature and practices . In a study at a large academic medical centre evaluating the clinical and financial implications of creatine kinase‐muscle/brain (CK‐MB) in the ED, it was shown that CK‐MB can be safely removed from ordering practices without affecting patient outcome and with cost savings of approximately $47 000 per year . Zhang et al estimated the financial impact of reduction in CK‐MB at a community hospital to be around $463 744 effectively decreasing the unnecessary lab tests for acute coronary syndrome with significant cost savings to the healthcare system .…”

The Value Proposition for Pathologists: A Population Health Approach

“…There are significant emotional costs of fear, anxiety, and concern to patients, families, and friends during periods of diagnostic and therapeutic uncertainty, as well as significant health risks for the patient when invasive procedures such as cardiac catheterization are involved. 18…”

“…18,19 Data about the ordering practices linked to actual outcomes can address the optimism bias inherent in human nature that “more is better” and that unconventional reasons for intervention will improve care. 18,19…”

“…The adoption of EMR and computerized order entry (CPOE) have facilitated laboratory test ordering, data collection, and analysis, 20 as well as interventions to reduce necessary and unnecessary testing. 18,21 -23 In theory, utilization management has already become a target for inpatient clinical laboratory services, as payment for laboratory testing has been reduced, particularly in the inpatient setting. A systematic review of publications between 1997 and 2012 identified more than 34 000 citations with medical subject headings for the combination of “utilization” and “laboratory test(s).” A discouraging but not surprising finding was that a review of these studies using strict criteria found only 42 (0.1%) of them were well-done.…”

“…21 Pathologists must be prepared to participate in and/or lead this process as a routine part of practice, particularly since inclusions of trainees in quality improvement studies are an Accreditation Council for Graduate Medical Education (ACGME) requirement for all residencies. While downstream savings associated with systems interventions are likely to lead to the greatest value for society and the biggest change in pathology practice, 18,24,28 these savings have been very difficult to quantify. 18 Absent evidence, hospital administrators may not invest, federal and other insurers may not recognize the work as having relative value, and funders of research may continue to ignore the size, scope, and importance of the opportunity.…”