School of Medicine and Health Sciences Poster Presentations

Title

Reducing Unnecessary Hospital Laboratory Testing

Poster Number

315

Document Type

Poster

Status

Medical Resident

Abstract Category

Quality Improvement

Keywords

Healthcare Expenditure, Laboratory Testing, Reducing Hospital Costs

Publication Date

Spring 2018

Abstract

Background:

Healthcare expenditures in the US account for 17.9% of the national GDP, or nearly $10,000 per person per year. Of this, waste has been estimated to represent approximately 1/3. This cost burden creates financial stress on the patient, care providers, and the system of care which attempts to allocate scarce medical resources. Several previous studies have shown that excessive or unnecessary clinical laboratory testing in the inpatient setting may be an opportunity to reduce waste without resulting in changes to care quality, patient or physician satisfaction[1]. In our academic medical center, “morning labs” have become a culturally ingrained on the medicine wards despite little evidence that testing actually results in a change in patient management for patients who are otherwise stable. Here we test a “goal-triggered” (i.e., will checking this laboratory test result in a change in management?) approach to routine inpatient laboratory testing.

Aim: Reduce unnecessary laboratory testing by 20% from baseline by July 2018

Methods:

We identified seven basic laboratory tests which are routinely included in morning laboratory draws, but could potentially be omitted in stable patients, where these labs would not change management. These included CBC, Differential, BMP, Liver Function Tests, Coagulation studies, Magnesium level, and Phosphorous level. A chart review was performed to identify all patients on a specific resident internal medicine team at a large university urban hospital throughout two months of 2017-2018. We first gathered baseline data on laboratory draws per patient without any intervention. The second PDSA cycle was composed of attending and resident education reminding care teams to only request laboratory testing if it would change the management for the patient. The third PDSA cycle included the use of laboratory cost sheets which were posted on the workstations of residents. Data regarding number of laboratory draws on each patient was obtained. A Microsoft Excel database maintaining subject confidentiality was created.

Results:

Reducing unnecessary laboratory testing was well received by both the hospital housestaff as well as attending physicians. During the two testing phases, only once was an intentionally unrequested laboratory test subsequently ordered due to clinician or patient preference. Despite qualitative acceptance, overall laboratory testing did not see a decline from our baseline in PDSA cycle #1 (2.9 to 3.2 tests per patient per day) ,in PDSA cycle #2 (2.9 to 3.5 tests per patient per day), or between PDSA cycles (3.2 to 3.5 tests per patient per day). Subgroup testing did show a significant reduction in certain laboratory tests, specifically the complete blood count differential (21% reduction overall)

Discussion:

Despite appropriate interventions, laboratory testing on a per-patient per-day basis increased during our study period. Possible reasons for this increase include increased awareness placed on laboratory testing (with subsequent increase in laboratory ordering), variations in housestaff team composition, variations in patient acuity, and ineffectiveness of our intervention. While our results do not convey a great change in the amount of laboratory testing that was ordered by internal medicine, it does bring to light an important focus of our healthcare spending that further research would be able to bring to light. Future quality improvement activities will focus on different interventions to reduce unnecessary laboratory ordering including ongoing physician education, changes to the electronic medical record order sets, and potential interventions by nursing and phlebotomy to ensure appropriateness of clinical testing.

Key Words: Healthcare Expenditure, Laboratory Testing, Reducing Hospital Costs

References:

  1. Yarbrough, Peter M., et al. “Multifaceted Intervention Including Education, Rounding Checklist Implementation, Cost Feedback, and Financial Incentives Reduces Inpatient Laboratory Costs.” Journal of Hospital Medicine, vol. 11, no. 5, 2016, pp. 348–354., doi:10.1002/jhm.2552.

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Reducing Unnecessary Hospital Laboratory Testing

Background:

Healthcare expenditures in the US account for 17.9% of the national GDP, or nearly $10,000 per person per year. Of this, waste has been estimated to represent approximately 1/3. This cost burden creates financial stress on the patient, care providers, and the system of care which attempts to allocate scarce medical resources. Several previous studies have shown that excessive or unnecessary clinical laboratory testing in the inpatient setting may be an opportunity to reduce waste without resulting in changes to care quality, patient or physician satisfaction[1]. In our academic medical center, “morning labs” have become a culturally ingrained on the medicine wards despite little evidence that testing actually results in a change in patient management for patients who are otherwise stable. Here we test a “goal-triggered” (i.e., will checking this laboratory test result in a change in management?) approach to routine inpatient laboratory testing.

Aim: Reduce unnecessary laboratory testing by 20% from baseline by July 2018

Methods:

We identified seven basic laboratory tests which are routinely included in morning laboratory draws, but could potentially be omitted in stable patients, where these labs would not change management. These included CBC, Differential, BMP, Liver Function Tests, Coagulation studies, Magnesium level, and Phosphorous level. A chart review was performed to identify all patients on a specific resident internal medicine team at a large university urban hospital throughout two months of 2017-2018. We first gathered baseline data on laboratory draws per patient without any intervention. The second PDSA cycle was composed of attending and resident education reminding care teams to only request laboratory testing if it would change the management for the patient. The third PDSA cycle included the use of laboratory cost sheets which were posted on the workstations of residents. Data regarding number of laboratory draws on each patient was obtained. A Microsoft Excel database maintaining subject confidentiality was created.

Results:

Reducing unnecessary laboratory testing was well received by both the hospital housestaff as well as attending physicians. During the two testing phases, only once was an intentionally unrequested laboratory test subsequently ordered due to clinician or patient preference. Despite qualitative acceptance, overall laboratory testing did not see a decline from our baseline in PDSA cycle #1 (2.9 to 3.2 tests per patient per day) ,in PDSA cycle #2 (2.9 to 3.5 tests per patient per day), or between PDSA cycles (3.2 to 3.5 tests per patient per day). Subgroup testing did show a significant reduction in certain laboratory tests, specifically the complete blood count differential (21% reduction overall)

Discussion:

Despite appropriate interventions, laboratory testing on a per-patient per-day basis increased during our study period. Possible reasons for this increase include increased awareness placed on laboratory testing (with subsequent increase in laboratory ordering), variations in housestaff team composition, variations in patient acuity, and ineffectiveness of our intervention. While our results do not convey a great change in the amount of laboratory testing that was ordered by internal medicine, it does bring to light an important focus of our healthcare spending that further research would be able to bring to light. Future quality improvement activities will focus on different interventions to reduce unnecessary laboratory ordering including ongoing physician education, changes to the electronic medical record order sets, and potential interventions by nursing and phlebotomy to ensure appropriateness of clinical testing.

Key Words: Healthcare Expenditure, Laboratory Testing, Reducing Hospital Costs

References:

  1. Yarbrough, Peter M., et al. “Multifaceted Intervention Including Education, Rounding Checklist Implementation, Cost Feedback, and Financial Incentives Reduces Inpatient Laboratory Costs.” Journal of Hospital Medicine, vol. 11, no. 5, 2016, pp. 348–354., doi:10.1002/jhm.2552.