Creating a novel strategy to reduce unnecessary laboratory testing based on healthcare cost analysis in high-risk pregnancies and delivery ward

INTRODUCTION

Inappropriate request for laboratory tests is a challenging problem and an important cause for additional healthcare costs. Indeed, it may have further ambiguity for the clinicians. This study aimed to design an education-based program to reduce unnecessary laboratory testing orders and the associated costs.

MATERIALS AND METHODS

In this interventional prospective study that took place in an educational hospital, the type and frequency of selected laboratory testing requested by gynecology, and obstetrics residents in the patients with gestational diabetes mellitus, preeclampsia, preterm labor, and premature preterm rupture of the membrane as well as cesarean section and normal vaginal delivery were analyzed periodically in a 1-year interval. At the same time, continuous educational supports and monitoring were performed. The results were compared before and after interventions.

RESULTS

The educational intervention regardless of the etiologies of the admission, decreased the requested laboratory testing significantly (p < 0.001), except for CBC. Indeed, no near misses or delays in treatment were observed. Cost analysis showed a 31.3% reduction of expenses per inpatient day due to the decrease in the number of daily laboratory testing ordered.

CONCLUSIONS

Appropriate education and continuous monitoring of the residents could reduce the unrequired laboratory testing as well as healthcare costs.

Large differences in laboratory utilisation between hospitals in Sweden

There are large differences in the use of laboratory tests between hospitals in Sweden. These differences are not only due to differences between the patients treated but also to differences in practice. Use of laboratory test seems to reflect local traditions to a large extent. These large variations in practice are not compatible with the objective of providing care on equal terms and reduce the cost-effectiveness of clinical chemistry. Recently, several intervention studies have been performed in Sweden with the aim to optimise the use of clinical chemistry tests in primary care. The results show that it is possible to reduce the cost in primary care by SEK 100 million per year while increasing the clinical usefulness. This constitutes approximately 10% of the total cost for clinical chemistry tests in primary care. It should also be possible to reduce the cost for clinical chemistry tests in secondary and tertiary care. Hospitals order more tests than primary care and the potential savings are thus greater. We have studied the ordering habits for eleven Swedish hospitals. The comparison was made in the form of ratios between related laboratory tests to reduce the effects of differences in size between the studied laboratories. The large variation between hospitals indicates that a continuous discussion between the clinicians and the laboratories could reduce the cost. We have used the figures from the comparison and calculated the potential savings for seven frequently used tests. The potential yearly saving in Sweden for these tests is approximately SEK 150 million.

To test or not to test, that is the question

This paper describes a system that is used in Maastricht, the Netherlands, to provide general practitioners with feedback about the adequateness of their test requesting behaviour. The system has proven to be effective. Since the screening of test requests and additional patient data is work-intensive a project was started in the framework of the AIM programme OPENLABS to design a computer-based feedback system. In this system the general practitioner sends test requests to the laboratory decision support system by means of electronic data interchange (EDI). The authors were involved in the development of the EDI messages, which are now accepted standards in the Netherlands. The requests are stored in a database that is part of the laboratory decision support system. The other part of the decision support system, an expert system, obtains the request data (including patient data) from the database, screens the requests for adequateness and provides feedback when necessary.

The responsible use of the clinical laboratory

Concern about spiralling health care costs is leading to a reexamination of the use of the clinical laboratory and other diagnostic technologies in patient care. Laboratory resources are viewed as limited and their use must be measured to meet real needs. Several observers have noted significant overutilization and inappropriate utilization of laboratory services by patient care physicians, especially at teaching hospitals. Efforts to modify physician behavior by use of educational programs, positive incentives and similar means have been largely disappointing. Several laboratory-based initiatives aimed at bringing about more responsible use of the laboratory are discussed. Improved education in the judicious use of the laboratory, beginning in medical school and carrying on through the early stages of a physician's career, is considered the most promising long-term approach. This, along with improved communication between the laboratory and the clinic, is the avenue most likely to bring about more responsible use of the clinical laboratory in health care.