An educational intervention to increase awareness reduces unnecessary laboratory testing in an internal medicine resident-run clinic

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.

Reducing vitamin D requests in a primary care cohort: a quality improvement study

Background

Since 2000, vitamin D requests have increased 2–6 fold with no evidence of a corresponding improvement in the health of the population. The ease of vitamin D requesting may contribue to the rapid rise in its demand and, hence, pragmatic interventions to reduce vitamin D test ordering are warranted.

Aim

To study the effect on vitamin D requests following a redesign of the electronic forms used in primary care. In addition, any potential harms were studied and the potential cost-savings associated with the intervention were evaluated.

Design & setting

An interventional study took place within primary care across Leicestershire, England.

Method

The intervention was a redesign of the electronic laboratory request form for primary care practitioners across the county. Data were collected on vitamin D requests for a 6-month period prior to the change (October 2016 to March 2017) and the corresponding 6-month period post-intervention (October 2017 to March 2018), data were also collected on vitamin D, calcium, and phosphate levels.

Results

The number of requests for vitamin D decreased by 14 918 (36.2%) following the intervention. Changes in the median calcium and phosphate were not clinically significant. Cost-modelling suggested that if such an intervention was implemented across primary care in the UK, there would be a potential annual saving to the NHS of £38 712 606.

Conclusion

A simple pragmatic redesign of the electronic request form for vitamin D test led to a significant reduction in vitamin D requests without any adverse effect on the quality of care.

Accuracy-Based Vitamin D Survey: Six Years of Quality Improvement Guided by Proficiency Testing

CONTEXT.—

The goal of the College of American Pathologists Accuracy-Based Proficiency Testing Program is to promote the quality, standardization, and harmonization of clinical laboratory results through proficiency testing specimens that are free from matrix effects, have target values that are traceable to reference methods, and that probe the limitations of current methods.

OBJECTIVE.—

To summarize the first 6 years of the Accuracy-Based Vitamin D Survey and highlight key insights from the data generated as it relates to assay performance.

DESIGN.—

Accuracy-based challenges were created by using pooled human serum samples. Certain samples were derived from participants in an institutional review board-approved protocol in which vitamin D-deficient participants were treated with ergocalciferol (vitamin D₂). Reference targets for the survey were set by the Centers for Disease Control and Prevention using isotope-dilution liquid chromatography-tandem mass spectrometry. Each method was compared with the reference method procedure over the course of the program (n = 43 proficiency testing samples).

RESULTS.—

Linear regression versus the reference method procedure revealed proportional biases across the methods, ranging from 0.0% to 16.7%. Pearson correlation coefficients (r²) ranged from 0.902 to 0.996. Results were influenced by the concentration of 25-hydroxyvitamin D₂ as well as the C-3 epimer of 25-hydroxyvitamin D₃. During the 6 years, 2 manufacturers altered their assays to match the reference method procedure more closely.

CONCLUSIONS.—

There is considerable bias, both proportional bias and sample-specific matrix effects, affecting many assays. This ongoing accuracy-based proficiency testing program for vitamin D will provide the data needed for laboratories and manufacturers to improve their assays and thereby patient care.

Major reductions in unnecessary aspartate aminotransferase and blood urea nitrogen tests with a quality improvement initiative

BACKGROUND/CONTEXT

Unnecessary laboratory testing leads to considerable healthcare costs. Aspartate aminotransferase (AST), commonly ordered with alanine aminotransferase (ALT) and blood urea nitrogen (BUN), commonly ordered with creatinine (Cr), often add little value to patient management at significant cost. We undertook a choosing wisely based quality improvement initiative to reduce the frequency of testing.

OBJECTIVES

To reduce the ratio of AST/ALT and BUN/Cr to less than 5% for all inpatient and outpatient test orders.

MEASURES

Absolute number and ratio of AST/ALT and BUN/Cr; AST, ALT, BUN and Cr tests per 100 hospital days; projected annualised cost savings and monthly acute inpatient bed days.

IMPROVEMENTS

We created guidelines for appropriate indications of AST and BUN testing, provided education with audit and feedback and removed AST and BUN from institutional order sets.

IMPACT/RESULTS

The ratios of AST/ALT and BUN/Cr decreased significantly over the study period (0.37 to 0.14, 0.57 to 0.14, respectively), although the goal of 0.05 was not achieved due to a delay in adopting the choosing wisely strategies during the study time period by some inpatient units. The number of tests per 100 hospital days decreased from 20 to 7 AST (95% CI 19 to 20.5, 5.6 to 8.7, p<0.001) and from 72 to 17 BUN (95% CI 70 to 73.4, 16.6 to 22.9, p<0.001). The initiative resulted in a projected annualised cost savings of C$221 749.

DISCUSSION

A significant decrease in the AST/ALT and BUN/Cr ratios can be achieved with a multimodal approach and will result in substantial healthcare savings.

Changes to the frequency and appropriateness of vitamin D testing after the introduction of new Medicare criteria for rebates in Australian general practice: evidence from 1.5 million patients in the NPS MedicineInsight database

OBJECTIVES

To assess changes in the frequency of vitamin D testing and detection of moderate/severe vitamin D deficiency (<30 nmol/L) among adults after the introduction of new Medicare Benefits Schedule (MBS) rebate criteria (November 2014), and their relationship to sociodemographic and clinical characteristics.

DESIGN

Dynamic (open) cohort study SETTING: Primary care PARTICIPANTS: About 1.5 million 'active' patients aged 18+ years visiting a general practitioner and included in the National Prescribing Service MedicineInsight database.

OUTCOME MEASURES

The frequency of vitamin D testing (per 1000 consultations) and moderate/severe vitamin D deficiency (%) recorded between October 2013 and March 2016, stratified by the release of the new MBS criteria for rebate.

RESULTS

More patients were female (57.7%) and 30.2% were aged 60+ years. Vitamin D testing decreased 47% (from 40.3 to 21.4 tests per 1000 consultations) after the new MBS criteria, while the proportion of tests with no indication for being performed increased from 71.3% to 76.5%. The proportion of patients identified as moderate/severe vitamin D deficient among those tested increased from 5.4% to 6.5%. Practices located in high socioeconomic areas continued to have the highest rates of testing, but moderate/severe vitamin D deficiency detection remained 90% more frequent in practices from low socioeconomic areas after the rebate change. Furthermore, the frequency of individuals being tested was reduced independent of the patients' sociodemographic or clinical condition, and the gap in the prevalence of vitamin D deficiency detection between those meeting or not meeting the criteria for being tested remained the same. Moderate/severe vitamin D deficiency detection decreased slightly among patients with hyperparathyroidism or chronic renal failure.

CONCLUSIONS

Although the new criteria for rebate almost halved the frequency of vitamin D testing, it also lessened the frequency of testing among those at higher risk of deficiency, with only a small improvement in vitamin D deficiency detection.

Optimization of Laboratory Ordering Practices for Complete Blood Count With Differential

Objectives

To investigate the utilization of CBC and CBC with differential (CBC w/diff) tests at University of Alabama at Birmingham Hospital, and to determine if a reduction in CBC w/diff tests could be achieved without negatively impacting patient care.

Methods

The quantity of testing and distribution of repeated tests before, during, and after an educational intervention were compared.

Results

CBC w/diff tests were ordered 10-fold more frequently than CBC tests. The trauma burn intensive care unit ordered the most CBC w/diff tests, with repeat tests done every 4 or 12 hours. The educational intervention reduced the number of CBC w/diff tests ordered and tests repeated every 12 hours.

Conclusions

The educational intervention changed the ordering practices of CBC w/diff and CBC tests. This was sustained after the intervention and no negative effects on patient care were noted. Similar interventions may lead to optimization of ordering practices of other laboratory tests.

Clinical Management of Low Vitamin D: A Scoping Review of Physicians' Practices

The role of vitamin D in the prevention and treatment of non-skeletal health issues has received significant media and research attention in recent years. Costs associated with clinical management of low vitamin D (LVD) have increased exponentially. However, no clear evidence supports vitamin D screening to improve health outcomes. Authoritative bodies and professional societies do not recommend population-wide vitamin D screening in community-dwelling adults who are asymptomatic or at low risk of LVD. To assess patterns of physicians’ management of LVD in this conflicting environment, we conducted a scoping review of three electronic databases and the gray literature. Thirty-eight records met inclusion criteria and were summarized in an evidence table. Thirteen studies published between 2006 and 2015 across seven countries showed a consistent increase in vitamin D lab tests and related costs. Many vitamin D testing patterns reflected screening rather than targeted testing for individuals at high risk of vitamin D deficiency or insufficiency. Interventions aimed at managing inappropriate clinical practices related to LVD were effective in the short term. Variability and controversy were pervasive in many aspects of vitamin D management, shining a light on physicians’ practices in the face of uncertainty. Future research is needed to inform better clinical guidelines and to assess implementation practices that encourage evidence-based management of LVD in adult populations.