Reducing waste: a guidelines-based approach to reducing inappropriate vitamin D and TSH testing in the inpatient rehabilitation setting

Taking risk to heart: An evaluation of cardiometabolic risk and screening guideline adherence in outpatients with spinal cord injury

OBJECTIVES

To evaluate cardiometabolic disease (CMD) in outpatients with spinal cord injury/disease (SCI/D). The study aims were to (1) estimate the prevalence of CMD risk factors in a cohort of Canadian adults with SCI/D; (2) assess whether the frequency of CMD screening aligns with evidence-based guidelines; and (3) gain a preliminary understanding of the barriers to CMD screening and/or treatment within a rehabilitation program setting.

DESIGN

Quality improvement initiative involving chart review extracting the presence of and frequency of screening for four CMD risk factors (obesity, hypertension, dyslipidemia, diabetes mellitus). Values were compared to evidence-based guidelines for CMD risk identification and management. Root cause analysis and focused interviews were conducted with clinic staff to identify barriers.

SETTING

Academic, tertiary rehabilitation hospital.

PARTICIPANTS

Consecutive outpatients with SCI/D from October 2020 to December 2021 (n = 73).

RESULTS

43.8% of outpatients sampled had established CMD (≥3 risk factors) and 94.5% had at least one risk factor. Obesity was the most prevalent (82.2%), followed by dyslipidemia (71.7%), hypertension (46.5%), and diabetes mellitus (34.8%). Hypertension and obesity screening were completed at 14.3% and 10.4% of appointments. The frequency of dyslipidemia and diabetes mellitus screening could not be determined. Eighteen barriers to timely CMD screening and treatment intensification were identified.

CONCLUSIONS

The prevalence of CMD risk factors in outpatients with SCI/D was high. While approximately two of every five outpatients had established CMD, adherence to screening guidelines was poor. These findings reinforce the need for strategies to improve screening and reduce preventable harm from CMD in this vulnerable population.

Six SIGMA evaluation of 17 biochemistry parameters using bias calculated from internal quality control and external quality assurance data

Background

Six Sigma is a popular quality management system that enables continuous monitoring and improvement of analytical performance in the clinical laboratory. We aimed to calculate sigma metrics and quality goal index (QGI) for 17 biochemical analytes and compare the use of bias from internal quality control (IQC) and external quality assurance (EQA) data in the calculation of sigma metrics.

Methods

This retrospective study was conducted in Marmara University Pendik E&R Hospital Biochemistry Laboratory. Sigma metrics calculation was performed as (TEa-bias)/CV). CV was calculated from IQC data from June 2018 - February 2019. EQA bias was calculated as the mean of % deviation from the peer group means in the last seven surveys, and IQC bias was calculated as (laboratory control result mean-manufacturer control mean)/ manufacturer control mean) x100. In parameters where sigma metrics were <5; QGI=bias/1.5 CV) score of <0.8 indicated imprecision, >1.2 pointed inaccuracy, and 0.8-1.2 showed both imprecision and inaccuracy.

Results

Creatine kinase (both levels), iron and magnesium (pathologic levels) showed an ideal performance with ≥6 sigma level for both bias determinations. Eight of the 17 parameters had different sigma levels when we compared sigma values calculated from EQA and IQC derived bias% while the rest were grouped at the same levels.

Conclusions

Sigma metrics is a good quality tool to assess a laboratory's analytical performance and facilitate the comparison of the assay performances in the same manner across multiple systems. However, we might need to design a tight internal quality control protocol for analytes showing poor assay performance.

Continuous quality improvement in peritoneal dialysis: Your questions answered

Peritoneal dialysis (PD) uptake around the globe has steadily increased over the last several decades as a viable alternative to haemodialysis. Continued success of this technique for patients is contingent on the application of continuous quality improvement (CQI) principles in PD practice which can improve patient outcomes and in turn lead to more successful PD programmes worldwide. In this installation of 'Your Questions Answered', we will outline an approach to quality improvement initiatives and examine the importance of CQI principles in PD practice. We will also highlight common pitfalls and provide strategies to identify potential targets for improvement within your PD programme.

Lean and Six Sigma as continuous quality improvement frameworks in the clinical diagnostic laboratory

Processes to enhance customer-related services in healthcare organizations are complex and it can be difficult to achieve efficient patient-focused services. Laboratories make an integral part of the healthcare service industry where healthcare providers deal with critical patient results. Errors in these processes may cost a human life, create a negative impact on an organization's reputation, cause revenue loss, and open doors for expensive lawsuits. To overcome these complexities, healthcare organizations must implement an approach that helps healthcare service providers to reduce waste, variation, and work imbalance in the service processes. Lean and Six Sigma are used as continuous process improvement frameworks in laboratory medicine. Six Sigma uses an approach that involves problem-solving, continuous improvement and quantitative statistical process control. Six Sigma is a technique based on the DMAIC process (Define, Measure, Analyze, Improve, and Control) to improve quality performance. Application of DMAIC in a healthcare organization provides guidance on how to handle quality that is directed toward patient satisfaction in a healthcare service industry. The Lean process is a technique for process management in which waste reduction is the primary purpose; this is accomplished by implementing waste mitigation practices and methodologies for quality improvement. Overall, this article outlines the frameworks for continuous quality and process improvement in healthcare organizations, with a focus on the impacts of Lean and Six Sigma on the performance and quality service delivery system in clinical laboratories. It also examines the role of utilization management and challenges that impact the implementation of Lean and Six Sigma in clinical laboratories.

Interruptive Electronic Alerts for Choosing Wisely Recommendations: A Cluster Randomized Controlled Trial

OBJECTIVE

To assess the efficacy of interruptive electronic alerts in improving adherence to the American Board of Internal Medicine's Choosing Wisely recommendations to reduce unnecessary laboratory testing.

MATERIALS AND METHODS

We administered 5 cluster randomized controlled trials simultaneously, using electronic medical record alerts regarding prostate-specific antigen (PSA) testing, acute sinusitis treatment, vitamin D testing, carotid artery ultrasound screening, and human papillomavirus testing. For each alert, we assigned 5 outpatient clinics to an interruptive alert and 5 were observed as a control. Primary and secondary outcomes were the number of postalert orders per 100 patients at each clinic and number of triggered alerts divided by orders, respectively. Post hoc analysis evaluated whether physicians experiencing interruptive alerts reduced their alert-triggering behaviors.

RESULTS

Median postalert orders per 100 patients did not differ significantly between treatment and control groups; absolute median differences ranging from 0.04 to 0.40 for PSA testing. Median alerts per 100 orders did not differ significantly between treatment and control groups; absolute median differences ranged from 0.004 to 0.03. In post hoc analysis, providers receiving alerts regarding PSA testing in men were significantly less likely to trigger additional PSA alerts than those in the control sites (Incidence Rate Ratio 0.12, 95% CI [0.03-0.52]).

DISCUSSION

Interruptive point-of-care alerts did not yield detectable changes in the overall rate of undesired orders or the order-to-alert ratio between active and silent sites. Complementary behavioral or educational interventions are likely needed to improve efforts to curb medical overuse.

CONCLUSION

Implementation of interruptive alerts at the time of ordering was not associated with improved adherence to 5 Choosing Wisely guidelines.

TRIAL REGISTRATION

NCT02709772.

Reducing overutilisation of serum vitamin D testing at a tertiary care centre

INTRODUCTION

Testing of 25-hydroxy (25-OH) vitamin D serum levels has increased drastically in recent years and much of it is considered inappropriate based on current guidelines.

METHODS

In consultation with our physician groups (experts and frequent orderers), we modified existing guidelines and implemented a rational policy for 25-OH vitamin D testing and 1,25 dihydroxy (1,25 di-OH) vitamin D testing at a tertiary care centre. A computer decision support tool requiring selection of one of five acceptable testing indications was created for each test as part of a computerised physician order entry system.

RESULTS

As a result of our intervention, we observed a 27% decrease in the average monthly test volume for 25-OH vitamin D from 504±62 (mean±SD) tests per month to 370±33 (p<0.001). 1,25 di-OH vitamin D testing decreased 58% from 71±18 to 30±10 (p<0.001). The departments ordering the tests were similar during the preintervention and postintervention periods, and further audits, patient chart reviews and individualised physician feedback were required to ensure appropriate ordering of 1,25 di-OH vitamin D. The most common ordering reasons selected were malabsorption/dietary concerns (46%) for 25-OH vitamin D and renal failure (42%) for 1,25 di-OH vitamin D.

CONCLUSIONS

Limitations of our computer decision support tool include a dependence on an honour system in selecting the testing indication and an inability to limit ordering frequency. Periodic monitoring of test volumes will be required to ensure adherence to guidelines. Despite these limitations, we have improved appropriate utilisation of these tests and reduced costs by approximately $C60 375 per year.