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Ahmed HAS, Al-Faris NA, Sharp JW, Abduljaber IO, Ghaida SSA. Managing Resource Utilization Cost of Laboratory Tests for Patients on Chemotherapy in Johns Hopkins Aramco Healthcare. GLOBAL JOURNAL ON QUALITY AND SAFETY IN HEALTHCARE 2023; 6:111-116. [PMID: 38404459 PMCID: PMC10887474 DOI: 10.36401/jqsh-23-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/16/2023] [Accepted: 08/08/2023] [Indexed: 02/27/2024]
Abstract
Introduction Laboratory testing is a fundamental diagnostic and prognostic tool to ensure the quality of healthcare, treatment, and responses. This study aimed to evaluate the cost of laboratory tests performed for patients undergoing chemotherapy treatment in the oncology treatment center at Johns Hopkins Aramco Healthcare in Saudi Arabia. Additionally, we aimed to reduce the cost of unnecessary laboratory tests in a 1-year period. Methods This was a quality improvement study with a quasi-experimental design using DMAIC methodology. The intervention strategy involved educating staff about adhering to the British Columbia Cancer Agency (BCCA) guidelines when ordering laboratory tests for chemotherapy patients, then integrating those guidelines into the electronic health record system. Data were collected for 200 randomly selected cases with 10 different chemotherapy protocols before and after the intervention. A paired t test was used to analyze differences in mean cost for all laboratory tests and unnecessary testing before and after the intervention. Results A significant cost reduction was achieved for unnecessary laboratory tests (77%, p < 0.01) when following the BCCA guidelines. In addition, the mean cost of all laboratory tests (including necessary and unnecessary) was significantly reduced by 45.5% (p = 0.023). Conclusion Lean thinking in clinical practice, realized by integrating a standardized laboratory test guided by BCCA guidelines into the electronic health record, significantly reduced financial costs within 1 year, thereby enhancing efficient resource utilization in the organization. This quality improvement project may serve to increase awareness of further efforts to improve resource utilization for other oncology treatment protocols.
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Affiliation(s)
- Huda Al-Sayed Ahmed
- Department of Quality & Patient Safety, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Nafeesa A Al-Faris
- Division of Oncology, Department of Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabi
| | - Joshua W Sharp
- Division of Oncology, Department of Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabi
| | - Issam O Abduljaber
- Division of Oncology, Department of Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabi
| | - Salam S Abou Ghaida
- Division of Oncology, Department of Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabi
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Ambasta A, Omodon O, Herring A, Ferrie L, Pokharel S, Mehta A, Liu L, Hews-Girard J, Tam C, Taylor S, Lonergan K, Faris P, Duncan D, Woodhouse D. Repurposing the Ordering of Routine Laboratory Tests in Hospitalised Medical Patients (RePORT): results of a cluster randomised stepped-wedge quality improvement study. BMJ Qual Saf 2023; 32:517-525. [PMID: 37164639 DOI: 10.1136/bmjqs-2022-015611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 04/19/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Low-value use of laboratory tests is a global challenge. Our objective was to evaluate an intervention bundle to reduce repetitive use of routine laboratory testing in hospitalised patients. METHODS We used a stepped-wedge design to implement an intervention bundle across eight medical units. Our intervention included educational tools and social comparison reports followed by peer-facilitated report discussion sessions. The study spanned October 2020-June 2021, divided into control, feasibility testing, intervention and a follow-up period. The primary outcomes were the number and costs of routine laboratory tests ordered per patient-day. We used generalised linear mixed models, and analyses were by intention to treat. RESULTS We included a total of 125 854 patient-days. Patient groups were similar in age, sex, Charlson Comorbidity Index and length of stay during the control, intervention and follow-up periods. From the control to the follow-up period, there was a 14% (incidence rate ratio (IRR)=0.86, 95% CI 0.79 to 0.92) overall reduction in ordering of routine tests with the intervention, along with a 14% (β coefficient=-0.14, 95% CI -0.07 to -0.21) reduction in costs of routine testing. This amounted to a total cost savings of $C1.15 per patient-day. There was also a 15% (IRR=0.85, 95% CI 0.79, 0.92) reduction in ordering of all common tests with the intervention and a 20% (IRR=1.20, 95% CI 1.10 to 1.30) increase in routine test-free patient-days. No worsening was noted in patient safety endpoints with the intervention. CONCLUSIONS A multifaceted intervention bundle using education and facilitated multilevel social comparison was associated with a safe and effective reduction in use of routine daily laboratory testing in hospitals. Further research is needed to understand how system-level interventions may increase this effect and which intervention elements are necessary to sustain results.
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Affiliation(s)
- Anshula Ambasta
- Medicine, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Onyebuchi Omodon
- Ward of the 21st Century, University of Calgary Cumming School of Medicine, Calgary, Canada
| | | | - Leah Ferrie
- Physician Learning Program, University of Calgary, Calgary, Canada
| | | | - Ashi Mehta
- Health Quality Council of Alberta, Calgary, Canada
| | | | | | - Cheuk Tam
- Medicine, University of Calgary Faculty of Medicine, Calgary, Canada
| | - Simon Taylor
- Medicine, University of Calgary, Calgary, Canada
| | | | - Peter Faris
- Measurement and Analysis; Research Excellence Support Team, Alberta Bone and Joint Health Institute; Alberta Health Services, Calgary, Canada
| | - Diane Duncan
- Physician Learning Program, University of Calgary, Calgary, Canada
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El-Alali EA, Maali LN. Improving the diagnostic yield of echocardiography in acute ischemic stroke: A quality improvement project in a community hospital in Maryland, USA. CASPIAN JOURNAL OF INTERNAL MEDICINE 2023; 14:640-647. [PMID: 38024176 PMCID: PMC10646359 DOI: 10.22088/cjim.14.4.640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/10/2022] [Accepted: 04/13/2022] [Indexed: 12/01/2023]
Abstract
Background Echocardiography is routinely ordered in acute ischemic stroke workup. No standardized or structured criteria is used to select or exclude echocardiography in such settings. Moreover, the diagnostic yield of echocardiography in stroke is low in our medical center. This article presents newly proposed selection criteria for echocardiography in ischemic stroke workup. Methods A quality improvement project was implemented in a 385-bed community hospital in Maryland, USA. A computerized decision support tool consisting of new criteria for selecting echocardiography in ischemic stroke workup was created. 639 patients hospitalized with ischemic stroke were followed-up over 12 months after intervention, and 686 matched-controls with ischemic stroke were retrospectively analyzed from the 12 months prior to intervention. Cost-effectiveness and diagnostic yield of echocardiography in ischemic stroke were measured before and after intervention. Results Following intervention, the diagnostic yield of echocardiography in ischemic stroke workup significantly increased by 51% (from 3.8% to 7.8%, odds ratio (OR) 2.1, P= 0.01). The number of echocardiography studies needed to detect and treat one patient with a cardiac source of embolism was reduced from 50 to 25 studies. The overall use of echocardiography in stroke workup significantly decreased (OR 0.4, p < 0.001). Patients with lacunar infarcts or atrial fibrillation had significant reduction in echocardiography (OR 0.2, p < 0.001 and OR 0.4, p < 0.001, respectively). Conclusion The new criteria for echocardiography selection in hospitalized patients with ischemic stroke significantly improved the cost-effectiveness and the diagnostic yield of echocardiography and reduced unnecessary echocardiography in lacunar infarcts or atrial fibrillation.
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Affiliation(s)
- Emran A El-Alali
- Department of Internal Medicine, Anne Arundel Medical Center, Annapolis, Maryland, USA
| | - Laith N Maali
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
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The impact of performance feedback reports on physician ordering behavior in the use of computed tomography pulmonary angiography (CTPA). Emerg Radiol 2023; 30:63-69. [PMID: 36378395 PMCID: PMC9664050 DOI: 10.1007/s10140-022-02100-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE The increased utilization, and potential overutilization, of computed tomography pulmonary angiography (CTPA) is a well-recognized issue within emergency departments (EDs). The objective of this study is to determine the impact of performance feedback reports on CTPA ordering behavior among ED physicians. METHODS We conducted a prospective study of the impact of individualized performance feedback reports on the ordering behavior of physicians working at two high-volume community EDs in Ontario, Canada. We generated individualized reports (or "Dashboards") for each ED physician containing detailed feedback and peer comparison for each physician's CTPA ordering. Our baseline pre-intervention period was January 1 to December 31, 2018, and our intervention period was January 1, 2019, to December 31, 2021. We tracked individual and group ordering behavior through the study period. Our primary outcomes are impact of feedback on (1) overall group ordering rate and (2) overall diagnostic yield. Secondary analysis was done to determine the impact of the intervention on those physicians with the highest CTPA utilization rate. RESULTS There was no statistically significant difference in the diagnostic yield of the included physicians in either of the years of the intervention period. There was a statically significant increase in the utilization rate for CTPA from 2018 to 2020 and 2021 from 5.9 to 7.9 and 11.4 CTPAs per 1000 ED visits respectively (p < 0.5). CONCLUSION Our study found no consistent significant impact of individualized feedback and peer comparison on physician ordering of CTPAs. This points to a potentially greater impact of environmental and institutional factors, as opposed to physician-targeted quality improvement measures, on physician ordering behavior.
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Kao DP. Electronic Health Records and Heart Failure. Heart Fail Clin 2022; 18:201-211. [PMID: 35341535 PMCID: PMC9167063 DOI: 10.1016/j.hfc.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Increasing the global adoption of electronic health records (EHRs) is transforming the delivery of clinical care. EHRs offer tools that are useful in the care of heart failure ranging from individualized risk stratification and decision support to population management. EHR tools can be combined to target specific areas of need such as the standardization of care, improved quality of care, and resource management. Leveraging EHR functionality has been shown to improve select outcomes including guideline-based therapies, reduction in adverse clinical outcomes, and improved cost-efficiency. Central to success is participation by clinicians and patients in the design and feedback of EHR tools.
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Affiliation(s)
- David P Kao
- University of Colorado School of Medicine, 12700 East 19th Avenue Box B-139, Research Center 2 Room 8005, Aurora, CO 80045, USA.
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Kini V, Breathett K, Groeneveld PW, Ho PM, Nallamothu BK, Peterson PN, Rush P, Wang TY, Zeitler EP, Borden WB. Strategies to Reduce Low-Value Cardiovascular Care: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2022; 15:e000105. [PMID: 35189687 PMCID: PMC9909614 DOI: 10.1161/hcq.0000000000000105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Low-value health care services that provide little or no benefit to patients are common, potentially harmful, and costly. Nearly half of the patients in the United States will receive at least 1 low-value test or procedure annually, creating risk of avoidable complications from subsequent cascades of care and excess costs to patients and society. Reducing low-value care is of particular importance to cardiovascular health given the high prevalence and costs of cardiovascular disease in the United States. This scientific statement describes the current scope and impact of low-value cardiovascular care; reviews existing literature on patient-, clinician-, health system-, payer-, and policy-level interventions to reduce low-value care; proposes solutions to achieve meaningful and equitable reductions in low-value care; and suggests areas for future research priorities.
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El-Kareh R, Sittig DF. Enhancing Diagnosis Through Technology: Decision Support, Artificial Intelligence, and Beyond. Crit Care Clin 2022; 38:129-139. [PMID: 34794627 PMCID: PMC8608279 DOI: 10.1016/j.ccc.2021.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Patient care in intensive care environments is complex, time-sensitive, and data-rich, factors that make these settings particularly well-suited to clinical decision support (CDS). A wide range of CDS interventions have been used in intensive care unit environments. The field needs well-designed studies to identify the most effective CDS approaches. Evolving artificial intelligence and machine learning models may reduce information-overload and enable teams to take better advantage of the large volume of patient data available to them. It is vital to effectively integrate new CDS into clinical workflows and to align closely with the cognitive processes of frontline clinicians.
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Affiliation(s)
- Robert El-Kareh
- University of California, San Diego, 9500 Gilman Drive, #0881 La Jolla, CA 92093-0881, USA.
| | - Dean F Sittig
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, TX 77030, USA. https://twitter.com/DeanSittig
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Hughes AEO, Jackups R. Clinical Decision Support for Laboratory Testing. Clin Chem 2021; 68:402-412. [PMID: 34871351 DOI: 10.1093/clinchem/hvab201] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/24/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND As technology enables new and increasingly complex laboratory tests, test utilization presents a growing challenge for healthcare systems. Clinical decision support (CDS) refers to digital tools that present providers with clinically relevant information and recommendations, which have been shown to improve test utilization. Nevertheless, individual CDS applications often fail, and implementation remains challenging. CONTENT We review common classes of CDS tools grounded in examples from the literature as well as our own institutional experience. In addition, we present a practical framework and specific recommendations for effective CDS implementation. SUMMARY CDS encompasses a rich set of tools that have the potential to drive significant improvements in laboratory testing, especially with respect to test utilization. Deploying CDS effectively requires thoughtful design and careful maintenance, and structured processes focused on quality improvement and change management play an important role in achieving these goals.
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Affiliation(s)
- Andrew E O Hughes
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ronald Jackups
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
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Factors Associated With Increased Laboratory Use in the Pediatric Cardiac Intensive Care Unit. Dimens Crit Care Nurs 2021; 40:295-300. [PMID: 34398566 DOI: 10.1097/dcc.0000000000000486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Laboratory testing is frequently used to guide postoperative management and contributes to hospital resource utilization; however, there is little evidence identifying patient or clinical factors to inform the appropriate frequency of laboratory testing in the pediatric cardiac intensive care unit. OBJECTIVES To examine the factors associated with increased laboratory utilization following pediatric congenital heart surgery. METHODS For each patient, the total number of tests and types of laboratory tests were recorded. Patients whose number of tests was greater than the 90th percentile were categorized as increased laboratory use. RESULTS A sample of 250 unique patients and 909 nursing shifts were obtained for patient- and shift-level analyses. The top 10% of patients identified as the high laboratory utilization group (>128 laboratory tests). High-use group reported significantly younger patients and longer bypass time (P < .001). Patients in the highest Risk Adjustment for Congenital Heart Surgery 1 risk category were 34.7 times more likely to be in high laboratory utilization group (P = .006), independent of age at time of surgery and time on bypass (receiver operating characteristic curve = 0.855). At the shift level, time on bypass (P = .002), age younger than 30 days at surgery (P < .001), 3 to 5 years' registered nurse experience (P < .001), staff precepting (P = .03), and weekday shift status (P = .03) were all independently associated with high laboratory utilization. CONCLUSIONS There are multiple factors associated with increased laboratory utilization. Recognition of specific patient and nursing factors can be used to impact patient management.
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Hunt TC, Ambrose JP, Haaland B, Kawamoto K, Dechet CB, Lowrance WT, Hanson HA, O'Neil BB. Decision fatigue in low-value prostate cancer screening. Cancer 2021; 127:3343-3353. [PMID: 34043813 DOI: 10.1002/cncr.33644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/22/2021] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Low-value prostate-specific antigen (PSA) testing is common yet contributes substantial waste and downstream patient harm. Decision fatigue may represent an actionable target to reduce low-value urologic care. The objective of this study was to determine whether low-value PSA testing patterns by outpatient clinicians are consistent with decision fatigue. METHODS Outpatient appointments for adult men without prostate cancer were identified at a large academic health system from 2011 through 2018. The authors assessed the association of appointment time with the likelihood of PSA testing, stratified by patient age and appropriateness of testing based on clinical guidelines. Appointments included those scheduled between 8:00 am and 4:59 pm, with noon omitted. Urologists were examined separately from other clinicians. RESULTS In 1,581,826 outpatient appointments identified, the median patient age was 54 years (interquartile range, 37-66 years), 1,256,152 participants (79.4%) were White, and 133,693 (8.5%) had family history of prostate cancer. PSA testing would have been appropriate in 36.8% of appointments. Clinicians ordered testing in 3.6% of appropriate appointments and in 1.8% of low-value appointments. Appropriate testing was most likely at 8:00 am (reference group). PSA testing declined through 11:00 am (odds ratio [OR], 0.57; 95% CI, 0.50-0.64) and remained depressed through 4:00 pm (P < .001). Low-value testing was overall less likely (P < .001) and followed a similar trend, declining steadily from 8:00 am (OR, 0.48; 95% CI, 0.42-0.56) through 4:00 pm (P < .001; OR, 0.23; 95% CI, 0.18-0.30). Testing patterns in urologists were noticeably different. CONCLUSIONS Among most clinicians, outpatient PSA testing behaviors appear to be consistent with decision fatigue. These findings establish decision fatigue as a promising, actionable target for reducing wasteful and low-value practices in routine urologic care. LAY SUMMARY Decision fatigue causes poorer choices to be made with repetitive decision making. This study used medical records to investigate whether decision fatigue influenced clinicians' likelihood of ordering a low-value screening test (prostate-specific antigen [PSA]) for prostate cancer. In more than 1.5 million outpatient appointments by adult men without prostate cancer, the chances of both appropriate and low-value PSA testing declined as the clinic day progressed, with a larger decline for appropriate testing. Testing patterns in urologists were different from those reported by other clinicians. The authors conclude that outpatient PSA testing behaviors appear to be consistent with decision fatigue among most clinicians, and interventions may reduce wasteful testing and downstream patient harms.
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Affiliation(s)
- Trevor C Hunt
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Jacob P Ambrose
- Population Sciences, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Benjamin Haaland
- Division of Biostatistics, Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - Christopher B Dechet
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - William T Lowrance
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Heidi A Hanson
- Population Sciences, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Brock B O'Neil
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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Lillo S, Larsen TR, Pennerup L, Antonsen S. The impact of interventions applied in primary care to optimize the use of laboratory tests: a systematic review. Clin Chem Lab Med 2021; 59:1336-1352. [PMID: 33561910 DOI: 10.1515/cclm-2020-1734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/26/2021] [Indexed: 11/15/2022]
Abstract
Laboratory tests are important tools in primary care, but their use is sometimes inappropriate. The aim of this review is to give an overview of interventions applied in primary care to optimize the use of laboratory tests. A search for studies was made in the MEDLINE and EMBASE databases. We also extracted studies from two previous reviews published in 2015. Studies were included if they described application of an intervention aiming to optimize the use of laboratory tests. We also evaluated the overall risk of bias of the studies. We included 24 studies. The interventions were categorized as: education, feedback reports and computerized physician order entry (CPOE) strategies. Most of the studies were classified as medium or high risk of bias while only three studies were evaluated as low risk of bias. The majority of the studies aimed at reducing the number of tests, while four studies investigated interventions aiming to increase the use of specific tests. Despite the studies being heterogeneous, we made results comparable by transforming the results into weighted relative changes in number of tests when necessary. Education changed the number of tests consistently, and these results were supported by the low risk of bias of the papers. Feedback reports have mainly been applied in combination with education, while when used alone the effect was minimal. The use of CPOE strategies seem to produce a marked change in the number of test requests, however the studies were of medium or high risk of bias.
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Affiliation(s)
- Serena Lillo
- Biochemistry Department, Odense University Hospital (OUH) and Svendborg Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark (SDU), Odense, Denmark
| | - Trine Rennebod Larsen
- Biochemistry Department, Odense University Hospital (OUH) and Svendborg Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark (SDU), Odense, Denmark
| | - Leif Pennerup
- Biochemistry Department, Odense University Hospital (OUH) and Svendborg Hospital, Svendborg, Denmark
| | - Steen Antonsen
- Biochemistry Department, Odense University Hospital (OUH) and Svendborg Hospital, Svendborg, Denmark
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Laboratory test ordering in inpatient hospitals: a systematic review on the effects and features of clinical decision support systems. BMC Med Inform Decis Mak 2021; 21:20. [PMID: 33461548 PMCID: PMC7814592 DOI: 10.1186/s12911-020-01384-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/25/2020] [Indexed: 01/09/2023] Open
Abstract
Background Studies have revealed inappropriate laboratory testing as a source of waste. This review aimed at evaluating the effects and features of CDSSs on physicians' appropriate laboratory test ordering in inpatient hospitals. Method Medline through PubMed, SCOPUS, Web of Science, and Cochrane were queried without any time period restriction. Studies using CDSSs as an intervention to improve laboratory test ordering as the primary aim were included. The study populations in the included studies were laboratory tests, physicians ordering laboratory tests, or the patients for whom laboratory tests were ordered. The included papers were evaluated for their outcomes related to the effect of CDSSs which were categorized based on the outcomes related to tests, physician, and patients. The primary outcome measures were the number and cost of the ordered laboratory tests. The instrument from The National Heart Lung and Blood Institute (NIH) was used to assess the quality of the included studies. Moreover, we applied a checklist for assessing the quality and features of the CDSSs presented in the included studies. A narrative synthesis was used to describe and compare the designs and the results of included studies.
Result Sixteen studies met the inclusion criteria. Most studies were conducted based on a quasi-experimental design. The results showed improvement in laboratory test-related outcomes (e.g. proportion and cost of tests) and also physician-related outcomes (e.g. guideline adherence and orders cancellation). Patient-related outcomes (e.g. length of stay and mortality rate) were not well investigated in the included studies. In addition, the evidence about applying CDSS as a decision aid for interpreting laboratory results was rare. Conclusion CDSSs increase appropriate test ordering in hospitals through eliminating redundant test orders and enhancing evidence-based practice. Appropriate testing and cost saving were both affected by the CDSSs. However, the evidence is limited about the effects of laboratory test CDSSs on patient-related outcomes.
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von Wedel P, Hagist C. Economic Value of Data and Analytics for Health Care Providers: Hermeneutic Systematic Literature Review. J Med Internet Res 2020; 22:e23315. [PMID: 33206056 PMCID: PMC7710451 DOI: 10.2196/23315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/12/2020] [Accepted: 10/24/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The benefits of data and analytics for health care systems and single providers is an increasingly investigated field in digital health literature. Electronic health records (EHR), for example, can improve quality of care. Emerging analytics tools based on artificial intelligence show the potential to assist physicians in day-to-day workflows. Yet, single health care providers also need information regarding the economic impact when deciding on potential adoption of these tools. OBJECTIVE This paper examines the question of whether data and analytics provide economic advantages or disadvantages for health care providers. The goal is to provide a comprehensive overview including a variety of technologies beyond computer-based patient records. Ultimately, findings are also intended to determine whether economic barriers for adoption by providers could exist. METHODS A systematic literature search of the PubMed and Google Scholar online databases was conducted, following the hermeneutic methodology that encourages iterative search and interpretation cycles. After applying inclusion and exclusion criteria to 165 initially identified studies, 50 were included for qualitative synthesis and topic-based clustering. RESULTS The review identified 5 major technology categories, namely EHRs (n=30), computerized clinical decision support (n=8), advanced analytics (n=5), business analytics (n=5), and telemedicine (n=2). Overall, 62% (31/50) of the reviewed studies indicated a positive economic impact for providers either via direct cost or revenue effects or via indirect efficiency or productivity improvements. When differentiating between categories, however, an ambiguous picture emerged for EHR, whereas analytics technologies like computerized clinical decision support and advanced analytics predominantly showed economic benefits. CONCLUSIONS The research question of whether data and analytics create economic benefits for health care providers cannot be answered uniformly. The results indicate ambiguous effects for EHRs, here representing data, and mainly positive effects for the significantly less studied analytics field. The mixed results regarding EHRs can create an economic barrier for adoption by providers. This barrier can translate into a bottleneck to positive economic effects of analytics technologies relying on EHR data. Ultimately, more research on economic effects of technologies other than EHRs is needed to generate a more reliable evidence base.
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Affiliation(s)
- Philip von Wedel
- Chair of Economic and Social Policy, WHU - Otto Beisheim School of Management, Vallendar, Germany
| | - Christian Hagist
- Chair of Economic and Social Policy, WHU - Otto Beisheim School of Management, Vallendar, Germany
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Changing Provider PSA Screening Behavior Using Best Practice Advisories: Interventional Study in a Multispecialty Group Practice. J Gen Intern Med 2020; 35:796-801. [PMID: 33107000 PMCID: PMC7652982 DOI: 10.1007/s11606-020-06097-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 07/30/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Most guidelines recommend against PSA-based screening for prostate cancer in men ≥ 70 years of age. Adherence to these guidelines is variable. OBJECTIVE To determine whether the use of a "Best Practice Advisory" (BPA) intervention within the electronic medical record (EMR) system can alter the rate of PSA screening in men ≥ 70 years of age. DESIGN This is an interventional study spanning the years 2013 through 2017, in men ≥ 70 years of age in Kaiser Permanente Northern California with no prior history of prostate cancer. The BPA intervention was activated in the EMR system on October 15, 2015, with no prior notice or education. SETTING Integrated healthcare system including all Kaiser Permanente Northern California facilities. PARTICIPANTS A population-based sample that included all male members ≥ 70 years of age without a history of prostate cancer. MAIN MEASURES The main outcome was the rate of PSA testing in men ≥ 70 years of age. We compared the rates of PSA testing between the pre-BPA period (January 1, 2013-October 14, 2015) and the post-BPA period (October 15, 2015-December 31, 2017). An interrupted time series analysis of PSA ordering rates was performed. KEY RESULTS Following the 2015 BPA intervention, screening rates substantially declined from 36.0 per 100 person-years to 14.9 per 100 person-years (rate ratio = 0.415; 95% CI: 0.410-0.419). The effect of the BPA was comparable among all patient races and ordering provider specialties. The interrupted time series analysis showed a rapid, large, and sustained drop in the rate of PSA ordering, and much less temporal variation in test ordering after activation of the BPA. CONCLUSION Following activation of a BPA within the EMR, the rates of inappropriate PSA testing significantly declined by 58.5% in men ≥ 70 years of age and temporal variation was reduced.
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Bai L, Gao S, Burstein F, Kerr D, Buntine P, Law N. A systematic literature review on unnecessary diagnostic testing: The role of ICT use. Int J Med Inform 2020; 143:104269. [PMID: 32927268 DOI: 10.1016/j.ijmedinf.2020.104269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/10/2020] [Accepted: 09/02/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The negative impact of unnecessary diagnostic tests on healthcare systems and patients has been widely recognized. Medical researchers in various countries have been devoting effort to reduce unnecessary diagnostic tests by using different types of interventions, including information and communications technology-based (ICT-based) intervention, educational intervention, audit and feedback, the introduction of guidelines or protocols, and the reward and punishment of staff. We conducted a review of ICT based interventions and a comparative analysis of their relative effectiveness in reducing unnecessary tests. METHOD A systematic Boolean search in PubMed, EMBase and EBSCOhost research databases was performed. Keyword search and citation analysis were also conducted. Empirical studies reporting ICT based interventions, and their implications on relative effectiveness in reducing unnecessary diagnostic tests (pathology tests or medical imaging) were evaluated independently by two reviewers based on a rigorously developed coding protocol. RESULTS 92 research articles from peer-reviewed journals were identified as eligible. 47 studies involved a single-method intervention and 45 involved multi-method interventions. Regardless of the number of interventions involved in the studies, ICT-based interventions were utilized by 71 studies and 59 of them were shown to be effective in reducing unnecessary testing. A clinical decision support (CDS) tool appeared to be the most adopted ICT approach, with 46 out of 71 studies using CDS tools. The CDS tool showed effectiveness in reducing test volume in 38 studies and reducing cost in 24 studies. CONCLUSIONS This review investigated five frequently utilized intervention methods, ICT-based, education, introduction of guidelines or protocols, audit and feedback, and reward and punishment. It provides in-depth analysis of the efficacy of different types of interventions and sheds insights about the benefits of ICT based interventions, especially those utilising CDS tools, to reduce unnecessary diagnostic testing. The replicability of the studies is limited due to the heterogeneity of the studies in terms of context, study design, and targeted types of tests.
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Affiliation(s)
- Lu Bai
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Shijia Gao
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Frada Burstein
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia.
| | - Donald Kerr
- USC Business School, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Paul Buntine
- Emergency Department, Box Hill Hospital, Melbourne, VIC, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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Keppel MH, Kolbitsch T, Hoppe UC, Auer S, Felder TK, Oberkofler H, Mrazek C, Haschke-Becher E, Cadamuro J. The clinically effective use of cardiac markers by restructuring laboratory profiles at Cardiology wards. Clin Chem Lab Med 2020; 58:1565-1571. [PMID: 32305953 DOI: 10.1515/cclm-2019-1229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/04/2020] [Indexed: 12/20/2022]
Abstract
Background Laboratory overutilization is associated with diagnostic error and potential patient risk. We applied a demand management strategy in collaboration with the local Department of Cardiology to reduce the cardiac markers high-sensitive troponin T (hsTropT) and N-terminal pro brain natriuretic peptide (NTproBNP) in laboratory ordering profiles (LOPs). The present study aimed to retrospectively evaluate the implemented strategies. Methods Strategies included educational measures and evidence-guided, active test de-selection from all cardiology ward LOPs, and/or permanent removal from LOPs. Tests remained available at all times. We evaluated overutilization by reductions in monthly orders, and assessed differences in 30-day all-cause readmission rate and length of patients' hospital stay. Results Overall, we observed a mean reduction of 66.1% ± 7.6% (n = 277 ± 31) in hsTropT tests. Educational measures effectively reduced NTproBNP orders by 52.8% ± 17.7% (n = 60 ± 20). Permanent removal of tests from LOPs additionally decreased orders to a final extent of 75.8% ± 8.0% (n = 322 ± 31) in NTproBNP tests. The 30-day readmission rate and overall length of hospital stay did not increase. Conclusions Our results indicate that cardiac markers in routine care are subject to extensive overutilization when used within LOPs. Educational measures are an effective strategy to overcome the overutilization of cardiac markers but may be more effective when combined with the removal of cardiac markers from LOPs.
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Affiliation(s)
- Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Tobias Kolbitsch
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Uta C Hoppe
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Simon Auer
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Thomas K Felder
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Hannes Oberkofler
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
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Uljon SN, Simmons DP, Rudolf JW, Baron JM, Dutta S, McEvoy DS, Murali M, Dighe AS. Validation and Implementation of an Ordering Alert to Improve the Efficiency of Monoclonal Gammopathy Evaluation. Am J Clin Pathol 2020; 153:396-406. [PMID: 31776551 DOI: 10.1093/ajcp/aqz180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To evaluate the use of a provider ordering alert to improve laboratory efficiency and reduce costs. METHODS We conducted a retrospective study to assess the use of an institutional reflex panel for monoclonal gammopathy evaluation. We then created a clinical decision support (CDS) alert to educate and encourage providers to change their less-efficient orders to the reflex panel. RESULTS Our retrospective analysis demonstrated that an institutional reflex panel could be safely substituted for a less-efficient and higher-cost panel. The implemented CDS alert resulted in 79% of providers changing their high-cost order panel to an order panel based on the reflex algorithm. CONCLUSIONS The validated decision support alert demonstrated high levels of provider acceptance and directly led to operational and cost savings within the laboratory. Furthermore, these studies highlight the value of laboratory involvement with CDS efforts to provide agile and targeted provider ordering assistance.
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Affiliation(s)
- Sacha N Uljon
- Departments of Pathology, Massachusetts General Hospital, Boston
| | - Daimon P Simmons
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA
| | - Joseph W Rudolf
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis
| | - Jason M Baron
- Departments of Pathology, Massachusetts General Hospital, Boston
| | - Sayon Dutta
- Departments of Pathology, Massachusetts General Hospital, Boston
- Emergency Medicine, Massachusetts General Hospital, Boston
| | | | | | - Anand S Dighe
- Departments of Pathology, Massachusetts General Hospital, Boston
- Partners HealthCare, Somerville, MA
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Hunt TC, O'Neil BB. Leveraging Behavioral Economics to Reduce Low-value Prostate Cancer Screening. Eur Urol 2020; 77:400-402. [PMID: 31959547 DOI: 10.1016/j.eururo.2020.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 01/02/2020] [Indexed: 10/25/2022]
Abstract
Behavioral economic principles model decision-making behavior, and offer promising and unexplored mechanisms for understanding the etiology of low-value care in urologic oncology. Clinical decision support built around these principles is poised to substantially reduce wasteful spending in prostate cancer screening.
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Affiliation(s)
- Trevor C Hunt
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Brock B O'Neil
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
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Boulet L, Vermeulin T, Vasiliu A, Gillibert A, Lottin M, Frébourg N, Boyer S, Merle V. Lack of effect of a poster-based intervention to reduce the number of blood culture samples collected. Med Mal Infect 2019; 50:78-82. [PMID: 31640881 DOI: 10.1016/j.medmal.2019.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 09/24/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To reduce the number of blood culture samples collected. PATIENTS AND METHOD We performed a cluster randomized controlled trial in adult acute care, and subacute care and rehabilitation wards in a university hospital in France. A poster associating an image of eyes looking at the reader with a summary of blood culture sampling guidelines was displayed in hospital wards in the intervention group. The incidence rate of blood cultures per 1000 days during pre- and post-intervention periods was calculated. RESULTS Thirty-one wards participated in the study. The median difference in blood cultures/1000 days between periods was -1.863 [-11.941; 1.007] in the intervention group and -5.824 [-14.763; -2.217] in the control group (P=0.27). CONCLUSION The intervention did not show the expected effect, possibly due to the choice of blood cultures as a target of good practice, but also to confounding factors such as the stringent policy of decreasing unnecessary costly testing.
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Affiliation(s)
- L Boulet
- Hospital Infection Control and Epidemiology Department, Rouen University Hospital, 76000 Rouen, France.
| | - T Vermeulin
- Clinique Mathilde, Department of Medical Information, 76000 Rouen, France
| | - A Vasiliu
- Hospital Infection Control and Epidemiology Department, Rouen University Hospital, 76000 Rouen, France
| | - A Gillibert
- Unit of Biostatistics, Rouen University Hospital, 76000 Rouen, France
| | - M Lottin
- Healthcare Associated Risk Department, Rouen University Hospital, 76000 Rouen, France
| | - N Frébourg
- Department of Microbiology, Rouen University Hospital, 76000 Rouen, France
| | - S Boyer
- Department of Microbiology, Rouen University Hospital, 76000 Rouen, France
| | - V Merle
- Hospital Infection Control and Epidemiology Department, Rouen University Hospital, 76000 Rouen, France; Dynamiques et Évènements des Soins et des Parcours research group, Rouen University Hospital, 76000 Rouen, France
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Harb R, Hajdasz D, Landry ML, Sussman LS. Improving laboratory test utilisation at the multihospital Yale New Haven Health System. BMJ Open Qual 2019; 8:e000689. [PMID: 31637323 PMCID: PMC6768328 DOI: 10.1136/bmjoq-2019-000689] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/26/2019] [Accepted: 08/20/2019] [Indexed: 02/05/2023] Open
Abstract
Background Waste persists in healthcare and negatively impacts patients. Clinicians have direct control over test ordering and ongoing international efforts to improve test utilisation have identified multifaceted approaches as critical to the success of interventions. Prior to 2015, Yale New Haven Health lacked a coherent strategy for laboratory test utilisation management. Methods In 2015, a system-wide laboratory formulary committee was formed at Yale New Haven Health to manage multiple interventions designed to improve test utilisation. We report here on specific interventions conducted between 2015 and 2017 including reduction of (1) obsolete or misused testing, (2) duplicate orders, and (3) daily routine lab testing. These interventions were driven by a combination of modifications to computerised physician order entry, test utilisation dashboards and physician education. Measurements included test order volume, blood savings and cost savings. Results Testing for a number of obsolete/misused analytes was eliminated or significantly decreased depending on alert rule at order entry. Hard stops significantly decreased duplicate testing and educational sessions significantly decreased daily orders of routine labs and increased blood savings but the impact waned over time for select groups. In total, we realised approximately $100 000 of cost savings during the study period. Conclusion Through a multifaceted approach to utilisation management, we show significant reductions in low-value clinical testing that have led to modest but significant savings in both costs and patients’ blood.
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Affiliation(s)
- Roa Harb
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - David Hajdasz
- Clinical Redesign, Office of Strategy Management, Yale New Haven Health System, New Haven, Connecticut, USA
| | - Marie L Landry
- Departments of Laboratory Medicine and Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - L Scott Sussman
- Clinical Redesign, Department of Medicine, Yale New Haven Health System, New Haven, Connecticut, USA
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Sue LY, Kim JE, Oza H, Chong T, Woo HE, Cheng EM, Leung AM. REDUCING INAPPROPRIATE SERUM T3 LABORATORY TEST ORDERING IN PATIENTS WITH TREATED HYPOTHYROIDISM. Endocr Pract 2019; 25:1312-1316. [PMID: 31412225 DOI: 10.4158/ep-2019-0215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Choosing Wisely is a campaign of the American Board of Internal Medicine that aims to promote evidence-based practices to reduce unnecessary ordering of tests or procedures. As part of this campaign, the Endocrine Society advises against ordering a serum total or free triiodothyronine (T3) level when assessing levothyroxine dosing in hypothyroid patients. This study was performed to assess and reduce inappropriate laboratory ordering practices among providers who manage patients with hypothyroidism within a large U.S. academic health system. Methods: A best practice alert (BPA) in the health record was developed and implemented following the collection of baseline data. This alert consisted of a popup window that was triggered when a serum T3 laboratory test was ordered for patients prescribed levothyroxine. The alert required user acknowledgement before the serum T3 laboratory test could be ordered. Results: During the 6-week period prior to launching the BPA, serum T3 tests were ordered a mean of 162.3 ± 15.4 (standard deviation) occurrences per 10,000 patients per week. Over a 15-week period following implementation of the BPA, the frequency of serum T3 orders steadily decreased and resulted in >44% fewer inappropriate tests being ordered. Conclusion: Although national societal guidelines recommend against ordering serum T3 concentrations while monitoring patients with hypothyroidism managed with levothyroxine, these laboratory tests are frequently ordered. Development of a triggered alert in the health record may reduce inappropriate monitoring practices, decrease costs, and improve utilization of limited health-care resources for this common clinical condition. Abbreviations: ATA = American Thyroid Association; BPA = best practice alert; T3 = triiodothyronine; TSH = thyroid-stimulating hormone.
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Jalbert R, Gob A, Chin-Yee I. Decreasing daily blood work in hospitals: What works and what doesn't. Int J Lab Hematol 2019; 41 Suppl 1:151-161. [PMID: 31069984 DOI: 10.1111/ijlh.13015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/27/2019] [Accepted: 03/01/2019] [Indexed: 12/19/2022]
Abstract
Recurrent, inappropriate laboratory testing is a costly and wasteful use of healthcare resources. Recognizing this problem, the American Board of Internal Medicine, Canadian Society of Internal Medicine, and the Canadian Association of Pathologist all supported the Choosing Wisely campaign to reduce laboratory investigations in patients who demonstrate clinical and laboratory stability. In this narrative, we review studies looking at a variety of approaches to reduce excessive testing including education, audit and feedback, computerized physician order entry system changes, and forcing functions. Each type of intervention has its own unique advantages and disadvantages, varying in complexity, disruptiveness, effectiveness, and sustainability. Before implementing any quality improvement project, it is important to analyze the local context to identify the root causes for the practice behavior and aim to use the minimal amount of intervention to achieve the desired result. Change is often incremental and will seldom occur with a single intervention or Plan-Do-Study-Act cycle. Garnering the support of opinion leaders and a quality improvement team will help make the process and intervention a success.
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Affiliation(s)
- Rochelle Jalbert
- Division of Hematology, Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Alan Gob
- Division of Hematology, Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Ian Chin-Yee
- Division of Hematology, Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada.,Department of Pathology and Laboratory Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
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Leis B, Frost A, Bryce R, Lyon AW, Coverett K. Altering standard admission order sets to promote clinical laboratory stewardship: a cohort quality improvement study. BMJ Qual Saf 2019; 28:846-852. [PMID: 31073090 DOI: 10.1136/bmjqs-2018-008995] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 03/15/2019] [Accepted: 04/23/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Careful design of preprinted order sets is needed to prevent medical overuse. Recent work suggests that removing a single checkbox from an order set changes physicians' clinical decision-making. LOCAL PROBLEM During a 2-month period, our coronary care unit (CCU) ordered almost eight times as many serum thyroid-stimulating hormone (TSH) tests as our neighbouring intensive care unit, many without a reasonable clinical basis. We postulated that we could reduce inappropriate testing and improve clinical laboratory stewardship by removing the TSH checkbox from the CCU admission order set. METHODS After we retrospectively evaluated CCU TSH ordering before intervention, the checkbox was removed from the CCU admission order set. Twelve weeks later, we commenced a prospective 2-month assessment of TSH testing and clinical sequelae of thyroid disease among all CCU admissions. If clinical indications were absent or testing had occurred within 6 weeks, TSH requests were labelled as 'inappropriate'. RESULTS Physician ordering and, specifically, inappropriate ordering decreased substantially after the intervention. In 2016 among physician-ordered TSH tests, 60.6% (66/109) were inappropriate; in 2017 this decreased to 20% (2/10, p=0.01). Overall, the net effect of checkbox removal saw the decrease in TSH testing without clinical indication outweigh an increase in missed testing where indications appear to exist. CONCLUSIONS Provision of an optional checkbox for a laboratory test in an admission order set can promote overuse of laboratory resources. Simple removal of a checkbox may dramatically change test ordering patterns and promote clinical laboratory stewardship. Given our reliance on order sets, particularly by trainees, changes to order sets must be cautious to assure guideline-directed care is maintained.
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Affiliation(s)
- Benjamin Leis
- Medicine, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Andrew Frost
- Medicine, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Rhonda Bryce
- Community Health and Epidemiology, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Andrew W Lyon
- Pathology and Laboratory Medicine, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Kelly Coverett
- Medicine, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
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Abstract
Laboratory tests are an integral part of the electronic health record (EHR). Providing clinical decision support (CDS) for the ordering, collection, reporting, viewing, and interpretation of laboratory testing is a fundamental function of the EHR. The implementation of a sustainable, effective laboratory CDS program requires a commitment to standardization and harmonization of the laboratory dictionaries that are the foundation of laboratory-based CDS. In this review, the authors provide an overview of the tools available within the EHR to improve decision making throughout the entire laboratory testing process, from test order to clinical action.
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Affiliation(s)
- Joseph W Rudolf
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, 420 Delaware Street Southeast, MMC 609 Mayo, Minneapolis, MN 55455, USA
| | - Anand S Dighe
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, USA.
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AI-Driven Pathology Laboratory Utilization Management via Data- and Knowledge-Based Analytics. Artif Intell Med 2019. [DOI: 10.1007/978-3-030-21642-9_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Bejjanki H, Mramba LK, Beal SG, Radhakrishnan N, Bishnoi R, Shah C, Agrawal N, Harris N, Leverence R, Rand K. The role of a best practice alert in the electronic medical record in reducing repetitive lab tests. CLINICOECONOMICS AND OUTCOMES RESEARCH 2018; 10:611-618. [PMID: 30323637 PMCID: PMC6181108 DOI: 10.2147/ceor.s167499] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The recommendations of the American Board of Internal Medicine Foundation’s “Choosing Wisely®” initiative recognize the importance of improving the appropriateness of testing behavior and reducing the number of duplicate laboratory tests. Objective To assess the effectiveness of an electronic medical record Best Practice Alert (BPA or “pop up”) intervention aimed at reducing duplicate laboratory tests and hospital costs. Design Comparison of the number of duplicated laboratory tests performed on inpatients before and after the intervention. Setting University of Florida Health Shands Hospital, Gainesville, FL, USA, during 2014–2017. Intervention The electronic medical record intervention was a BPA pop-up alert that informed the ordering physician if a recent identical order already existed along with the “ordering time”, “collecting time”, “resulting time”, and the result itself. Main outcome measures Percentage change in the number of inpatient duplicate orders of selected clinical biochemistry tests and cost savings from reduction of the duplicates. Student’s t-test and beta-binomial models were used to analyze the data. Results Results from the beta-binomial model indicated that the intervention reduced the overall duplicates by 18% (OR=0.82, standard error=0.016, P-value<0.000). Percent reductions in 9 of the 17 tests were statistically significant: serum hemoglobin A1C level, vitamin B12, serum erythrocyte sedimentation rate, serum folate, serum iron, lipid panel, respiratory viral panel, serum thyroid stimulating hormone level, and Vitamin D. Additionally, important cost savings were realized from the reduction of duplicates for each lab test (with the exception of CRP) with an estimated overall savings of $72,543 over 17 months in the post-intervention period. Conclusions The present study included all hospital inpatients and covered 17 clinical laboratory tests. This rather simple and low-cost intervention resulted in significant reductions in percentage duplicates of several tests and resulted in cost savings. The study also highlights the role of hospitalists in quality improvement.
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Affiliation(s)
- Harini Bejjanki
- Division of Hospital Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA,
| | - Lazarus K Mramba
- Statistics, Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Stacy G Beal
- Department of Pathology, Immunology, & Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Nila Radhakrishnan
- Division of Hospital Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA,
| | - Rohit Bishnoi
- Division of Hospital Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA,
| | - Chintan Shah
- Division of Hospital Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA,
| | - Nikhil Agrawal
- Department of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Neil Harris
- Department of Pathology, Immunology, & Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Robert Leverence
- Division of Hospital Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA,
| | - Kenneth Rand
- Department of Pathology, Immunology, & Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
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Bindraban RS, Ten Berg MJ, Naaktgeboren CA, Kramer MHH, Van Solinge WW, Nanayakkara PWB. Reducing Test Utilization in Hospital Settings: A Narrative Review. Ann Lab Med 2018; 38:402-412. [PMID: 29797809 PMCID: PMC5973913 DOI: 10.3343/alm.2018.38.5.402] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/23/2018] [Accepted: 05/06/2018] [Indexed: 11/19/2022] Open
Abstract
Background Studies addressing the appropriateness of laboratory testing have revealed approximately 20% overutilization. We conducted a narrative review to (1) describe current interventions aimed at reducing unnecessary laboratory testing, specifically in hospital settings, and (2) provide estimates of their efficacy in reducing test order volume and improving patient-related clinical outcomes. Methods The PubMed, Embase, Scopus, Web of Science, and Canadian Agency for Drugs and Technologies in Health-Health Technology Assessment databases were searched for studies describing the effects of interventions aimed at reducing unnecessary laboratory tests. Data on test order volume and clinical outcomes were extracted by one reviewer, while uncertainties were discussed with two other reviewers. Because of the heterogeneity of interventions and outcomes, no meta-analysis was performed. Results Eighty-four studies were included. Interventions were categorized into educational, (computerized) provider order entry [(C)POE], audit and feedback, or other interventions. Nearly all studies reported a reduction in test order volume. Only 15 assessed sustainability up to two years. Patient-related clinical outcomes were reported in 45 studies, two of which found negative effects. Conclusions Interventions from all categories have the potential to reduce unnecessary laboratory testing, although long-term sustainability is questionable. Owing to the heterogeneity of the interventions studied, it is difficult to conclude which approach was most successful, and for which tests. Most studies had methodological limitations, such as the absence of a control arm. Therefore, well-designed, controlled trials using clearly described interventions and relevant clinical outcomes are needed.
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Affiliation(s)
- Renuka S Bindraban
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands.,Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Maarten J Ten Berg
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christiana A Naaktgeboren
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark H H Kramer
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Wouter W Van Solinge
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Prabath W B Nanayakkara
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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Morris TF, Ellison TL, Mutabagani M, Althawadi SI, Heppenheimer M. Demand management and optimization of clinical laboratory services in a tertiary referral center in Saudi Arabia. Ann Saudi Med 2018; 38:299-304. [PMID: 30078029 PMCID: PMC6086671 DOI: 10.5144/0256-4947.2018.299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Demand for clinical laboratory services in our insti.tution has increased by 7% each year in the past 5 years, while the amount budgeted for services has remained fixed. To address the issue, we conducted a pilot study to curb inappropriate demand by implementing a minimum retest interval (time-based restrictions on the ordering certain tests) and thus reduce costs. OBJECTIVE Explore the impact (financial and work volume) of restricting overuse of laboratory tests that add to costs but provide no additional clinical value. DESIGN Pilot study of means to reduce costs and workload. SETTING Clinical laboratory that provides diagnostic support to a tertiary care center specializing in transplantation and oncology. METHODS With the engagement of clinical colleagues, we selected 13 tests characterized by high volume, high cost, or a perception of overuse that adds no clinical value. The selection was also based on established lock-out frequencies identified in a literature review. Data was captured on test numbers before and after initiating computer-based lock-outs along with the reference laboratory cost of these tests for the first 6 months of 2016 and 2017. MAIN OUTCOME MEASURES Alterations in testing patterns (mimimum retest intervals) and frequencies for tests. RESULTS The number of tests ordered during the 6-month period in 2017 were reduced by an average of 6.6% versus the same period for 2016, saving 2.03 million Saudi Arabian Riyals (SAR). Given a 7% annual growth in the preceding 5 years, the volume was reduced by 13% in real terms. The percentage reduction in number of tests ranged from as little as 0.2% for PT to 70.3% for an enzyme immunoassay. Savings were 1.4 million SAR in hematology and 0.36 million SAR in microbiology over the 6-month period. CONCLUSION Minimum retest intervals using computer-based rules are effective in supporting strategies to manage demand. LIMITATIONS This approach may not be applicable to all laboratory tests; however, the success of this pilot study would encourage more widespread use of this approach. CONFLICT OF INTEREST None.
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Affiliation(s)
- Thomas F Morris
- Thomas F. Morris,, MBC 10 Cytogenetics Laboratory,, Department of Pathology and Laboratory Medicine,, King Faisal Specialist Hospital and Research Centre,, PO Box 3354, Riyadh 11211, Saudi Arabia, T: 966-11-4647272 ext. 34269, , ORCID: http://orcid.org/0000-0001-7770-387X
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Bagai A, Eberg M, Koh M, Cheema AN, Yan AT, Dhoot A, Bhavnani SP, Wijeysundera HC, Bhatia RS, Kaul P, Goodman SG, Ko DT. Population-Based Study on Patterns of Cardiac Stress Testing After Percutaneous Coronary Intervention. Circ Cardiovasc Qual Outcomes 2018; 10:CIRCOUTCOMES.117.003660. [PMID: 29017997 DOI: 10.1161/circoutcomes.117.003660] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 09/07/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The appropriate use criteria considers cardiac stress testing within 2 years after percutaneous coronary intervention (PCI) to be rarely appropriate, unless prompted by symptoms or change in clinical status. Little is known about the patterns of cardiac stress testing after PCI in the single-payer Canadian healthcare system, where mechanisms for reimbursement are different from the United States. METHODS AND RESULTS Frequency and timing of cardiac stress testing within 2 years of PCI performed between April 2004 and March 2013 in Ontario, Canada, was determined from linked provincial databases. Subsequent rates of coronary angiography and revascularization after stress testing were ascertained. Of the 112 691 patients with PCI, 67 442 (59.8%) underwent at least 1 stress test, with 38 267 (34.0%) undergoing repeat stress testing (ie, >1 stress test) within 2 years. Patients who underwent stress testing were younger, had less medical comorbidities, were more likely to reside in urban areas, and had higher incomes. Spikes in incidence of repeat stress testing were observed at 3 to 4 months, 6 to 7 months, and 12 to 13 months after the prior stress test. Of those tested, only 5.9% underwent subsequent coronary angiography, and only 3.1% underwent repeat revascularization within 60 days of stress testing. CONCLUSIONS More than half of all patients undergo cardiac stress testing within 2 years of PCI, with one third undergoing repeat stress tests. Only 1 of 30 tested patients underwent repeat revascularization. These findings reinforce the appropriate use criteria recommendations against routine stress testing after PCI. Further work is needed to aid with the selection of patients most likely to benefit from stress testing after PCI.
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Affiliation(s)
- Akshay Bagai
- From the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (A.B.); Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B., A.N.C., A.T.Y., A.D., S.G.G.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.E., M.K., H.C.W., D.T.K.); Division of Cardiology, Scripps Clinic and Research Institute, San Diego, CA (S.P.B.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (H.C.W., D.T.K.); Peter Munk Cardiac Center of the University Health Network, University of Toronto, Ontario, Canada (S.B.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (S.B.); and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (P.K., S.G.G.).
| | - Maria Eberg
- From the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (A.B.); Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B., A.N.C., A.T.Y., A.D., S.G.G.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.E., M.K., H.C.W., D.T.K.); Division of Cardiology, Scripps Clinic and Research Institute, San Diego, CA (S.P.B.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (H.C.W., D.T.K.); Peter Munk Cardiac Center of the University Health Network, University of Toronto, Ontario, Canada (S.B.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (S.B.); and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (P.K., S.G.G.)
| | - Maria Koh
- From the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (A.B.); Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B., A.N.C., A.T.Y., A.D., S.G.G.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.E., M.K., H.C.W., D.T.K.); Division of Cardiology, Scripps Clinic and Research Institute, San Diego, CA (S.P.B.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (H.C.W., D.T.K.); Peter Munk Cardiac Center of the University Health Network, University of Toronto, Ontario, Canada (S.B.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (S.B.); and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (P.K., S.G.G.)
| | - Asim N Cheema
- From the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (A.B.); Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B., A.N.C., A.T.Y., A.D., S.G.G.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.E., M.K., H.C.W., D.T.K.); Division of Cardiology, Scripps Clinic and Research Institute, San Diego, CA (S.P.B.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (H.C.W., D.T.K.); Peter Munk Cardiac Center of the University Health Network, University of Toronto, Ontario, Canada (S.B.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (S.B.); and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (P.K., S.G.G.)
| | - Andrew T Yan
- From the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (A.B.); Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B., A.N.C., A.T.Y., A.D., S.G.G.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.E., M.K., H.C.W., D.T.K.); Division of Cardiology, Scripps Clinic and Research Institute, San Diego, CA (S.P.B.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (H.C.W., D.T.K.); Peter Munk Cardiac Center of the University Health Network, University of Toronto, Ontario, Canada (S.B.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (S.B.); and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (P.K., S.G.G.)
| | - Arti Dhoot
- From the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (A.B.); Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B., A.N.C., A.T.Y., A.D., S.G.G.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.E., M.K., H.C.W., D.T.K.); Division of Cardiology, Scripps Clinic and Research Institute, San Diego, CA (S.P.B.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (H.C.W., D.T.K.); Peter Munk Cardiac Center of the University Health Network, University of Toronto, Ontario, Canada (S.B.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (S.B.); and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (P.K., S.G.G.)
| | - Sanjeev P Bhavnani
- From the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (A.B.); Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B., A.N.C., A.T.Y., A.D., S.G.G.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.E., M.K., H.C.W., D.T.K.); Division of Cardiology, Scripps Clinic and Research Institute, San Diego, CA (S.P.B.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (H.C.W., D.T.K.); Peter Munk Cardiac Center of the University Health Network, University of Toronto, Ontario, Canada (S.B.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (S.B.); and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (P.K., S.G.G.)
| | - Harindra C Wijeysundera
- From the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (A.B.); Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B., A.N.C., A.T.Y., A.D., S.G.G.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.E., M.K., H.C.W., D.T.K.); Division of Cardiology, Scripps Clinic and Research Institute, San Diego, CA (S.P.B.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (H.C.W., D.T.K.); Peter Munk Cardiac Center of the University Health Network, University of Toronto, Ontario, Canada (S.B.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (S.B.); and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (P.K., S.G.G.)
| | - R Sacha Bhatia
- From the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (A.B.); Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B., A.N.C., A.T.Y., A.D., S.G.G.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.E., M.K., H.C.W., D.T.K.); Division of Cardiology, Scripps Clinic and Research Institute, San Diego, CA (S.P.B.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (H.C.W., D.T.K.); Peter Munk Cardiac Center of the University Health Network, University of Toronto, Ontario, Canada (S.B.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (S.B.); and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (P.K., S.G.G.)
| | - Padma Kaul
- From the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (A.B.); Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B., A.N.C., A.T.Y., A.D., S.G.G.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.E., M.K., H.C.W., D.T.K.); Division of Cardiology, Scripps Clinic and Research Institute, San Diego, CA (S.P.B.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (H.C.W., D.T.K.); Peter Munk Cardiac Center of the University Health Network, University of Toronto, Ontario, Canada (S.B.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (S.B.); and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (P.K., S.G.G.)
| | - Shaun G Goodman
- From the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (A.B.); Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B., A.N.C., A.T.Y., A.D., S.G.G.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.E., M.K., H.C.W., D.T.K.); Division of Cardiology, Scripps Clinic and Research Institute, San Diego, CA (S.P.B.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (H.C.W., D.T.K.); Peter Munk Cardiac Center of the University Health Network, University of Toronto, Ontario, Canada (S.B.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (S.B.); and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (P.K., S.G.G.)
| | - Dennis T Ko
- From the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (A.B.); Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B., A.N.C., A.T.Y., A.D., S.G.G.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.E., M.K., H.C.W., D.T.K.); Division of Cardiology, Scripps Clinic and Research Institute, San Diego, CA (S.P.B.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (H.C.W., D.T.K.); Peter Munk Cardiac Center of the University Health Network, University of Toronto, Ontario, Canada (S.B.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (S.B.); and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (P.K., S.G.G.)
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Tchou MJ, Tang Girdwood S, Wormser B, Poole M, Davis-Rodriguez S, Caldwell JT, Shannon L, Hagedorn PA, Biondi E, Simmons J, Anderson J, Brady PW. Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods. Pediatrics 2018; 141:peds.2017-3187. [PMID: 29618583 PMCID: PMC7008632 DOI: 10.1542/peds.2017-3187] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite studies indicating a high rate of overuse, electrolyte testing remains common in pediatric inpatient care. Frequently repeated electrolyte tests often return normal results and can lead to patient harm and increased cost. We aimed to reduce electrolyte testing within a hospital medicine service by >25% within 6 months. METHODS We conducted an improvement project in which we targeted 6 hospital medicine teams at a large academic children's hospital system by using the Model for Improvement. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. Our primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. We tracked medical emergency team calls and readmission rates as balancing measures. RESULTS The mean baseline rate of electrolyte testing was 2.0 laboratory draws per 10 patient days, and this rate decreased by 35% after 1 month of initial educational interventions to 1.3 electrolyte laboratory draws per 10 patient days. This change has been sustained for 9 months and could save an estimated $292 000 in patient-level charges over the course of a year. Use of our highest-charge electrolyte panel decreased from 67% to 22% of testing. No change in rates of medical emergency team calls or readmission were found. CONCLUSIONS Our improvement intervention was associated with significant and rapid reduction in electrolyte testing and has not been associated with unintended adverse events.
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Affiliation(s)
- Michael J. Tchou
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio;,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
| | | | | | - Meifawn Poole
- Pediatric Residency Training Program, Cincinnati, Ohio
| | | | | | - Lauren Shannon
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio
| | - Philip A. Hagedorn
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio
| | - Eric Biondi
- Department of Pediatrics, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Jeffrey Simmons
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio;,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
| | - Jeffrey Anderson
- James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio;,Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick W. Brady
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio;,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
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Zhang H, Song Y, Zhang X, Hu J, Yuan S, Ma J. Extent and cost of inappropriate use of tumour markers in patients with pulmonary disease: a multicentre retrospective study in Shanghai, China. BMJ Open 2018; 8:e019051. [PMID: 29490961 PMCID: PMC5855297 DOI: 10.1136/bmjopen-2017-019051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES The currently implemented healthcare reform in China requires substantial capital investment. Although overtreatment results in serious waste, inappropriate laboratory use is widespread, and overuse of tumour markers (TMs) has attracted increasing attention. DESIGN Retrospective study. SETTING The respiratory, thoracic surgery and oncology departments of three hospitals in Shanghai from 2014 to 2015. PARTICIPANTS Patients with chronic obstructive pulmonary disease (COPD) and primary bronchogenic lung cancer (PLC). Based on clinical guidelines and physician experience, the criteria of suitability of TM examinations were determined, and the number, cost and proportion of inappropriate TM requests were analysed. RESULTS The area under the receiver operating characteristic curve for carcinoembryonic antigen+cytokeratin fragment 21-1+squamous cell carcinoma antigen+neuron-specific enolase in patients with COPD and PLC was 0.813, in accordance with the cost-effectiveness principle, indicating good clinical and health economics values. In the 2706 patients, 12 496-16 956 (58.27%-79.06%) of TM requests were inappropriate. Furthermore, the involved expense was 650 200-1 014 156 yuan, accounting for 7.69%-12.00% of examination expenses and 1.35%-2.11% of hospitalisation costs. CONCLUSIONS We found that the inappropriate use of TMs was widespread for patients with pulmonary disease. Clinicians should use TMs strictly according to the guidelines to effectively manage laboratory resources and control costs.
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Affiliation(s)
- Haichen Zhang
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Clinical Laboratory, Shanghai Xuhui Central Hospital, Shanghai, China
| | - Yunxiao Song
- Department of Clinical Laboratory, Shanghai Xuhui Central Hospital, Shanghai, China
| | - Xiong Zhang
- Department of Information Service, Shanghai Xuhui Central Hospital, Shanghai, China
| | - Jun Hu
- Department of Respiratory Medicine, Shanghai Xuhui Central Hospital, Shanghai, China
| | - Suwei Yuan
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jin Ma
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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32
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Clustered interventions to reduce inappropriate duplicate laboratory tests in an Irish tertiary hospital. Clin Biochem 2018; 52:26-32. [DOI: 10.1016/j.clinbiochem.2017.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 10/06/2017] [Accepted: 10/18/2017] [Indexed: 12/30/2022]
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Tewell CE, Talbot TR, Nelson GE, Harris BD, Jones WA, Midha NM, Mulherin DP, Stephens EB, Thirwani A, Wright PW. Reducing Inappropriate Testing for the Evaluation of Diarrhea Among Hospitalized Patients. Am J Med 2018; 131:193-199.e1. [PMID: 29061499 DOI: 10.1016/j.amjmed.2017.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 09/29/2017] [Accepted: 10/03/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Diarrhea is one of the most common illnesses in the United States. Evaluation frequently does not follow established guidelines. The objective of this study was to evaluate the effectiveness of a computerized physician order entry-based test guidance algorithm with regard to the clinical, financial, and operational impacts. METHODS Our population was patients with diarrheal illness at a tertiary academic medical center. The intervention was a computerized physician order entry-based test guidance algorithm that restricted the use of stool cultures and ova and parasites testing of diarrhea in the adult inpatient location vs nonintervention sites, which were the emergency department, pediatric inpatient and adult and pediatric outpatient locations. We measured stool culture, ova and parasites, and Clostridium difficile testing rates from July 1, 2012 to January 31, 2016. Additionally, we calculated advisor usage, consults generated, accuracy of information, and cost savings. RESULTS There was a significant decrease in stool culture and ova and parasites testing rates at the adult inpatient (P = .001 for both), pediatric (P < .001 for both), and adult emergency department (P < .001; P = .009) locations. The decrease at the intervention site was immediate, whereas the other locations showed a delayed but sustained decrease that suggests a collateral impact. A significant increase in the rate of stool culture and ova and parasites testing was observed in the outpatient setting (P = .02 and P = .001). We estimate that $21,931 was saved annually. CONCLUSIONS A point-of-order test restriction algorithm for hospitalized adults with diarrhea reduced stool testing. Similar programs should be considered at other institutions and for the evaluation of other conditions.
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Affiliation(s)
| | - Thomas R Talbot
- Departments of Medicine, Nashville, Tenn; Health Policy of Vanderbilt University School of Medicine, Nashville, Tenn
| | | | | | - Whitney A Jones
- Department of Pharmaceutical Services of Vanderbilt University Medical Center, Nashville, Tenn
| | - Narinder M Midha
- Departments of Pathology, Microbiology, and Immunology, Nashville, Tenn
| | - David P Mulherin
- Department of Pharmaceutical Services of Vanderbilt University Medical Center, Nashville, Tenn; Biomedical Informatics of Vanderbilt University School of Medicine, Nashville, Tenn
| | - Eric B Stephens
- Biomedical Informatics of Vanderbilt University School of Medicine, Nashville, Tenn
| | - Anuj Thirwani
- Department of Pharmaceutical Services of Vanderbilt University Medical Center, Nashville, Tenn
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Saluvan M, Ozonoff A. Functionality of hospital information systems: results from a survey of quality directors at Turkish hospitals. BMC Med Inform Decis Mak 2018; 18:6. [PMID: 29329532 PMCID: PMC5767047 DOI: 10.1186/s12911-018-0581-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 01/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to determine availability of core Hospital Information Systems (HIS) functions implemented in Turkish hospitals and the perceived importance of these functions on quality and patient safety. METHODS We surveyed quality directors (QDs) at civilian hospitals in the nation of Turkey. Data were collected via web survey using an instrument with 50 items describing core functionality of HIS. We calculated mean availability of each function, mean and median values of perceived impact on quality, and we investigated the relationship between availability and perceived importance. RESULTS We received responses from 31% of eligible institutions, representing all major geographic regions of Turkey. Mean availability of 50 HIS functions was 65.6%, ranging from 19.6% to 97.4%. Mean importance score was 7.87 (on a 9-point scale) ranging from 7.13 to 8.41. Functions related to result management (89.3%) and decision support systems (52.2%) had the highest and lowest reported availability respectively. Availability and perceived importance were moderately correlated (r = 0.52). CONCLUSION QDs report high importance of the HIS functions surveyed as they relate to quality and patient safety. Availability and perceived importance of HIS functions are generally correlated, with some interesting exceptions. These findings may inform future investments and guide policy changes within the Turkish healthcare system. Financial incentives, regulations around certified HIS, revisions to accreditation manuals, and training interventions are all policies which will help integrate HIS functions to support quality and patient safety in Turkish hospitals.
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Affiliation(s)
- Mehmet Saluvan
- Center for Applied Pediatric Quality Analytics, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Al Ozonoff
- Center for Applied Pediatric Quality Analytics, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
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Prgomet M, Li L, Niazkhani Z, Georgiou A, Westbrook JI. Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis. J Am Med Inform Assoc 2017; 24:413-422. [PMID: 28395016 DOI: 10.1093/jamia/ocw145] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 08/31/2016] [Indexed: 11/12/2022] Open
Abstract
Objective To conduct a systematic review and meta-analysis of the impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay (LOS), and mortality in intensive care units (ICUs). Methods We searched for English-language literature published between January 2000 and January 2016 using Medline, Embase, and CINAHL. Titles and abstracts of 586 unique citations were screened. Studies were included if they: (1) reported results for an ICU population; (2) evaluated the impact of CPOE or the addition of CDSSs to an existing CPOE system; (3) reported quantitative data on medication errors, ICU LOS, hospital LOS, ICU mortality, and/or hospital mortality; and (4) used a randomized controlled trial or quasi-experimental study design. Results Twenty studies met our inclusion criteria. The transition from paper-based ordering to commercial CPOE systems in ICUs was associated with an 85% reduction in medication prescribing error rates and a 12% reduction in ICU mortality rates. Overall meta-analyses of LOS and hospital mortality did not demonstrate a significant change. Discussion and Conclusion Critical care settings, both adult and pediatric, involve unique complexities, making them vulnerable to medication errors and adverse patient outcomes. The currently limited evidence base requires research that has sufficient statistical power to identify the true effect of CPOE implementation. There is also a critical need to understand the nature of errors arising post-CPOE and how the addition of CDSSs can be used to provide greater benefit to delivering safe and effective patient care.
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Affiliation(s)
- Mirela Prgomet
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Zahra Niazkhani
- Department of Health Information Technology, Urmia University of Medical Sciences, Urmia, Iran.,Nephrology and Kidney Transplant Research Center, Urmia University of Medical Sciences, Urmia, Iran
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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Mora A, Krug BS, Grigonis AM, Dawson A, Jing Y, Hammerman SI. Optimizing laboratory test utilization in long-term acute care hospitals. Proc AMIA Symp 2017; 30:26-29. [PMID: 28127124 DOI: 10.1080/08998280.2017.11929516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Laboratory tests can be considered inappropriate if overused or when repeated, unnecessary "routine" testing occurs. For chronically critically ill patients treated in long-term acute care hospitals (LTACHs), inappropriate testing may result in unnecessary blood draws that could potentially harm patients or increase infections. A quality improvement initiative was designed to increase physician awareness of their patterns of lab utilization in the LTACH environment. Within a large network of LTACHs, 9 hospitals were identified as having higher patterns of lab utilization than other LTACHs. Meetings were held with administrative staff and physicians, who designed and implemented hospital-specific strategies to address lab utilization. Lab utilization was measured in units of lab tests ordered per inpatient day (lab UPPD) for 8 months prior to the initial meeting and 7 months after the meeting. A repeated measures mixed model determined that postintervention lab utilization improved, on average and adjusted by case mix index, by 0.37 lab UPPD (t = -3.61, 95% CI 0.17 to 0.58) compared to the preintervention period. Overall, the case mix index 8 months prior to the intervention was no different than it was 7 months after the initial meeting (t[8] = -0.96, P = 0.37). Patient safety and outcome measures, including percentage of patients weaned from a ventilator, readmission rates, central catheter utilization rates, and the incidence of methicillin-resistant Staphylococcus aureus and other multidrug resistant organisms, showed no significant change. Hospital staff meetings focused on lab utilization and the development and deployment of tailored lab utilization strategies were associated with LTACHs achieving significantly lower lab utilization without negatively impacting quality outcomes.
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Affiliation(s)
- Adan Mora
- Baylor University Medical Center at Dallas (Mora) and Select Medical Corporation, Mechanicsburg, Pennsylvania (Krug, Grigonis, Dawson, Jing, Hammerman)
| | - Brian S Krug
- Baylor University Medical Center at Dallas (Mora) and Select Medical Corporation, Mechanicsburg, Pennsylvania (Krug, Grigonis, Dawson, Jing, Hammerman)
| | - Antony M Grigonis
- Baylor University Medical Center at Dallas (Mora) and Select Medical Corporation, Mechanicsburg, Pennsylvania (Krug, Grigonis, Dawson, Jing, Hammerman)
| | - Amanda Dawson
- Baylor University Medical Center at Dallas (Mora) and Select Medical Corporation, Mechanicsburg, Pennsylvania (Krug, Grigonis, Dawson, Jing, Hammerman)
| | - Yuqing Jing
- Baylor University Medical Center at Dallas (Mora) and Select Medical Corporation, Mechanicsburg, Pennsylvania (Krug, Grigonis, Dawson, Jing, Hammerman)
| | - Samuel I Hammerman
- Baylor University Medical Center at Dallas (Mora) and Select Medical Corporation, Mechanicsburg, Pennsylvania (Krug, Grigonis, Dawson, Jing, Hammerman)
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Sim EY, Tan DJA, Abdullah HR. The use of computerized physician order entry with clinical decision support reduces practice variance in ordering preoperative investigations: A retrospective cohort study. Int J Med Inform 2017; 108:29-35. [DOI: 10.1016/j.ijmedinf.2017.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/12/2017] [Accepted: 09/26/2017] [Indexed: 12/19/2022]
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Abstract
OBJECTIVE To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. DATA SOURCES PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015. STUDY SELECTION Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed. DATA EXTRACTION Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation. DATA SYNTHESIS The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations. CONCLUSIONS This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.
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Quaglini S, Sacchi L, Lanzola G, Viani N. Personalization and Patient Involvement in Decision Support Systems: Current Trends. Yearb Med Inform 2017; 10:106-18. [PMID: 26293857 DOI: 10.15265/iy-2015-015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES This survey aims at highlighting the latest trends (2012-2014) on the development, use, and evaluation of Information and Communication Technologies (ICT) based decision support systems (DSSs) in medicine, with a particular focus on patient-centered and personalized care. METHODS We considered papers published on scientific journals, by querying PubMed and Web of ScienceTM. Included studies focused on the implementation or evaluation of ICT-based tools used in clinical practice. A separate search was performed on computerized physician order entry systems (CPOEs), since they are increasingly embedding patient-tailored decision support. RESULTS We found 73 papers on DSSs (53 on specific ICT tools) and 72 papers on CPOEs. Although decision support through the delivery of recommendations is frequent (28/53 papers), our review highlighted also DSSs only based on efficient information presentation (25/53). Patient participation in making decisions is still limited (9/53), and mostly focused on risk communication. The most represented medical area is cancer (12%). Policy makers are beginning to be included among stakeholders (6/73), but integration with hospital information systems is still low. Concerning knowledge representation/management issues, we identified a trend towards building inference engines on top of standard data models. Most of the tools (57%) underwent a formal assessment study, even if half of them aimed at evaluating usability and not effectiveness. CONCLUSIONS Overall, we have noticed interesting evolutions of medical DSSs to improve communication with the patient, consider the economic and organizational impact, and use standard models for knowledge representation. However, systems focusing on patient-centered care still do not seem to be available at large.
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Affiliation(s)
- S Quaglini
- Silvana Quaglini, Department of Electrical, Computer, and Biomedical Engineering, University of Pavia, Via Ferrata 5, 27100 Pavia, Italy, Tel: +39 0382 985058, Fax: +39 0382 985060, E-mail:
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Beal SG, Tremblay E, Harris N, Rand K. Removing Cerebrospinal Fluid Antibody Orders from the Test Menu Results in a Dramatic Decrease in Order Volume. J Appl Lab Med 2017; 2:47-54. [PMID: 33636964 DOI: 10.1373/jalm.2017.023515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/18/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Antibody tests for Borrelia burgdorferi (agent of Lyme disease), Toxoplasma gondii, and cytomegalovirus in cerebrospinal fluid (CSF) are rarely useful. One reason for misutilization of laboratory tests is simply the convenience offered by a computerized physician order entry (CPOE) system. METHODS The cytomegalovirus (CMV) antibodies-CSF, B. burgdorferi antibodies-CSF, and T. gondii antibodies-CSF orders were removed from the test menu. A provider could still order these tests using a miscellaneous order. We collected monthly volumes of test orders before and after the tests were removed from the CPOE. RESULTS Orders for CSF antibody testing for B. burgdorferi, T. gondii, and CMV decreased by 91%, 93%, and 98%, respectively (P < 0.01), after they were removed from the CPOE test menu. This result correlates to a savings of $50053.44 per year. Additionally, we did not see a paradoxical increase in CMV PCR or T. gondii PCR orders after the intervention. CONCLUSIONS Removal of test orders from the CPOE dramatically decreased test order volume, which led to substantial cost savings and availability of CSF for more useful tests. There was no compensatory increase in order volume for related tests, indicating that providers were not looking for alternate tests.
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Affiliation(s)
- Stacy G Beal
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL
| | - Elizabeth Tremblay
- Infection Prevention and Control, University of Florida Health Shands Hospital, Gainesville, FL
| | - Neil Harris
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL
| | - Kenneth Rand
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL.,Division of Infectious Diseases and Global Medicine, Department of Internal Medicine, University of Florida, Gainesville, FL
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Colla CH, Mainor AJ, Hargreaves C, Sequist T, Morden N. Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review. Med Care Res Rev 2016; 74:507-550. [PMID: 27402662 DOI: 10.1177/1077558716656970] [Citation(s) in RCA: 206] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.
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Affiliation(s)
- Carrie H Colla
- 1 Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | | | - Thomas Sequist
- 2 Harvard Medical School, Boston, MA, USA.,3 Brigham and Women's Hospital, Boston, MA, USA.,4 Partners HealthCare, Boston, MA, USA
| | - Nancy Morden
- 1 Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,5 Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Reducing Unnecessary Shoulder MRI Examinations Within a Capitated Health Care System: A Potential Role for Shoulder Ultrasound. J Am Coll Radiol 2016; 13:780-7. [PMID: 27162045 DOI: 10.1016/j.jacr.2016.03.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/01/2016] [Accepted: 03/11/2016] [Indexed: 02/07/2023]
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Yılmaz FM, Kahveci R, Aksoy A, Özer Kucuk E, Akın T, Mathew JL, Meads C, Zengin N. Impact of Laboratory Test Use Strategies in a Turkish Hospital. PLoS One 2016; 11:e0153693. [PMID: 27077653 PMCID: PMC4831677 DOI: 10.1371/journal.pone.0153693] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 04/03/2016] [Indexed: 11/19/2022] Open
Abstract
Objectives Eliminating unnecessary laboratory tests is a good way to reduce costs while maintain patient safety. The aim of this study was to define and process strategies to rationalize laboratory use in Ankara Numune Training and Research Hospital (ANH) and calculate potential savings in costs. Methods A collaborative plan was defined by hospital managers; joint meetings with ANHTA and laboratory professors were set; the joint committee invited relevant staff for input, and a laboratory efficiency committee was created. Literature was reviewed systematically to identify strategies used to improve laboratory efficiency. Strategies that would be applicable in local settings were identified for implementation, processed, and the impact on clinical use and costs assessed for 12 months. Results Laboratory use in ANH differed enormously among clinics. Major use was identified in internal medicine. The mean number of tests per patient was 15.8. Unnecessary testing for chloride, folic acid, free prostate specific antigen, hepatitis and HIV testing were observed. Test panel use was pinpointed as the main cause of overuse of the laboratory and the Hospital Information System test ordering page was reorganized. A significant decrease (between 12.6–85.0%) was observed for the tests that were taken to an alternative page on the computer screen. The one year study saving was equivalent to 371,183 US dollars. Conclusion Hospital-based committees including laboratory professionals and clinicians can define hospital based problems and led to a standardized approach to test use that can help clinicians reduce laboratory costs through appropriate use of laboratory tests.
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Affiliation(s)
- Fatma Meriç Yılmaz
- Yildirim Bayezid University, Department of Biochemistry, Ankara, Turkey
- * E-mail:
| | - Rabia Kahveci
- Ankara Numune Training and Research Hospital, Health Technology Assessment Unit, Ankara, Turkey
| | - Altan Aksoy
- Ankara Numune Training and Research Hospital, Department of Microbiology, Ankara, Turkey
| | - Emine Özer Kucuk
- Ankara Numune Training and Research Hospital, Health Technology Assessment Unit, Ankara, Turkey
| | - Tezcan Akın
- Ankara Numune Training and Research Hospital, Department of General Surgery, Ankara, Turkey
| | - Joseph Lazar Mathew
- Advanced Pediatrics Centre PostGraduate Institute of Medical Education and Research, Chandigarh, India
| | - Catherine Meads
- Brunel University, Health Economics Research Group, Uxbridge, United Kingdom
| | - Nurullah Zengin
- Ankara Numune Training and Research Hospital, Department of Oncology, Ankara, Turkey
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Gottheil S, Khemani E, Copley K, Keeney M, Kinney J, Chin-Yee I, Gob A. Reducing inappropriate ESR testing with computerized clinical decision support. BMJ QUALITY IMPROVEMENT REPORTS 2016; 5:bmjquality_uu211376.w4582. [PMID: 27096092 PMCID: PMC4822023 DOI: 10.1136/bmjquality.u211376.w4582] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 03/19/2016] [Accepted: 03/31/2016] [Indexed: 12/20/2022]
Abstract
Laboratory test overutilization increases health care costs, leads to unwarranted investigations, and may have a negative impact on health outcomes. The American Society of Clinical Pathology, in its Choosing Wisely Campaign, advocates that inflammation be investigated with C-reactive protein (CRP) instead of Erythrocyte Sedimentation Rate (ESR). London Health Sciences Centre (LHSC), a tertiary care hospital organization in Ontario, Canada, set a goal to reduce inappropriate ESR orders by 50%. After developing appropriateness criteria for ESR, we used a series of PDSA cycles to reduce inappropriate ESR ordering and analyzed our results with an interrupted time series design. Our intervention began with an educational bulletin and moved to city-wide implementation of computerized Clinical Decision Support (CDS). After implementation, ESR orders decreased by 40% from 386 orders per week to 241 orders per week. Our results are supported by previous literature on the effectiveness of CDS in reducing overutilization and suggest that provider habit is a significant contributor to inappropriate ordering.
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Affiliation(s)
| | | | | | | | | | | | - Alan Gob
- University of Western Ontario, Canada
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45
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Moyer AM, Saenger AK, Willrich M, Donato LJ, Baumann NA, Block DR, Botz CM, Khan MA, Jaffe AS, Hanson CA, Karon BS. Implementation of Clinical Decision Support Rules to Reduce Repeat Measurement of Serum Ionized Calcium, Serum Magnesium, and N-Terminal Pro-B-Type Natriuretic Peptide in Intensive Care Unit Inpatients. Clin Chem 2016; 62:824-30. [PMID: 27022069 DOI: 10.1373/clinchem.2015.250514] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 02/24/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND We assessed the impact of clinical decision support (CDS) rules within the electronic health record for ionized calcium (iCa), serum magnesium (Mg), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in intensive care unit (ICU) inpatients at a large academic center. METHODS A repeat order for measurement of iCa or Mg placed within 24 (iCa) or 48 (Mg) h of a previously nonactionable result, or additional orders for NT-proBNP beyond 1 within a single hospitalization, triggered a CDS pop-up alert showing the prior result and offering the opportunity to cancel the order or to place the order after entering an indication for repeat testing. The number of tests performed for each of these analytes and incidence of adverse clinical outcomes potentially associated with hypocalcemia or hypomagnesemia were compared between the 90-day period before CDS implementation and two 90-day periods immediately following. RESULTS iCa test volumes decreased by 48%, Mg by 39%, and NT-proBNP by 28% in the 90-day period immediately following implementation and remained decreased by 54%, 49%, and 22%, respectively, during the following 90-day period (all P values <0.0002). Adverse clinical outcomes potentially associated with hypocalcemia or hypomagnesemia did not increase (all P-values >0.17). CONCLUSIONS Implementation of CDS dramatically decreased repeat testing of iCa, Mg, and NT-proBNP without adversely impacting clinical outcomes in the ICU. Expansion of the rules from the ICU units to include the entire hospitalized patient population and expansion to additional analytes is expected to lead to further reductions in testing.
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Affiliation(s)
- Ann M Moyer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Amy K Saenger
- Department of Laboratory Medicine and Pathology, University of Minnesota Health, Minneapolis, MN
| | - Maria Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Leslie J Donato
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Nikola A Baumann
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Darci R Block
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Chad M Botz
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Munawwar A Khan
- Department of Systems and Procedures, Mayo Clinic, Rochester, MN
| | - Allan S Jaffe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Curtis A Hanson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Brad S Karon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN;
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Poole S, Schroeder LF, Shah N. An unsupervised learning method to identify reference intervals from a clinical database. J Biomed Inform 2015; 59:276-84. [PMID: 26707631 DOI: 10.1016/j.jbi.2015.12.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 12/08/2015] [Accepted: 12/13/2015] [Indexed: 12/15/2022]
Abstract
Reference intervals are critical for the interpretation of laboratory results. The development of reference intervals using traditional methods is time consuming and costly. An alternative approach, known as an a posteriori method, requires an expert to enumerate diagnoses and procedures that can affect the measurement of interest. We develop a method, LIMIT, to use laboratory test results from a clinical database to identify ICD9 codes that are associated with extreme laboratory results, thus automating the a posteriori method. LIMIT was developed using sodium serum levels, and validated using potassium serum levels, both tests for which harmonized reference intervals already exist. To test LIMIT, reference intervals for total hemoglobin in whole blood were learned, and were compared with the hemoglobin reference intervals found using an existing a posteriori approach. In addition, prescription of iron supplements were used to identify individuals whose hemoglobin levels were low enough for a clinician to choose to take action. This prescription data indicating clinical action was then used to estimate the validity of the hemoglobin reference interval sets. Results show that LIMIT produces usable reference intervals for sodium, potassium and hemoglobin laboratory tests. The hemoglobin intervals produced using the data driven approaches consistently had higher positive predictive value and specificity in predicting an iron supplement prescription than the existing intervals. LIMIT represents a fast and inexpensive solution for calculating reference intervals, and shows that it is possible to use laboratory results and coded diagnoses to learn laboratory test reference intervals from clinical data warehouses.
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Affiliation(s)
- Sarah Poole
- Center for Biomedical Informatics Research, Stanford University, Stanford, CA, United States.
| | - Lee Frederick Schroeder
- Department of Pathology, University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - Nigam Shah
- Center for Biomedical Informatics Research, Stanford University, Stanford, CA, United States
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Boggan JC, Schulteis RD, Donahue M, Simel DL. Guideline-based decision support has a small, non-sustained effect on transthoracic echocardiography ordering frequency. BMJ Qual Saf 2015; 25:57-62. [DOI: 10.1136/bmjqs-2015-004284] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/01/2015] [Indexed: 11/04/2022]
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Impact of the Electronic Medical Record on Mortality, Length of Stay, and Cost in the Hospital and ICU: A Systematic Review and Metaanalysis. Crit Care Med 2015; 43:1276-82. [PMID: 25756413 DOI: 10.1097/ccm.0000000000000948] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate effects of health information technology in the inpatient and ICU on mortality, length of stay, and cost. Methodical evaluation of the impact of health information technology on outcomes is essential for institutions to make informed decisions regarding implementation. DATA SOURCES EMBASE, Scopus, Medline, the Cochrane Review database, and Web of Science were searched from database inception through July 2013. Manual review of references of identified articles was also completed. STUDY SELECTION Selection criteria included a health information technology intervention such as computerized physician order entry, clinical decision support systems, and surveillance systems, an inpatient setting, and endpoints of mortality, length of stay, or cost. Studies were screened by three reviewers. Of the 2,803 studies screened, 45 met selection criteria (1.6%). DATA EXTRACTION Data were abstracted on the year, design, intervention type, system used, comparator, sample sizes, and effect on outcomes. Studies were abstracted independently by three reviewers. DATA SYNTHESIS There was a significant effect of surveillance systems on in-hospital mortality (odds ratio, 0.85; 95% CI, 0.76-0.94; I=59%). All other quantitative analyses of health information technology interventions effect on mortality and length of stay were not statistically significant. Cost was unable to be quantitatively evaluated. Qualitative synthesis of studies of each outcome demonstrated significant study heterogeneity and small clinical effects. CONCLUSIONS Electronic interventions were not shown to have a substantial effect on mortality, length of stay, or cost. This may be due to the small number of studies that were able to be aggregately analyzed due to the heterogeneity of study populations, interventions, and endpoints. Better evidence is needed to identify the most meaningful ways to implement and use health information technology and before a statement of the effect of these systems on patient outcomes can be made.
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Olson J, Hollenbeak C, Donaldson K, Abendroth T, Castellani W. Default settings of computerized physician order entry system order sets drive ordering habits. J Pathol Inform 2015; 6:16. [PMID: 25838968 PMCID: PMC4382759 DOI: 10.4103/2153-3539.153916] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 02/24/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Computerized physician order entry (CPOE) systems are quickly becoming ubiquitous, and groups of orders ("order sets") to allow for easy order input are a common feature. This provides a streamlined mechanism to view, modify, and place groups of related orders. This often serves as an electronic equivalent of a specialty requisition. A characteristic, of these order sets is that specific orders can be predetermined to be "preselected" or "defaulted-on" whenever the order set is used while others are "optional" or "defaulted-off" (though there is typically the option is to "deselect" defaulted-on tests in a given situation). While it seems intuitive that the defaults in an order set are often accepted, additional study is required to understand the impact of these "default" settings in an order set on ordering habits. This study set out to quantify the effect of changing the default settings of an order set. METHODS For quality improvement purposes, order sets dealing with transfusions were recently reviewed and modified to improve monitoring of outcome. Initially, the order for posttransfusion hematocrits and platelet count had the default setting changed from "optional" to "preselected." The default settings for platelet count was later changed back to "optional," allowing for a natural experiment to study the effect of the default selections of an order set on clinician ordering habits. RESULTS Posttransfusion hematocrit values were ordered for 8.3% of red cell transfusions when the default order set selection was "off" and for 57.4% of transfusions when the default selection was "preselected" (P < 0.0001). Posttransfusion platelet counts were ordered for 7.0% of platelet transfusions when the initial default order set selection was "optional," increased to 59.4% when the default was changed to "preselected" (P < 0.0001), and then decreased to 7.5% when the default selection was returned to "optional." The posttransfusion platelet count rates during the two "optional" periods: 7.0% versus 7.5% - were not statistically different (P = 0.620). DISCUSSION Default settings in CPOE order sets can significantly influence physician selection of laboratory tests. Careful consideration by all stakeholders, including clinicians and pathologists, should be obtained when establishing default settings in order sets.
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Affiliation(s)
- Jordan Olson
- Department of Laboratory Medicine, Geisinger Health System, Danville, USA
| | | | - Keri Donaldson
- Department of Pathology and Laboratory Medicine, Penn State Hershey Medical Center, PA, USA
| | - Thomas Abendroth
- Department of Pathology and Laboratory Medicine, Penn State Hershey Medical Center, PA, USA
| | - William Castellani
- Department of Pathology and Laboratory Medicine, Penn State Hershey Medical Center, PA, USA
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Krasowski MD, Chudzik D, Dolezal A, Steussy B, Gailey MP, Koch B, Kilborn SB, Darbro BW, Rysgaard CD, Klesney-Tait JA. Promoting improved utilization of laboratory testing through changes in an electronic medical record: experience at an academic medical center. BMC Med Inform Decis Mak 2015; 15:11. [PMID: 25880934 PMCID: PMC4344785 DOI: 10.1186/s12911-015-0137-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 02/04/2015] [Indexed: 11/23/2022] Open
Abstract
This case study over time describes five years of experience with interventions to improve laboratory test utilization at an academic medical center. The high-frequency laboratory tests showing the biggest declines in order volume post intervention were serum albumin (36%) and erythrocyte sedimentation rate (17%). Introduction of restrictions for 170 high-cost send-out tests resulted in a 23% decline in order volume. Targeted interventions reduced mis-orders involving several “look-alike” tests: 1,25-dihydroxyvitamin D, 25-hydroxyvitamin D; manganese, magnesium; beta-2-glycoprotein, beta-2-microglobulin. Lastly, targeted alerts reduced duplicate orders of germline genetic testing and orders of hepatitis B surface antigen within 2 weeks of hepatitis B vaccination.
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Affiliation(s)
- Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA.
| | - Deborah Chudzik
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA.,Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Anna Dolezal
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Bryan Steussy
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Michael P Gailey
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Benjamin Koch
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Sara B Kilborn
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Benjamin W Darbro
- Stead Family Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Carolyn D Rysgaard
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Julia A Klesney-Tait
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
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