Inpatient Laboratory Testing Research Articles

Utility of Vizient Clinical Data Base as a benchmarking tool for laboratory stewardship programs

Abstract Establishing an effective laboratory stewardship program across healthcare systems to improve patient care has been of growing interest. Despite general guidelines from various organizations, clear definitions for these laboratory-based quality measures, and associated benchmarks, are still lacking. Hence, we utilized Vizient® Clinical Data Base (CDB) as a tool to benchmark our institution against U.S. News and World Reports’ Honor Roll (USNW) healthcare organizations 2021-2022. We focused on inpatient laboratory testing with specific targets including mean laboratory resource units used per patient per day to obtain an overview of our institution’s overall performance, daily basic metabolic panel and CBC test ordering patterns across various service lines, and C-reactive protein (CRP) to erythrocyte sedimentation rate (ESR) order ratios compared to USNW hospitals. As one of the five institutions with the highest mean laboratory resource units used per case per day (12.7) from January 1, 2021-January 31, 2022, we investigated this further to identify tests driving this result. Of all the laboratory tests ordered, blood gas was identified at the 99th percentile compared to peers. Stratifying by service, we found cardiac surgery (17%), general medicine (15%), pulmonary/critical care (11%), neonatology (10%) and transplant (9%) services at our institution were the major contributors to blood gas orders. Investigating daily laboratory test orders (BMP, CBC) showed that our institution was at the 46th and 71st percentile overall, respectively. Further CBC analysis showed that general medicine (28%) and oncology (11%) services were the major contributors for the test volume and highest total resource units used per quarter in 2021. Assessing CRP to ESR ratio depicted that our institution’s ratio of 2.2 was lower compared to USNW hospitals’ average of 2.9, meaning ESR is likely overutilized. In conclusion, Vizient CDB can be used as a resource for benchmarking laboratory utilization patterns. It can be helpful in developing road maps and prioritizing interventions for lab stewardship programs. This study identified a general overuse of laboratory resources at the hospital compared to peers, and identified some intervention targets including blood gas testing and ESR.

Interventions to reduce repetitive ordering of low-value inpatient laboratory tests: a systematic review

BackgroundOver-ordering of daily laboratory tests adversely affects patient care through hospital-acquired anaemia, patient discomfort, burden on front-line staff and unnecessary downstream testing. This remains a prevalent issue despite the 2013...

Improving Healthcare Value: Effectiveness of a Program to Reduce Laboratory Testing for Non-Critically-Ill Patients With COVID-19.

Avoiding routine, repetitive inpatient laboratory testing is a Choosing Wisely® recommendation, with benefits that may be even more pronounced in the setting of the COVID-19 pandemic, considering the need to limit unnecessary exposure, use of personal protective equipment, and laboratory resources. However, the COVID-19 pandemic presented a unique challenge: how to efficiently develop and standardize care for a disease process that had yet to be fully characterized. This article describes the development of a local committee to critically review evidence-based practices, reach consensus, and guide practice patterns, with the aim of delivering high-value care. Following the local introduction of recommendations and electronic health record order sets, non-critically-ill COVID-19 patients at our hospital had more inpatient days where they did not receive laboratory tests, achieving sustained special cause variation on statistical process control charts. The principles of Choosing Wisely® can be applied even within novel and rapidly evolving situations.

Hospital-Initiated Care Bundle, Posthospitalization Care, and Outcomes in Adults with Asthma Exacerbation

Hospitalization for asthma exacerbation is an opportune setting for initiating preventive efforts. However, hospital-initiated preventive asthma care remains underdeveloped and its effectiveness is uncertain. To examine the effectiveness of a hospital-initiated asthma care bundle on posthospitalization asthma care and clinical outcomes. Prospective multicenter study of adults (18-54 years) hospitalized for asthma exacerbation in 2017 to 2019. During the hospitalization, we implemented an asthma-care bundle (inpatient laboratory testing, asthma education, and discharge care), and prospectively measured chronic asthma care (eg, immunoglobulin E testing, specialist care) and asthma exacerbation (ie, systemic corticosteroid use, emergency department [ED] visit, hospitalizations) outcomes. By applying a self-controlled case series method, we examined within-person changes in these outcomes before (2-year period) and after (1-year period) the bundle implementation. Of 103 adults hospitalized for asthma exacerbation, the median age was 40 years and 72% were female. Compared with the preimplementation period, the postimplementation period had improved posthospitalized asthma care, including serum specific immunoglobulin E testing (rate ratio [RR] 2.18; 95% confidence interval [95% CI] 0.99-4.84; P= .051) and evaluation by asthma specialist (RR 2.66; 95% CI 1.77-4.04; P<.001). Likewise, after care bundle implementation, patients had significantly lower annual rates of systemic corticosteroid use (4.2 vs 2.9 per person-year; RR 0.70; 95% CI 0.61-0.80; P<.001), ED visits (3.2 vs 2.7 per person-year; RR 0.83; 95% CI 0.72-0.95; P= .008), and hospitalizations (2.1 vs 1.8 per person-year; RR 0.82; 95% CI 0.69-0.97; P= .02). Stratified analyses by sex, race and ethnicity, and health insurance yielded consistent results. After hospital-initiated care bundle implementation, patients had improved posthospitalization care and reduced rates of asthma exacerbation.

Impact of an education and multilevel social comparison–based intervention bundle on use of routine blood tests in hospitalised patients at an academic tertiary care hospital: a controlled pre-intervention post-intervention study

BackgroundRepetitive inpatient laboratory testing contributes to waste in healthcare. We evaluated an intervention bundle combining education and multilevel social comparison feedback to safely reduce repetitive use of inpatient routine laboratory...

Evidence-Based Duplicate Order Alerts Promote Effective Test Utilization and Reduce Unnecessary Laboratory Testing

Abstract Introduction Unnecessary and inappropriate laboratory testing contributes to increased health care costs, increases length of stay, and increases odds for blood product transfusion. The Choosing Wisely campaign recommends a judicious use of laboratory blood testing to combat iatrogenic anemia. Reducing the number of duplicate test orders may help address these issues. We evaluated duplicate order alert thresholds in our electronic health record for 10 common laboratory tests at an academic medical center. Methods In January 2019, alert intervals for 10 common inpatient laboratory tests (thyroid stimulating hormone, complete blood count, hemoglobin A1c, troponin, lactic acid, hemoglobin and hematocrit, urinalysis, vitamin D, urine beta HCG, and triglycerides) were adjusted to evidence-based, disease-specific thresholds. If a test was ordered within a timeframe shorter than this threshold, an alert interrupted the provider’s workflow. The provider was allowed to override the alert based on clinical judgment. This is a change from the previous settings, which alerted any test if ordered more frequently than 8 hours. Postintervention duplicate order alerts were compared to baseline rates and adjusted for number of inpatient discharges. Results In total, 914 orders were cancelled in 1 month as a result of tailored duplicate order alerts versus the baseline mean of 710 (95% CI, 633-786) and a predicted 552 (95% CI, 475-628) when adjusted for number of inpatient discharges, with the majority of cancelled orders being for CBC (530 accepted alerts). Overall, this reduction in unnecessary duplicate tests is equivalent to 3,092 mL of blood not collected from patients per month. Conclusion Tailoring duplicate order alert interval thresholds to evidence-based criteria helps reduce unnecessary testing, reduces costs, and may play an important role in reducing hospital-acquired anemia.

Expert Recommendations on Frequency of Utilization of Common Laboratory Tests in Medical Inpatients: a Canadian Consensus Study.

Repetitive inpatient laboratory testing in the face of clinical stability is a marker of low-value care. However, for commonly encountered clinical scenarios on medical units, there are no guidelines defining appropriate use criteria for laboratory tests. This study seeks to establish consensus-based recommendations for the utilization of common laboratory tests in medical inpatients. This study uses a modified Delphi method. Participants completed two rounds of an online survey to determine appropriate testing frequencies for selected laboratory tests in commonly encountered clinical scenarios. Consensus was defined as agreement by at least 80% of participants. Participants were 36 experts in internal medicine across Canada defined as internists in independent practice for ≥ 5years with experience in medical education, quality improvement, or both. Experts represented 8 of the 10 Canadian provinces and 13 of 17 academic institutions. Laboratory tests and clinical scenarios included were those that were considered common on medical units. The final survey contained a total of 45 clinical scenarios looking at the utilization of six laboratory tests (complete blood count, electrolytes, creatinine, urea, international normalized ratio, and partial thromboplastin time). The possible frequency choices were every 2-4h, 6-8h, twice a day, daily, every 2-3days, weekly, or none unless there was specific diagnostic suspicion. These scenarios were reviewed by two internists with training in quality improvement and survey methods. Of the 45 initial clinical scenarios included, we reached consensus on 17 scenarios. We reached weak consensus on an additional 19 scenarios by combining two adjacent frequency categories. A Canadian expert panel of internists has provided frequency recommendations on the utilization of six common laboratory tests in medical inpatients. These recommendations need validation in prospective studies to assess whether restrictive versus liberal laboratory test ordering impacts patient outcomes.

Impact of Clinical Specialty on Attitudes Regarding Overuse of Inpatient Laboratory Testing.

Routine laboratory testing is common among hospitalized patients, with associated harm. Attitudes toward testing and drivers across clinical specialties have not been described. We performed a cross-sectional study and anonymously surveyed inpatient clinicians (nurses, advanced practice providers, and physicians) at a tertiary cancer center regarding attitudes toward unnecessary laboratory testing and its drivers across clinical specialties. A total of 837 providers completed surveys (response rate 53%). Most respondents agreed with daily testing of hospitalized patients and that daily labs generally enhance safety, and those from pediatric and surgical specialties generally valued testing less than others. Participants most commonly indentified habit and institutional culture as important drivers of unnecessary testing. There were differences in other drivers across specialties, with pediatric clinicians identifying family pressure more commonly and fear of litigation less commonly compared to others. Future interventions to reduce unnecessary inpatient laboratory testing should acknowledge different attitudes based on specialty and tailor interventions accordingly.

How Can Inpatient Clinicians Cut Unnecessary Lab Testing

Despite negative consequences of excessive inpatient laboratory testing, patients often undergo daily blood draws. Investigators at a single U.S.

Association of Attitudes Regarding Overuse of Inpatient Laboratory Testing With Health Care Provider Type

Association of Attitudes Regarding Overuse of Inpatient Laboratory Testing With Health Care Provider Type

Effect of a Price Transparency Intervention in the Electronic Health Record on Clinician Ordering of Inpatient Laboratory Tests

Many health systems are considering increasing price transparency at the time of order entry. However, evidence of its impact on clinician ordering behavior is inconsistent and limited to single-site evaluations of shorter duration. To test the effect of displaying Medicare allowable fees for inpatient laboratory tests on clinician ordering behavior over 1 year. The Pragmatic Randomized Introduction of Cost data through the electronic health record (PRICE) trial was a randomized clinical trial comparing a 1-year intervention to a 1-year preintervention period, and adjusting for time trends and patient characteristics. The trial took place at 3 hospitals in Philadelphia between April 2014 and April 2016 and included 98 529 patients comprising 142 921 hospital admissions. Inpatient laboratory test groups were randomly assigned to display Medicare allowable fees (30 in intervention) or not (30 in control) in the electronic health record. Primary outcome was the number of tests ordered per patient-day. Secondary outcomes were tests performed per patient-day and Medicare associated fees. The sample included 142 921 hospital admissions representing patients who were 51.9% white (74 165), 38.9% black (55 526), and 56.9% female (81 291) with a mean (SD) age of 54.7 (19.0) years. Preintervention trends of order rates among the intervention and control groups were similar. In adjusted analyses of the intervention group compared with the control group over time, there were no significant changes in overall test ordering behavior (0.05 tests ordered per patient-day; 95% CI, -0.002 to 0.09; P = .06) or associated fees ($0.24 per patient-day; 95% CI, -$0.42 to $0.91; P = .47). Exploratory subset analyses found small but significant differences in tests ordered per patient-day based on patient intensive care unit (ICU) stay (patients with ICU stay: -0.16; 95% CI, -0.31 to -0.01; P = .04; patients without ICU stay: 0.13; 95% CI, 0.08-0.17; P < .001) and the magnitude of associated fees (top quartile of tests based on fee value: -0.01; 95% CI, -0.02 to -0.01; P = .04; bottom quartile: 0.03; 95% CI, 0.002-0.06; P = .04). Adjusted analyses of tests that were performed found a small but significant overall increase in the intervention group relative to the control group over time (0.08 tests performed per patient day, 95% CI, 0.03-0.12; P < .001). Displaying Medicare allowable fees for inpatient laboratory tests did not lead to a significant change in overall clinician ordering behavior or associated fees. clinicaltrials.gov Identifier: NCT02355496.

The impact of out-of-pocket payments for dental care on household finances in low and middle income countries

BackgroundDental care is extremely costly and beyond most people means in developing countries. The primary aim of this study was to determine the impact of out-of-pocket payments for dental care on household finances in 40 low and middle income countries. A second aim was to compare the burden of payments for dental care with that for other health services.MethodsWe used data from 174,257 adults, aged 18 years and above, who reported their total and itemized household expenditure in the past four weeks as part of the World Health Surveys. The financial burden on households was measured using the catastrophic health expenditure (CHE) and impoverishment approaches. A household was classified as facing CHE if it spent 40% or more of its capacity to pay, and as facing impoverishment if it fell below the country-specific poverty line after spending on health care was subtracted from household expenditure. The odds of experiencing CHE and impoverishment due to expenditure on dental care were estimated from two-level logistic regression models, controlling for various individual- and country-level covariates.ResultsHouseholds that paid for dental care had 1.88 (95% Confidence Interval: 1.78-1.99) greater odds of incurring CHE and 1.65 (95% CI: 1.52–1.80) greater odds of facing impoverishment, after adjustment for covariates. Furthermore, the impact of paying for dental care was lower than that for medications or drugs, inpatient care, outpatient care and laboratory tests but similar to that of health care products, traditional medicine and other health services.ConclusionHouseholds with recent dental care spending were more likely to use a large portion of their disposable income and fall below the poverty line. Policy makers ought to consider including dental care as part of universal health care and advocate for the inclusion of dental care coverage in health insurance packages.

Overusing laboratory tests: more advantages or drawbacks?

After decades of accumulating evidence, the inappropriate use of laboratory services has now become a well-known critical issue. An interesting survey, just recently published in JAMA Internal Medicine (1), describes some interesting aspects concerning the prescription attitudes and the overuse of inpatient laboratory testing in a large American cancer center (i.e., Memorial Sloan Kettering Cancer Center, New York, NY, USA).

Residents' self-report on why they order perceived unnecessary inpatient laboratory tests.

Resident physicians routinely order unnecessary inpatient laboratory tests. As hospitalists face growing pressures to reduce low-value services, understanding the factors that drive residents' laboratory ordering can help steer resident training in high-value care. We conducted a qualitative analysis of internal medicine (IM) and general surgery (GS) residents at a large academic medical center to describe the frequency of perceived unnecessary ordering of inpatient laboratory tests, factors contributing to that behavior, and potential interventions to change it. The sample comprised 57.0% of IM and 54.4% of GS residents. Among respondents, perceived unnecessary inpatient laboratory test ordering was self-reported by 88.2% of IM and 67.7% of GS residents, occurring on a daily basis by 43.5% and 32.3% of responding IM and GS residents, respectively. Across both specialties, residents attributed their behaviors to the health system culture, lack of transparency of the costs associated with health care services, and lack of faculty role models that celebrate restraint. Journal of Hospital Medicine 2015;11:869-872. © 2015 Society of Hospital Medicine.

Costs of the diagnostic odyssey in children with inherited leukodystrophies.

Our objective was to determine the extent of testing and costs solely related to diagnosis (the diagnostic odyssey) in a cohort of children with inherited leukodystrophies. We determined all inpatient and outpatient laboratory testing, including brain MRIs obtained for the purpose of diagnosis, over an 8-year time period in a retrospective population cohort of children with inherited leukodystrophies. Costs were determined from an activity-based cost accounting system and were standardized to 2013 constant US dollars. Each patient had on average 20 tests (range 2-42 tests), with costs of $4,200 (range $357-$15,611). Diagnostic yield plateaued after 25 tests, and costs increased significantly after 32 tests. Fifty-three percent of patients were diagnosed in 20 or fewer tests, compared with 17% if more than 20 tests were performed. Our findings provide details on the amount and costs of testing in children who often undergo a diagnostic odyssey. Our results suggest that diagnostic testing is a relatively modest contributor to the overall health care costs in patients with leukodystrophy, and offer insights into the diagnostic odyssey of children with neurologic impairment.

A novel strategy for evaluating the effects of an electronic test ordering alert message: Optimizing cardiac marker use

Background: Laboratory ordering functions within computerized provider order entry (CPOE) systems typically support the display of electronic alert messages to improve test utilization or implement new ordering policies. However, alert strategies have been shown to vary considerably in their success and the characteristics contributing to an alert's success are poorly understood. Improved methodologies are needed to evaluate alerts and their mechanisms of action. Materials and Methods: Clinicians order inpatient and emergency department laboratory tests using our institutional CPOE system. We analyzed user interaction data captured by our CPOE system to evaluate how clinicians responded to an alert. We evaluated an alert designed to implement an institutional policy restricting the indications for ordering creatine kinase-MB (CKMB). Results: Within 2 months of alert implementation, CKMB-associated searches declined by 79% with a corresponding decline in CKMB orders. Furthermore, while prior to alert implementation, clinicians searching for CKMB ultimately ordered this test 99% of the time, following implementation, only 60% of CKMB searches ultimately led to CKMB test orders. This difference presumably represents clinicians who reconsidered the need for CKMB in response to the alert, demonstrating the alert's just-in-time advisory capability. In addition, as clinicians repeatedly viewed the alert, there was a “dose-dependant” decrease in the fraction of searches without orders. This presumably reflects the alerting strategy's long-term educational component, as clinicians aware of the new policy will not search for CKMB when not indicated. Conclusions: Our analytic approach provides insight into the mechanism of a CPOE alert and demonstrates that alerts may act through a combination of just-in-time advice and longer term education. Use of this approach when implementing alerts may prove useful to improve the success of a given alerting strategy.

The Economic Burden of Late Entry Into Medical Care for Patients With HIV Infection

A large proportion of people with human immunodeficiency virus (HIV) infection enter care late in the HIV disease course. Late entry can increase expenditures for care. To estimate direct medical care expenditures for HIV patients as a function of disease status at initial presentation to care. Late entry is defined as initial CD4 test result ≤ 200 cells/mm3, intermediate entry as initial CD4 counts >200, and ≤ 500 cells/mm3; and early entry as initial CD4 count >500. The study included 8348 patients who received HIV primary care and who were newly enrolled between 2000 and 2006 at one of 10 HIV clinics participating in the HIV Research Network. We reviewed medical record data from 2000 to 2007. We estimated costs per outpatient visit and inpatient day, and monthly medication costs (antiretroviral and opportunistic illness prophylaxis). We multiplied unit costs by utilization measures to estimate expenditures for inpatient days, outpatient visits, HIV medications, and laboratory tests. We analyzed the association between cumulative expenditures and initial CD4 count, stratified by years in care. Late entrants comprised 43.1% of new patients. The number of years receiving care after enrollment did not differ significantly across initial CD4 groups. Mean cumulative treatment expenditures ranged from $27,275 to $61,615 higher for late than early presenters. After 7 to 8 years in care, the difference was still substantial. Patients who enter medical care late in their HIV disease have substantially higher direct medical treatment expenditures than those who enter at earlier stages. Successful efforts to link patients with medical care earlier in the disease course may yield cost savings.

Health care services utilization stratified by virological and immunological markers of HIV: evidence from a universal health care setting

The aim of the study was to determine rates of utilization of in-patient, out-patient and laboratory services stratified by virological and immunological markers of HIV disease among patients on antiretroviral treatment in British Columbia, Canada. We estimated resource utilization for in-patient visits, out-patient visits, and laboratory tests among patients initiating antiretroviral treatment between 1 April 1994 and 31 December 2000, with follow-up to 31 March 2001. Resource use was stratified by CD4 cell count and plasma HIV viral load (pVL) at the time of utilization and rates per 100 patient-years were calculated for each health care resource. A total of 2718 patients were included in our analyses. The overall rates of in-patient visits, out-patient visits, and laboratory tests were 902, 3001 and 840 per 100 patient-years, respectively. Utilization was higher for patients with low CD4 cell counts and high pVLs when compared with patients with high CD4 cell counts and low pVLs. Patients with low CD4 cell counts and high pVLs had the highest use of health care services. Regular follow-up with health care providers in an out-patient setting, allowing for proper monitoring and maintenance of HIV care, is important in minimizing unnecessary and potentially costly in-patient care.

Reducing Unnecessary Inpatient Laboratory Testing in a Teaching Hospital

After an inpatient phlebotomy-laboratory test request audit for 2 general inpatient wards identified 5 tests commonly ordered on a recurring basis, a multidisciplinary committee developed a proposal to minimize unnecessary phlebotomies and laboratory tests by reconfiguring the electronic order function to limit phlebotomy-laboratory test requests to occur singly or to recur within one 24-hour window. The proposal was implemented in June 2003. Comparison of fiscal year volume data from before (2002-2003) and after (2003-2004) implementation revealed 72,639 (12.0%) fewer inpatient tests, of which 41,765 (57.5%) were related directly to decreases in the 5 tests frequently ordered on a recurring basis. Because the electronic order function changes did not completely eliminate unnecessary testing, we concluded that the decrease in inpatient testing represented a minimum amount of unnecessary inpatient laboratory tests. We also observed 17,207 (21.4%) fewer inpatient phlebotomies, a decrease sustained in fiscal year 20042005. Labor savings allowed us to redirect phlebotomists to our understaffed outpatient phlebotomy service.

Reducing Unnecessary Inpatient Laboratory Testing in a Teaching Hospital

Reducing Unnecessary Inpatient Laboratory Testing in a Teaching Hospital