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Ordering repetitive daily lab tests for hospitalized patients can result in adverse health outcomes—and possibly more unnecessary tests, some experts contend. To reduce this practice, healthcare institutions should educate providers on more judicious ordering, give them feedback on ordering practices, and leverage electronic medical records (EMRs) to curb repetitive tests. A group of researchers that devised this strategy discuss the real-world application of these interventions in JAMA Internal Medicine.
Unnecessary, repetitive testing constitutes a large portion of inappropriate laboratory testing, Andrew Parsons, MD, MPH, the study’s senior author and an assistant professor in the General Medicine, Geriatrics and Palliative Care Division at the University of Virginia School of Medicine in Charlottesville, told CLN Stat.
Lab expenditures comprise just 5% of a hospital’s budget on average, yet laboratory tests influence a majority of all healthcare decisions. As Parsons and his colleagues wrote, studies have shown that daily, routine labs lead to preventable harms. “For example, one single-center observational study “found a direct correlation between the volume of phlebotomy and the decrease in hemoglobin levels,” a condition that often leads to repeat testing, the article stated. “Excessive phlebotomy causes patient discomfort and can result in hospital-acquired anemia and unnecessary downstream testing and procedures,” Parsons elaborated. In comparison, other studies have determined that curbing repetitive lab testing does not lead to an increase in hospital readmissions or mortality, or missed diagnoses.Given the large volume of laboratory testing in clinical medicine, reducing tests can lead to significant cost savings for a hospital, Parsons said.
The study cited numerous examples of healthcare institutions adopting interventions to tamp down on unnecessary lab tests. “The most successful interventions described in the literature utilized a multimodal approach with engagement of clinical leaders and key stakeholders to support educational efforts and promote institutional change,” Parsons said. Institutions reported success stories in reducing lab tests and in some cases saving millions of dollars without compromising patient care.
One large, urban academic medical center that educated clinicians on the potential harms and costs associated with overusing lab services and administered weekly reports on ordering patterns was able to reduce test orders by 21% and saw a $1.3 million reduction in charges. In another study involving a University of California, San Francisco facility, the institution adopted a series of resident-led interventions that included a monetary incentive to residents for reducing certain tests, and as a result, saw an 8% reduction in cumulative lab test ordering and saved more than $2 million over 3 years. No changes in readmission rates or mortality took place during this time period.
What these institutional interventions have lacked is a standardized approach, Parsons said. To guide teams aimed at improving appropriate routine lab testing among hospitalized patients, he and his colleagues decided to craft an evidence-based implementation blueprint.
The authors’ key recommendations include:
- Adopt data-supported educational initiatives that standardize best practices on ordering, customizing materials for each medical specialty;
- Establish an auditing system that provides real-time feedback to providers on their ordering habits, and encourages high-utilization users to adopt practices that reduce unnecessary ordering; and
- Use EMR ordering systems to restrict daily, repetitive ordering of laboratory tests. The goal is not to reduce overall lab testing, but to increase targeted testing and encourage clinicians to reflect more carefully on their ordering patterns.
Although reducing daily laboratory testing addresses only one aspect of hospitalized care, such a change can have a profound effect on healthcare’s institutional culture. “Successful interventions must target all stakeholders including laboratorians,” Parson emphasized.
The article in JAMA Internal Medicine represents the second paper crafted by residents and faculty from the High Value Practice Academic Alliance, a consortium of 80-plus academic medical centers working to improve healthcare quality and safety by reducing wasteful practices. The alliance has a number of ongoing and planned investigations to lead improvements in healthcare value through collaborative quality improvement, education, and research, Parsons said.
“Teams from experienced centers are coauthoring evidence-based guides to guide reduction of unnecessary diagnostics and treatments,” he said.