Send out tests are associated with error and patient harm due to their complexity. Ordering the right test is challenging for a variety of reasons, including limited physician training in specialty areas, difficult computerized physician order entry (CPOE) systems, numerous reference laboratory options, unique insurance authorization requirements, confusing test nomenclature, and rapidly evolving testing strategies (1,2). When the wrong test is ordered or the result is unacknowledged, patient harm is possible from delayed diagnosis and treatment, need for sample recollection, and false reassurances from a normal test result. In fact, finding the best solution for improving test order practices can be a lot like developing a new lab test: it takes the willingness to try and fail before finding the best match.
The Facts About Vitamin D Tests
Vitamin D is an example of a test that is challenging to get right. In our institution, we found that 66% of the 1,25 dihydroxyvitamin D tests were ordered in error, and that in these cases, 25-OH vitamin D was the intended test. As laboratorians know, 25-OH vitamin D is most useful in nutritional assessment, primarily due to its longer half-life of approximately 3 weeks. 25-OH vitamin D is elevated with vitamin D intoxication, and decreased with malabsorption, nutritional deficiency, and in liver disease. Conversely, the circulating half-life of 1,25 dihydroxyvitamin D is relatively short (4–6 hours), limiting utility for overall vitamin D assessment.
A 1,25 dihydroxyvitamin D test also can be useful in the diagnosis of renal dysfunction in conjunction with parathyroid hormone. It is elevated in sarcoidosis and primary hyperparathyroidism, and decreased in renal failure and hypoparathyroidism.
Many Paths to the Top of the Mountain: Route 1
A variety of tools from the utilization management toolbox can be used to improve utilization of a test (Table 1)—ranging from gentle to strong, and from manual to technology-based interventions. We began with a manual email intervention describing the utility of both vitamin D tests, and asked the provider to decide whether to modify his or her request to 25-OH vitamin D, or to continue with the order as entered (3). After 1 year of the intervention, we found that 53% of 1,25 dihydroxyvitamin D test orders were canceled and modified to 25-OH vitamin D, reducing our monthly orders for the former from 25 to less than 10. We removed the intervention for 2 months to see if the year of active intervention education was sustainable. 1,25 dihydroxyvitamin D test orders jumped back up to 17 per month, suggesting that not much learning had occurred and that we needed a permanent intervention (Figure 1).
Another Path to the Top: Route 2
Several other institutions with similar misorders of 1,25 dihydroxyvitamin D demonstrated success using CPOE tools. Simple name changes and pop-ups on test ordering screens seemed reasonably effective and straightforward to implement. While an IT solution isn’t easy or feasible in some institutions, we decided it was time to try.
In the first phase—and in collaboration with our endocrinologists—we changed the name from 1,25 dihydroxyvitamin D, which appears first in searches for “vitamin D,” to “Vitamin D, Bone Disease” and “Vitamin D, Renal Disease.” The 25-OH vitamin D was changed to “Vitamin D, Nutritional Assessment.” This had an interesting, unintended effect of increasing orders for 1,25 dihydroxyvitamin D from less than 10 per month to greater than 20. After investigating, we discovered that this increase was due to bone specialists (orthopedists) and renal specialists (nephrologists) adding the orders to their routine ordersets because it had their specialties in the title.
If at First You Don’t Succeed: Route 3
In phase two of our CPOE intervention, we implemented a pop-up using adapted language from other similar institutions that had seen a reduction in orders (Figure 1). The pop-up began, “Do not order 1,25 dihydroxyvitamin D….” After 4 months, we confirmed the theory that pop-up messages easily can be ignored, and are not enough to change behavior (5). Orders for 1,25 dihydroxyvitamin D remained at an average of 19 per month.
Let’s Try That Again: Route 4
Our final effort involved hiding the 1,25 dihydroxyvitamin D orderable entirely within our CPOE. We made sure it was available in the order sets for endocrinology and nephrology, but it was not searchable otherwise. Providers intentionally looking for 1,25 dihydroxyvitamin D who were not endocrinologists or nephrologists would have to order a miscellaneous test.
Since implementing this solution 1 month ago, we sent out seven tests, three of which were ordered as miscellaneous. We have not received any calls or complaints from providers looking for the test. Is it too soon to declare victory? Maybe, but I choose cautious optimism and believe that this could be the end of our 2-year struggle.
Conclusion
While IT solutions often seem like an attractive fix for utilization management problems, the interventions require fitting within the confines and culture of your particular institution, and there should be a process in place to measure and check success. Many times, interventions require a bit of tweaking to achieve that perfect fit.
References
- Dickerson JA, Cole B, Conta JH, et al. Improving the value of costly genetic reference laboratory testing with active utilization management. Arch Pathol Lab Med 2014;138:110–3.
- Dickerson J, Cole B, Astion M. Ten ways to improve the quality of send-out testing. Clin Lab News April 2012;38:12–3.
- Dickerson JA, Cole B, Jack RM, et al. Another laboratory test utilization program: Our approach to reducing unnecessary 1,25 vitamin D orders with a simple intervention. Am J Clin Pathol 2013;140:446–7.
- Solomon DH, Hashimoto H, Daltroy L, et al. Techniques to improve physicians’ use of diagnostic tests: A new conceptual framework. JAMA 1998;280:2020–7.
- Procop GW, Yerian LM, Wyllie R, et al. Duplicate laboratory test reduction using a clinical decision support tool. AJCP 2014; 141:718–23.
Jane Dickerson, PhD, DABCC, and Michael Astion, MD, PhD
Seattle Children’s Hospital, Department of Laboratories and University of Washington, Department of Laboratory Medicine
Utilization management tools, adapted from Solomon DH, et al. (4)
T1 Utilization management tools, adapted from Solomon DH, et al. (4)
CLN's Patient Safety Focus is sponsored by ARUP Laboratories
