Elsevier

Clinical Biochemistry

Volume 52, February 2018, Pages 26-32
Clinical Biochemistry

Clustered interventions to reduce inappropriate duplicate laboratory tests in an Irish tertiary hospital

https://doi.org/10.1016/j.clinbiochem.2017.10.012Get rights and content

Highlights

  • There is increasing emphasis on understanding the rate, and avoidable costs, of inappropriate laboratory testing in hospitals internationally.

  • There are no published data relevant to Ireland. This is the first implementation of interventions, and assessment of their effect in Ireland.

  • Approximately two-thirds of inpatients were unaware of why they underwent blood tests.

  • The interventions resulted in sustained reduction in rates of inappropriate testing and financial savings.

Abstract

Background

There is increasing emphasis on understanding the rate, and avoidable costs, of inappropriate laboratory testing in hospitals, especially associated with duplication of tests following transfer of patients from one hospital to another. While studies of inappropriate testing have been reported previously, there are no published data relevant to Ireland.

Aims

To determine the baseline rate of inappropriate testing for a subset of clinical parameters, specifically, full blood counts (FBC), biochemistry profiles (Bio) and coagulation (Coag) screens for geriatric patients transferring to and from University Hospital Limerick (UHL). Prospective pilot-scale implementation of five clustered interventions, and assessment of their effect.

Methods

Baseline testing levels were determined between October 2013 and January 2014. A patient survey was conducted to evaluate patient awareness of the blood tests they underwent. Five interventions were trialed sequentially each month between January and May 2014. These included: educational poster, intern training, presentations and communication to consultants; automated prompt in the Lab Information Technology system; highlighting of patient survey results to medical staff; inclusion of laboratory test details on patient transfer document; patient booklet promoting empowerment. Impact was assessed by determining rates of inappropriate laboratory testing monthly, and associated actual cost reductions were calculated.

Results

Approximately two-thirds of geriatric inpatients were unaware of why they underwent blood tests. Baseline numbers of inappropriate duplicate FBCs, Bio profiles and Coag tests were 758, 749 and 268 respectively for patients transferring to and from UHL. Following the interventions, these numbers dropped to 85, 84 and 0, respectively.

Conclusion

The interventions resulted in sustained reduction in rates of inappropriate testing by May 2014. Extrapolated cost reductions exceed two million Euro annually. The most effective intervention involved staff education.

Introduction

The Irish Government has implemented a funding model for hospitals known defined as Activity-Based Funding (ABF), formerly “Money Follows the Patient”, representing a considerable modification of the mechanism by which hospitals are funded [1], [2]. In January 2014, this policy came into force for 38 of the state's largest public hospitals' inpatient and day case activity. The policy replaces the previous arrangement of block grant allocation and, as elsewhere [3], places an emphasis on specific episodes of care, adjusted as appropriate for complexity of cases. Two specific outcomes of this model of funding are an increased vigilance regarding “cost per case” and a keen focus on the economic evaluation of procedure and processes. Such focus, however, is not specific to Ireland and has been described in reports from other countries where this model has been adopted, e.g., with reference to Medicare in the USA and the UK's National Health Service (NHS) [4], [5].

In the context of economic scrutiny, therefore, it is not surprising that clinical laboratory testing, as the highest volume medical activity in hospitals [6], has become a focus of cost-reducing initiatives. Performing a thorough history and physical examination are necessary to formulate possible differential diagnoses. Furthermore, at least 10% of diagnoses are not considered final until clinical laboratory testing is complete [7], [8], [9]. That said, however, laboratory test overutilization has been the focus of multiple studies internationally as they can increase costs, lead to unnecessary investigations, and may have a negative impact on patient outcomes [10], [11].

Such international studies include recent publications that have highlighted the challenges associated with laboratory overutilization or inappropriate laboratory testing. Specifically, in 2017, Chemi et al. [12] reported rates of inappropriate laboratory investigations of up to 20% between 2006 and 2010 in Ontario, defined as testing > 2 weeks prior to the minimum threshold to reorder defined by practice guidelines, and noted that up to 85% of the time the ordering physician of an inappropriate test was the same physician who ordered the previous appropriate test. Further data from 103,000 Canadian patients, provided by Morgan & Naugler [13], showed an inappropriate testing rate of 16% in Calgary, while in 2016, Meidani et al. [14] detailed incidence of 26.4% in Iran. The most comprehensive study of the subject, compiled by Zhi et al. in 2013 [15] from a 15 year meta-analysis of international literature demonstrated laboratory over- and underutilization rates of 20.6% (95% CI 16.2–24.9%) and 44.8% (95% CI 33.8–55.8%), respectively, with the latter being greatly more under-studied.

In light of these relatively high rates of lab over-use, it is perhaps unsurprising that the excellent review by Kobewka et al. in 2015 [16] evaluated 109 eligible papers, published between 1946 and 2013, detailing interventions for reduction of unnecessary tests. Although of varying quality, these interventions were identified as belonging to one or more non-exclusive category of education, audit and feedback, system based, or incentive or penalty. Results ranged from a 99.7% reduction to a 27.7% increase in test use. The authors noted that numerous studies use low investment strategies to reduce test utilization and recommended that it was these low investment strategies that may be the most promising for achievable and durable reductions in inappropriate test use.

Malone [17] described interventions that asked physicians not to order blood counts and metabolic panels if they did not have a specific indication in mind. Varying complementary reinforcements were employed: posters displayed in the Intensive Care Unit listing acceptable indications for FBCs and electrolyte tests; doctors were educated; prompts were added to order systems for lab tests reading, e.g., “please do not order without an indication”. The approaches were rewarded with reductions overall of up to 24%, with patient safety and quality of care unaffected adversely.

Based on anecdotal evidence of lab test over-utilization of lab tests, similar to that discussed by Stewart et al. [18] whereby 32% of medical inpatients transferring between hospitals were subjected to inappropriate duplicate testing, the objective of our quality improvement project was to assess and to attempt reduction of inappropriate duplicate laboratory testing of acutely unwell geriatric medical patients transferred to and from University Hospital Limerick (UHL). Wishing to utilize low investment tactics, we choose to assess the impact of a series of interventions modeled on the Malone's previously described successful approach.

Section snippets

Setting and patients

The University Hospital Limerick Group consists of the University Hospital Limerick (UHL); Ennis General Hospital; Nenagh General Hospital; St John's Hospital Limerick; the University Hospital Maternity Hospital and Croom Hospital. UHL provides 24/7 acute surgery, acute medicine, and critical care, as well as tertiary care. The other five hospitals provide the majority of hospital activity including extended day surgery, selected acute medicine, local injuries and a range of diagnostic

Patient survey

Twenty patients were surveyed as that was the number of patients (in the care of the geriatric department) transferred on a single random day who experienced interaction with the phlebotomy service. The survey was anonymized and their age, gender, and reason for hospitalization was not recorded. Each of the participating patients recalled having blood samples taken, with 18 of the 20 remembering whether a doctor (9/18) or phlebotomist had performed the venipuncture. Only 7/18 patients

Discussion

Laboratory tests appropriately play a role in modern medicine, and rapidly evolving molecular techniques expedite patient care and enhance outcomes [19], [20], [21]. However, there is acknowledgement of inappropriate, and over-utilization of, laboratory testing. In this context, a series of sequential interventions were implemented successfully in a mid-West of Ireland hospital group, resulting in reduction of unnecessary tests and generation of financial savings. Although performed in relation

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

No specific funding was provided for this work.

Author contributions

All authors contributed to the following. (1) The conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article and revising it critically for important intellectual content, and (3) final approval of the submitted version.

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