Clinical research study
An Educational and Administrative Intervention to Promote Rational Laboratory Test Ordering on an Academic General Medicine Service

https://doi.org/10.1016/j.amjmed.2016.08.021Get rights and content

Abstract

Background

Overuse of clinical laboratory testing in the inpatient setting is a common problem. The objective of this project was to develop an inexpensive and easily implemented intervention to promote rational laboratory use without compromising resident education or patient care.

Methods

The study comprised of a cluster-randomized, controlled trial to assess the impact of a multifaceted intervention of education, guideline development, elimination of recurring laboratory orders, unbundling of laboratory panels, and redesign of the daily progress note on laboratory test ordering. The population included all patients hospitalized “general medicine” was duplicated during 2 consecutive months on a general medicine teaching service within a 999-bed tertiary care hospital in Boston, Massachusetts. The primary outcome was the total number of commonly used laboratory tests per patient day during 2 months in 2008. Secondary outcomes included a subgroup analysis of each individual test per patient day, adverse events, and resident and nursing satisfaction.

Results

A total of 5392 patient days were captured. The intervention produced a 9% decrease in aggregate laboratory use (rate ratio, 0.91; P = .021; 95% confidence interval, 0.84-0.98). Six instances of delayed diagnosis of acute kidney injury and 11 near misses were reported in the intervention arm.

Conclusions

A bundled educational and administrative intervention promoting rational ordering of laboratory tests on a single academic general medicine service led to a modest but significant decrease in laboratory use. To our knowledge, this was the first study to examine the daily progress note as a tool to limit excessive test ordering. Unadjudicated near misses and possible harm were reported with this intervention. This finding warrants further study.

Section snippets

Materials and Methods

The Massachusetts General Hospital is a 999-bed tertiary care teaching hospital located in Boston, Massachusetts. At the time of this study, the Bigelow Medical Service was staffed by 5 teams of resident and attending physicians regionalized by floor. Each of the 5 Bigelow teams consisted of 4 interns, 1 to 2 junior residents, 1 to 2 attending physicians, and 2 to 3 medical students. Teams A and E covered 24 beds, whereas teams B, C, and D covered 20 beds, respectively. Physicians and medical

Results

A total of 5392 patient days were captured in the trial, 2790 in the control groups and 2602 in the intervention groups. Patient characteristics are represented in Table 1. Mortality, comorbidities, and length of stay were similar in all groups. The crossover design necessarily dictated that a population of patients transitioned from an intervention team in May to a control team in June and vice versa; as a result, these patients and their demographics were counted and analyzed separately in

Discussion

This report describes a successful collaborative intervention to promote rational laboratory use and develop an inpatient medical service into a research engine with trainees as key stakeholders. We achieved a modest reduction in laboratory volume while preserving the educational mission of our training program. Common strategies to change physician practice patterns include education, feedback, consensus-building, administrative changes, incentives, and penalties. All of these strategies have

Conclusions

We found that a bundled educational and administrative intervention to promote rational ordering of laboratory tests on a single academic general medicine service led to a modest but significant decrease in the most commonly ordered studies.

Acknowledgments

The authors thank Chris Lofgren for assistance with laboratory data collection and Arjun Rao, MBBS, MBA and Ciaran McMullan, MD for assistance with study implementation. The authors also thank the residents, faculty, and staff of the Massachusetts General Hospital Department of Medicine and Internal Medicine Residency Training Program for assistance and financial support of this project.

References (18)

  • S.E. Kellerman et al.

    Physician response to surveys. A review of the literature

    Am J Prev Med

    (2001)
  • F.W. Peabody

    The physician and the laboratory

    Boston Med Surg J

    (1922)
  • P.F. Griner et al.

    Use of the laboratory in a teaching hospital: implications for patient care, education, and hospital costs

    Ann Intern Med

    (1971)

  • Editorial: Routine laboratory tests–the physician's responsibility

    N Engl J Med

    (1966)
  • C. van Walraven et al.

    Do we know what inappropriate laboratory utilization is? A systematic review of laboratory clinical audits

    JAMA

    (1998)
  • D.W. Bates et al.

    Contaminant blood cultures and resource utilization. the true consequences of false-positive results

    JAMA

    (1991)
  • C. Chant et al.

    Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study

    Crit Care

    (2006)
  • A.C. Salisbury et al.

    Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction

    Arch Intern Med

    (2011)
  • P. Thavendiranathan et al.

    Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels

    J Gen Intern Med

    (2005)
There are more references available in the full text version of this article.

Cited by (0)

Present affiliations: BMW: Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Mass; AJA: Dana-Farber Cancer Institute, Boston, Mass; JC: Division of Cardiology, Department of Medicine, San Francisco General Hospital University of California; APJ: Department of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pa; GM: Intermountain Blood and Marrow Transplant/Acute Leukemia Program, LDS Hospital, Salt Lake City, Utah; SR: Gwinnett Clinic, Lawrenceville, Ga; DPH: Emory University Division of Hospital Medicine, Atlanta, Ga.

Funding: This work was conducted with support from Harvard Catalyst, the Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award UL1 TR001102), and financial contributions from Harvard University and its affiliated academic healthcare centers. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, or the National Institutes of Health.

Conflict of Interest: BMW was paid by the Massachusetts General Hospital Department of Medicine for his work as a research assistant on this study. EAM is supported by National Institutes of Health Grant UL1 TR001102 and is a paid Data and Safety Monitoring Board member of Acorda Therapeutics and Shire Human Genetic Therapies. GM was paid for work for the Blinatumomab Acute Lymphoblastic Leukemia Advisory Board in 2015.

Authorship: All authors had access to the data and played a role in writing this manuscript.

View full text
© 2016 Elsevier Inc. All rights reserved.