A competition-based multimodal approach to improving routine laboratory utilization among residents

From the 2018 HVPAA National Conference

Stephen Clark (University of Virginia Health System), Samir Panvelker (University of Virginia Health System), Garret Rhodes (University of Virginia Health System), George Hoke (University of Virginia Health System), Andrew Parsons (University of Virginia Health System)

Background

Residents are known to order unnecessary laboratory tests as part of a habitual culture, contributing to significant waste. The most effective means of combating unnecessary laboratory testing remains elusive with evidence suggesting a multimodal approach can be effective.

Objectives

We sought to evaluate the effect of a multimodal educational intervention with direct feedback and peer comparison in decreasing unnecessary daily laboratory ordering by general medicine residents.

Methods

We determined mean laboratory (CBC; CBC with differential, BMP, CMP, magnesium, phosphorus) ordering patterns of six inpatient general medicine teams over the previous five months to determine control data. We then staged an educational intervention, which included an interactive educational module, weekly emails, and flyers. Additionally, we provided direct feedback to residents during the three week intervention that compared ordering behavior to the control data and other resident teams.

Results

Following the intervention, with the exception of CBC with differential, mean laboratory ordering for combined general medicine teams was significantly reduced: CBC 9.4% (0.96 vs 1.06, p=.0065), BMP 12% (1.13 vs 1.29, p<.0001), CMP 20% (0.32 vs 0.40, p<.0009), magnesium 26% (0.78 vs 1.05, p<.0001), phosphorus 28% (0.54 vs 0.75, p<.0001). CBC with differential ordering was reduced by 10% (0.26 vs 0.29, p=.1282). Sustained reduction for 12 months would result in cost savings of $148,405 compared to baseline. There was no significant difference between readmission, ICU transfer, and mortality data between the two groups.

Conclusion

Our multimodal intervention was effective in reducing routine laboratory ordering among medicine residents. The sustainability of the observed reduction in laboratory utilization is uncertain, however, our intervention imposes limited cost and time and could be easily replicated at other academic medical centers. We plan to continue to implement routine interval feedback and peer comparison into resident workflow on the general medicine service to promote sustainability.

Implications for the Patient

This intervention decreased laboratory utilization waste without significant difference in mortality, ICU transfer, and readmission data. With further study, this intervention could prove an effective means for sustainable increase in value of patient care.