From the 2018 HVPAA National Conference
Rachna Rawal (St. Louis University), Oluwasayo Adeyemo (St. Louis University), Paul Kunnath (St. Louis University), Hala Saad (St. Louis University), Ara Vartanyan (St. Louis University), Jennifer Schmidt (St. Louis University)
Laboratory over-ordering is well recognized in healthcare and contributes to delivery of high-cost, low-value care. Our goal was to integrate high-value care education in our residency program, thereby reducing the number of CBCs with and without differential, BMP, and CMP by 15% in one academic year.
1. Introduce residents to the concept of “High-Value Care”
2. Incorporate Mindful Lab Ordering into residents’ daily practice
3. Generate a High-Value Care culture
Subjects were resident and attending physicians rotating through the inpatient Medicine service. Data included pre- and post-intervention surveys (designed by the study team) to assess lab ordering practices and barriers to cost-conscious care. We obtained the number of labs ordered, the lab frequency utilized, and patient census from the electronic medical record (EMR). The project was divided into four sixteen-week blocks. Phase 1 focused on educational interventions. During Phase 2, educational interventions were stopped while EMR changes offered varied lab ordering options. In Phase 3, the study team presented case-based high-value care sessions; mid-block presentations updated residents on “real time” lab ordering. In Phase 4, we continued the interventions from Phase 3 and initiated attending education on mindful ordering.
After four phases, residents have decreased ordering of CMPs and increased the number of BMPs (Figure 1); residents also order more CBCs without differential than CBCs with differential (35% of all CBCs are without differential compared to 6% in control; statistically significant, p<0.05) (Figure 1). Residents decreased use of the “labs every morning” lab option by 20% through Phase 3 (Figure 3). Compared to control data, phase 3 showed a 20% decrease in total labs ordered per week (Figure 2) (statistically significant, p<0.05).
At the end of Phase 1, 23% of the attending physicians noted a difference in resident lab ordering practices; this value increased to 97% after phase 4 (statistically significant, p<0.05). Additionally, after phase 3, 83% of attending physicians felt they noticed a reduction in lab ordering, increasing to 100% after phase 4. Similarly, 40% of residents noted a difference in their own ordering practices after phase 1, with 100% noting a difference after phase 4 (statistically significant, p<0.05). In post-phase one through four surveys, residents perceived themselves ordering more mindfully on non-Medicine services.
Pre-survey data revealed that 24% of residents ordered daily labs due to fear of repercussions from the attending and 57% discussed labs with their teams. After phase 4, 0% of residents fear attending repercussions and 100% discuss labs with their teams (both statistically significant, p<0.05).
Total labs/week have decreased with both resident and attending physicians perceiving this change. Residents are ordering more judiciously by choosing more specific laboratory panels. We feel a shift in culture with more residents discussing labs with their teams and not identifying attending physicians repercussions as a barrier (which we attribute to the Phase 4 attending education). We believe one of the strongest markers of culture change is residents’ perception of changed ordering practices on non-Medicine services.
Implications for the Patient
Literature suggests that to have the greatest impact on a physician’s career, high-value care education and training should be implemented early in training. Residents have changed how they think about and order labs, and are generating culture change in our hospital.