An Educational and Administrative Intervention to Promote Rational Laboratory Test Ordering on an Academic General Medicine Service - 18/04/17
, Andrew J. Aguirre, MD, PhD a, b, Roby P. Bhattacharyya, MD, PhD b, c, John Chorba, MD a, Ashutosh P. Jadhav, MD, PhD a, Vanessa B. Kerry, MD, MSc b, d, Eric A. Macklin, PhD e, Gabriela Motyckova, MD, PhD a, Shveta Raju, MD a, f, Kent Lewandrowski, MD b, g, Daniel P. Hunt, MD a, h, Douglas E. Wright, MD, PhD a, bAbstract |
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.
Le texte complet de cet article est disponible en PDF.Keywords : Diagnostic tests, Medical education, Resource use
Plan
| 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. |
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| 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. |
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| 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. |
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| Authorship: All authors had access to the data and played a role in writing this manuscript. |
Vol 130 - N° 1
P. 47-53 - janvier 2017 Retour au numéro
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