Evidence Based Guidelines to Eliminate Repetitive Laboratory Testing
Clinlabnavigator published a weekly series of blogs dedicated to reducing unnecessary laboratory tests between December 8, 2013 and December 22, 2013. The December 8th issue reviewed environmental interventions, while the Dec 15th blog covered administrative interventions and the Dec 22nd blog discussed educational interventions.
A recent Special Communication in JAMA Internal Medicine, that was dedicated to their “Less is More” campaign, reviewed evidence-based guidelines to eliminate repetitive laboratory testing. The main intervention categories focused on three strategies; education, audit and feedback on provider ordering practices and EMR-enabled restrictive ordering.
Interventions based on educating clinicians about appropriated indications and costs of laboratory testing had mixed results. Decreased test ordering following education was not sustained. A randomized clinical trial revealed no significant effect on clinicians ordering practices after displaying Medicare fees for 30 different laboratory tests in the EMR.
Several studies that audited physician test ordering practices and provided individual and group feedback of their results reported a significant reduction in laboratory testing per patient day. The biggest impact occurred with high utilizers.
May EMR interventions that limited the ability of providers to repeat laboratory tests led to a consistent and sustainable reduction in blood draws. In one example, clinicians were limited to ordering 5 common laboratory tests only once or with an expiration of 24 hours. EMR based strategies were consistent and sustainable.
Studies that combined education, audit and feedback and EMR restrictions yielded the best results. Several studies confirmed reducing repetitive laboratory testing was not associated with an increase in adverse patient outcomes.
The authors of the JAMA paper provided a blueprint for a multimodal approach to reducing repetitive laboratory testing.
- Collectively outline and standardize best practice. Data should be provided by those with authority and responsibility to implement institutional change.
- Target a multidisciplinary audience across all departments and services that care for hospitalized patients.
- Tailor educational material for each specialty.
- Include all health care professional levels to foster culture change.
- Engage senior leadership and respected professional leaders in each department to deliver the lectures or at least be present at educational events.
- Focus educational materials on the appropriate indication for various laboratory tests for high utilizers. Consider including laboratory costs.
- Emphasize education on potential adverse effects of repetitive testing, including patient discomfort, hospital-acquired anemia, cost, and resultant downstream testing.
- Provide evidence-based reassurance that less laboratory testing does not lead to delayed diagnosis or misdiagnosis.Encourage daily discussions on rounds to specify the clinical rationale for laboratory testing.
- Provide ordering clinicians with real-time data on their personal ordering patterns with an institutional benchmark. Provide anonymized, specialty-specific comparison data at routine intervals that include peer comparisons on laboratory utilization.
- Encourage high utilizers to develop a personalized, educative approach to reduce unnecessary ordering practices.
- Leverage the EMR to restrict the ability to order repetitive daily laboratory tests.
- Identify and remove repetitive laboratory testing options from all order sets.
- If this is not feasible, begin by limiting preordered, repeated daily laboratory tests to a short, defined period, such as 48 to 72 hours.
- Create alerts that display prior normal or stable results for the test being ordered.
- Encourage clinicians to engage in reflective ordering patterns based on clinical indication review. The goal is to increase targeted testing rather than decrease laboratory testing overall.
Reference
Eaton KP, et al. Evidence-based Guidelines to Eliminate Repetitive Laboratory Testing. JAMA Intern Med, doi:10.1001/jamainternmed.2017.5152 , published online October 16, 2017.
