A new tool developed at University of Utah Health Care reduces superfluous lab testing, according to a paper published Feb. 4 in the Journal of Hospital Medicine.
The tool, called Value Driven Outcomes, was used at University of Utah Health Care as part of a multifaceted quality improvement initiative, according to a news release. When VDO was used by hospitalists in a 15-month period, the number of tests ordered each day dropped, leading to a decrease in lab costs of 10% per patient visit. Researchers said if the approach was applied to all inpatient visits, the hospital could save more than $1.5 million a year. “Frequently, patients do need labs every morning, but that can create a culture where you’re ordering tests without really thinking about what you’re going to do with the results,” lead author Peter Yarbrough, MD, an assistant professor of internal medicine who practices at the VA Salt Lake City Health Care System, said in the release.
Unnecessary testing not only increases costs, it can lead to incidental findings that result in unnecessary follow-up testing and potentially harmful interventions. VDO promotes understanding of the true costs of healthcare by providing cost data down to the patient level, according to the release. “The novelty of it is that it’s so simple and it could potentially be widely disseminated,” said senior author Kensaku Kawamoto, MD, PhD, MHS, an assistant professor of biomedical informatics.
Yarbrough, Kawamoto, and co-authors Devin Horton, MD, Karli Edholm, MD, and Polina V. Kukhareva, MS, MPH, describe in the paper a 15-month intervention launched in 2013 to address this problem of unnecessary laboratory testing. “Prior to VDO, we never had cost information,” Yarbrough said. “All you ever had were charges, and charges are very difficult to interpret as far as how much things really cost.”
With the goal of changing the culture of routine test ordering into a thoughtful process, a working group analyzed workflows to determine how lab tests were ordered. One finding was that it’s often one of the least experienced members of the care team, the intern, who is in charge of ordering.
The group looked at efforts that had been successful at other institutions and opted to incorporate multiple approaches into a single intervention to determine if the combination would be sustainable. Rounding processes were standardized to include a checklist review for all patients that ensured discussion of labs, telemetry, pain, central lines, nursing presence, communication with family and follow-up needed. Decisions about lab tests had to be discussed with more senior members of the team. Third-year medical students were responsible for ensuring that all items were covered daily for each patient.
Over a 15-month period an intervention group of 6,310 hospitalist patient visits were compared to a control group of 25,586 non-hospitalist visits. The interventions reduced the mean cost per day for laboratory testing from $138 to $123 and the mean cost per visit decreased from $618 to $558. There was also a significant reduction in laboratory cost per day, laboratory cost per visit, and the number of tests per day.
The hospitalists continue to use the checklist system, and they consider routine VDO data essential to know how they are doing with lab costs.“It’s one thing to tell somebody that they’re ordering too many tests, it’s another to quantify it and put dollars and cents to their activity,” Kawamoto said. “Having the VDO tool allowed for timely feedback to be provided to physicians so they know how they’re doing.”
To comment, email [email protected]