Background: Common labs such as a daily complete blood count (CBC) or a daily basic metabolic panel (BMP) represent possible waste and have been targeted by professional societies and the Choosing Wisely campaign for critical evaluation. We undertook a multifaceted quality improvement (QI) intervention in a large hospitalist group to decrease unnecessary common labs.
Methods: The QI intervention was comprised of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered as daily within the hospitalist group. We performed a pre-post analysis comparing a cohort of patients during the 10-month baseline period before the QI intervention, and the 6-month post-intervention period. Demographic and clinical data were collected from the electronic medical record. The primary endpoint was number of common labs ordered per patient day. Secondary endpoints included length of stay, hospital mortality, 30-day readmission, blood transfusion, amount of blood transfused, and cost per patient.
Results: The baseline (n=5721) and intervention (n=9368) cohorts were similar in their demographics, though the distribution of primary discharge diagnosis-related groups (DRGs) differed. At baseline, a mean of 2.06 (SD 1.40) common labs were ordered per patient day. After adjusting for age, sex and principle discharge diagnosis, the number of common labs ordered per patient day decreased by 0.25 (12.1%) during the intervention period compared to baseline (95% CI, 0.30-0.20; P<0.01). There was a non-significant reduction in hospital mortality in the intervention period compared to baseline (2.2 vs. 1.8%, P = 0.1). No effect was seen on length of stay or readmission rate. The volume of blood transfused per patient who received a transfusion decreased by 103 ml (P = 0.02). The intervention decreased hospital direct costs by an estimated $16.19 per admission or $159,682 annualized for the cohort (95% CI $127,746 – $191,618).
Conclusions: Implementation of a multifaceted QI intervention was associated with a significant decrease in the number of common lab tests ordered per patient day. Additionally, the volume of blood transfused in transfused patients and hospital direct costs were decreased. No effect was seen on hospital length of stay, mortality or readmission rate. This intervention suggests that a hospitalist-based QI intervention focused on daily labs can decrease waste.