Background: Choosing Wisely recommends against testing for amylase in the diagnosis and management of acute pancreatitis; however, national CMS data shows over $19 million in charges for amylase laboratory testing per year. Our hospital spent over $341,000 on roughly 38,000 amylase orders in the past year.

Purpose: We developed a quality improvement project to reduce amylase lab testing in the ED by targeting identified drivers of overuse specific to our institution.

Description: This quality improvement project was done in an urban, academic tertiary hospital. Our previous local survey data (Holzer 2017) showed that amylase ordering by hospitalist and medicine housestaff was driven primarily by lack of awareness of the recommendation. By contrast, all emergency department (ED) attendings and housestaff surveyed (N=12) were aware of the recommendation. In 2014, ED providers had removed amylase from several common ordersets to reduce overuse. Yet, ED providers were still responsible for several thousand orders in 2016.
When we searched a repository of EMR order sets, we identified 22 ordersets designed for use in the ED that still contained an option to order amylase (Table 1b). Working with ED clinicians and administrators, we subsequently removed amylase from the remaining order sets. We then reviewed weekly reports of amylase orders on adult patients by the ED staff. We compared pre-intervention data (Jan-Mar 2017) with post-intervention data (Apr-Sept 2017). A student t-test was performed to compare the average weekly amylase order rate between the two groups.

In the 13 weeks pre-intervention, the ED averaged 86 amylase orders per week. In the 26 weeks following our intervention, there was a 99% reduction in utilization, with only 1 amylase order per week (p<0.001) (Figure 1). This represented a cost savings of $19,514, with a projected annual savings of $39,028.

Conclusions: Within the ED, the overuse of amylase testing was driven almost entirely by EMR order sets, and not by lack of awareness of the recommendation to test for lipase alone. Our team achieved a significant and sustained reduction in amylase testing with a targeted elimination of amylase from these order sets. These findings indicate the profound impact that outdated order sets can have on the overutilization of lab testing. Moving forward, our team will broaden this intervention to target order sets from other departments (Table 1a) that similarly over-order amylase.

IMAGE 1: Figure 1

IMAGE 2: Table 1a, 1b