Background: As part of the ABIM Foundation’s Choosing Wisely campaign the Society of Hospital Medicine recommended providers avoid performing repetitive CBC and chemistry testing in the face of clinical and lab stability. In 2014 as part of an EMR upgrade our institution removed the “daily labs” order. A 1-year post change audit showed no change in lab volume. Further discussion revealed that labs could be ordered several days in a row, by creating separate orders set to occur each day. Our High Value Care (HVC) committee set out to reduce lab overuse via provider education, peer champion advocacy, and team based feedback on lab ordering patterns. Our goal is to reduce by 25% the medicine service’s use of “routine” or basic labs, defined as labs ordered >24 hours in advance of being done and reduce our total lab use by 5% over the next 6 months.
Methods: We surveyed 119 Internal Medicine (IM) residents about prospective HVC initiatives to be implemented at our institution. Of the 52 (44%) responders, 64% believed that lab overutilization should be addressed in our hospital. Baseline lab ordering patterns were reviewed from March to July 2016 for 3 of our teaching service IM wards. Lab ordering data was obtained from our EMR software. The primary outcome was the percentage of post admission basic labs ordered >24 hours in advance of being done. Patients in the medical and cardiac intensive care units and respiratory step-down unit were excluded. An educational presentation based on the Choosing Wisely campaign and our baseline lab ordering pattern was given to IM residents and hospitalists to discuss a thoughtful approach to lab ordering. This intervention was performed at the start of each 4-week block from August to November 2016. IM service lab ordering data was reported bi-weekly to team members, reviewing the percentage of labs ordered >24 hours in advance for their block period.
Results: A baseline review of our IM residents’ lab ordering pattern from March to June 2016 and July of the new academic year showed that up to 21% of basic labs were ordered >24 hours in advance. No change in lab ordering was seen in block 1 of our intervention. With an enhanced and ongoing focus on culture change, peer championing and feedback to team members the intervention led to increasing relative reductions in lab ordering, with a peak of 37.5% (Table 1).
Conclusions: We present an approach for reducing lab use that focuses on routine labs ordered in our institution and providing team-specific feedback. Educating residents and hospitalists on HVC recommendations for appropriate testing with individual or group feedback should improve lab overutilization. Although we have obtained short term success, we know that culture change takes time and plan continued intervention with monitoring for sustained change.
