Background: Overtreatment or low value care, including overutilization of laboratory testing, has an estimated annual cost of waste of $75.7 to 101.2 billion annually. Providing performance feedback to hospitalists has been shown to be an effective way to encourage the practice of quality improvement focused medicine. There remains limited data regarding implementation of performance feedback and direct results on hospital laboratory testing spending in the short term. The objective of this project was to identify whether performance-based feedback on lab utilization between both hospitalists and resident teams results in more conservative utilization of laboratory testing.

Methods: This quality improvement project was conducted at a 550-bed tertiary academic medical center including both direct care and house-staff teams. We started with a presentation to providers regarding lab utilization costs, areas for waste reduction and quality improvement, and a brief overview of the performance feedback to come. Performance dashboards were generated using data from Epic®. Data reported to providers included laboratory orders of Basic Metabolic Panels (BMP), Comprehensive Metabolic Panel (CMP) and Complete Blood Counts (CBC), average daily census of patients, and overall lab utilization rate. Lab utilization rate was calculated as total tests ordered (BMP/CMP+CBC) divided by average daily census divided by number of days. Emails with performance dashboards were sent on a weekly basis, therefore the number of days used in lab utilization rate was seven. Emails included an individual report per provider, as well as a table listing all other provider teams and associated data for peer comparison. Averages were reported to providers as hospitalist averages, which included hospitalist and APP data, as well as General Internal Medicine (GIM) averages, which included data from providers leading resident teams. Performance dashboards were sent to providers weekly for three months, starting in January 2020 and ending in March 2020. Final lab utilization rate for the entire intervention period was calculated as total laboratory tests ordered divided by total encounters. The three-month period without intervention of January – March 2019 was identified as a control for comparison.

Results: We found that following intervention during January – March 2020, CBC utilization rate decreased from 5.54 to 4.83 per patient encounter and BMP/CMP utilization rate decreased from 6.65 to 6.11 per patient encounter compared to January – March 2019. This equated to roughly a cost savings of ~ $42,700 in total for the quarter. Additionally, we did not see an increase in our balancing measures of hospital mortality (2.59% versus 1.16%) and ICU transfers (11.92% versus 12.03%, p=0.91) in the two time periods. Week by week plot of test utilization shows a non-random change in ordering practices for CBCs and BMPs/CMPs during the implementation phase of the project.

Conclusions: We found that our intervention did result in a decrease in lab test utilization rates across hospitalist and resident teams without significantly impacting the quality of patient care. This study lays promising groundwork for one tool that can be used in both eliminating a source of hospital waste and improving the quality and efficiency of patient care. While the time frame of this project was shortened due to the emergence of SARS COV2, similar studies and interventions can hopefully be utilized to improve overall healthcare quality.

IMAGE 1: Basic metabolic panel orders over time. Points in red constitute a “run” and represent a non-random decline in test ordering due to the intervention.

IMAGE 2: Complete blood count orders over time. Points in red constitute a “run” and represent a non-random decline in test ordering due to the intervention.