Background: As part of the ABIM Choosing Wisely initiative, the Society of Hospital Medicine has emphasized repetitive complete blood count (CBC) and chemistry testing among its top 5 practices that physicians and patients should question. Reduction of unnecessary laboratory testing is important not only for cost containment, but also for improved patient experience and avoidance of iatrogenic harm. We sought to reduce daily laboratory testing through a process improvement initiative among the general medicine inpatient services, including both housestaff and direct-care hospitalist teams.
Methods: Interventions consisted of education and feedback and were tailored for housestaff and hospitalist audiences. Education included didactic presentations and informational emails, supplemented by marketing materials such as flyers and lab cost displays. Clinicians were encouraged to order blood tests deliberately rather than reflexively, but no active regulatory measures were put into place to determine appropriateness of laboratory ordering. Feedback regarding each team’s daily ordering of CBCs and basic metabolic profiles (BMPs) was provided via a weekly email. This evaluation used data from December 2013 to November 2014 to compare the pre- and post-intervention periods in number of CBC and BMP orders per patient day, estimated cost savings from the reduction in CBC and BMP testing, and number of zero-lab days (i.e., no laboratory test ordered). Comparisons were performed separately for housestaff and hospitalist services.
Results: Eight general medicine teams (4 housestaff and 4 hospitalist services) received the interventions and were included in the analysis. For both housestaff and hospitalist teams, significant reductions were seen in mean number of CBC and BMP orders per patient day and in mean estimated CBC and BMP costs per week. Housestaff teams reduced CBC orders from a mean of 0.89 tests per patient day pre-intervention to 0.52 tests per patient day post-intervention (p<0.001) and reduced BMP orders from 1.05 to 0.76 per patient day (p<0.001) (see Figure). Among hospitalist teams, CBC orders decreased from 0.51 to 0.33 per patient day (p<0.001) and BMP orders declined from 0.67 to 0.49 (p<0.001). Cost savings were estimated at over $25K and $14K per week for housestaff and hospitalist cohorts, respectively. Across the 4 housestaff teams, the average number of patients per day with no laboratory orders increased from 1.2 to 3.0 (p<0.001); across the hospitalist teams, the average number increased from 6.1 to 9.2 (p<0.001).
Conclusions: Through a series of educational interventions and weekly feedback, we achieved a significant and sustained reduction in CBC and BMP ordering by housestaff and hospitalists on general medicine services. By changing clinician behavior around lab ordering, we also demonstrated significant cost savings and a greater number of patient days without venipuncture, which is likely to enhance the patient experience.