The American Board of Internal Medicine Choosing Wisely initiative advocates avoiding automatic daily labs as a way to lower hospital costs. The Legacy Health Inpatient Medicine Service (LIMS) aimed to reduce unnecessary and inappropriate lab testing amongst internal medicine inpatients within our five hospital health system.
Purpose:
To decrease inpatient lab costs in fiscal year 2016 by 2% compared to fiscal year 2015 baseline, focusing on judicious ordering of high volume lab tests.
Description:
In January 2015, a Cost per Case Committee composed of Legacy Medical Group administration, LIMS physicians, finance, and information services met monthly to design and implement the project.
We identified lab order types that provide near equivalent clinical information but have different costs. We focused specifically on common lab tests: Automated Blood Count compared to Complete Blood Count with differential; Basic Metabolic Panel compared to Comprehensive Metabolic Panel and Renal Panel; and Magnesium.
We educated physicians via email, monthly meetings, peer-to-peer interactions and a “cost conscious” retreat. Physicians were encouraged to avoid automated recurrent standing orders for daily labs, informed about the differences in relative costs of the tests, and were asked to order lower cost labs when appropriate.
To promote standard work, we utilized a daily rounding checklist embedded in progress notes (via a function in Epic) to prompt physicians to assess their lab ordering practices. Data regarding direct lab costs, total number of lab tests ordered and number of patient encounters per quarter was compared from baseline FY15 Q2 (July-Sept 2014) to FY16 Q2 (July-Sept 2015). The number of patient encounters per quarter allows to control for fluctuations in patient census and to produce a lab cost per patient visit. All data was annualized to show projected annual costs and savings.
Our intervention produced three main results. First, we successfully shifted the ordering practices of physicians towards high value, low cost lab tests (Fig 1). Second, physicians ordered 14,104 (13.8% reduction) fewer lab tests in the post-intervention period compared to baseline even though patient visits increased by 8,332 (6.8%) (Fig. 2). Third, annualized direct lab costs declined by $314,629. After accounting for increased patient census, the total cost per patient encounter was reduced by 20.1% (Fig. 2).
Conclusions:
The initiative described here achieved a 20% reduction in lab costs. We used a multi-faceted approach including a widespread and reiterative education campaign and feedback process while simultaneously enabling standard work with a daily checklist, to change physician behavior in a way that lowers costs, improves the patient experience (by preventing unnecessary needle sticks) and promotes evidence-based practices.