Background: Routine laboratory testing is a cornerstone of inpatient care. However, indiscriminate ordering can lead to resource waste, prolonged length of stay, and unnecessary costs. At our community teaching hospital in Queens, New York, we identified high rates of vitamin level testing—specifically vitamin B12, folate, and vitamin D25—which were often ordered without clinical indication. This practice resulted in interpretive challenges due to the lack of clinical context, unnecessary follow-up testing, and potentially unwarranted interventions or treatments. Recognizing this, we aimed to align testing practices with high-value care principles, improving care quality and reducing waste across the hospital.
Purpose: Our project aimed to reduce inappropriate orders for vitamin B12, folate, and vitamin D25 levels by aligning ordering practices with evidence-based guidelines and principles of high-value care. Additionally, we assessed whether this intervention had a halo effect on the ordering practices for unrelated tests, including lipid profiles, thyroid-stimulating hormone (TSH), and iron profiles.
Description: We monitored test ordering rates and associated costs from January 2019 to August 2024, with an intervention implemented in August 2021. The intervention included:1. Provider education: Hospitalists, internal medicine residents, and nurse practitioners received training on principles of high-value care and society guidelines for vitamin level testing in alignment with the ABIM Foundation’s Choosing Wisely Campaign.2. Individualized feedback: Weekly monitoring of orders from August 2021 to March 2022 identified providers with above-average order rates. These providers received tailored feedback on their practices, including whether tests were clinically indicated.3. Medical admitting residents: Since this group was responsible for most vitamin level orders, admitting residents received additional education targeting their ordering practices during the admission process.Baseline data from 2019 showed high test ordering rates and costs for vitamin levels (e.g., 5011 folate level orders, $38,084; 7509 vitamin B12 level orders, $64,577; 4003 vitamin D25 level orders, $34,026). By 2022, orders decreased by over 80% for all three tests (e.g., folate: 688 orders, $5229; vitamin B12: 938 orders, $8067; vitamin D25: 280 orders, $2380) and remained low through 2024, demonstrating sustainability even after completing our intervention.Despite no specific education on unrelated tests, orders for lipid profiles, TSH, and iron profiles also declined substantially from 2019 to 2023 (e.g., lipid profiles: 7619 to 2412; TSH: 8366 to 3669), suggesting a cultural shift toward high-value care principles. Orders continued to remain low through August 2024, again demonstrating sustainability.
Conclusions: Our multi-faceted intervention resulted in a sustained reduction in unnecessary vitamin level testing, decreasing resource utilization and financial costs while fostering efficient, patient-centered care. Our intervention, which emphasized high-value care in the context of vitamin level testing, led to a halo effect, reducing orders for other tests that were not specifically targeted. This reflects a broader cultural change, emphasizing thoughtful laboratory ordering tailored to clinical presentation. This model can serve as a framework for similar efforts to reduce unnecessary testing in other areas of healthcare.