USING PEER COACHING TO REDUCE INAPPROPRIATE OR DUPLICATE LABORATORY TESTING

Background: The Choosing Wisely campaign was launched in 2012 with a goal of “advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures.[1] ”  The Society of Hospital Medicine published 5 recommendations for Adult Hospital Medicine in 2013[2] , including one that advised against performing repetitive complete blood count (CBC) and chemistry testing in the face of clinical and lab stability. 

Purpose: We developed a Maintenance of Certification (MOC) project at Seattle Children’s Hospital with the goal of reducing inappropriate or duplicate CBC ordering by 20% over a 3-month period.  The project’s outcome measure was the number of times a CBC with differential was ordered 2 or more times per encounter on the General Medicine teaching service and the Hospitalist non-teaching service.  Data were obtained from the medical record via an electronic tool that pulled laboratory ordering history per patient.  Secondary drivers included weekly audit reports, chart reviews for contributors to inappropriate testing, and peer coaching.  Peer coaching with the attending physician was performed weekly, either via email or phone call, by the MOC team members. 

Description: In the 3-month pre-intervention period, there were 151 instances of duplicate CBC ordering noted.  In the 3-month post-intervention period there were 125 instances of duplicate CBC ordering, for a total reduction of 17%.  On the General Medicine service, there were 138 instances in the pre-intervention period and 117 in the post-intervention period, for a decrease of 15%.  On the Hospitalist service, there were 13 instances in the pre-intervention period and 8 in the post-intervention period, for a decrease of 38%.  62 encounters with inappropriate ordering were reviewed and 36 unique patients were identified.  The MOC team provided individual peer coaching opportunities to the responsible attending for 23 of these patients. 

Conclusions: The initial goal of a 20% reduction was met on the Hospitalist non-teaching service, but not on the General Medicine teaching service, potentially highlighting the complexity of lab ordering when trainees are involved in patient care.  Although the MOC project timeframe was short, real time data collection and provider feedback via peer coaching seemed to influence provider ordering patterns.  The success of this pilot provides a template for evaluating unnecessary medical tests, treatments, and procedures within our organization.