Utah Hospitalists Reduce Unnecessary Laboratory Tests
Healthcare costs continue to increase and are estimated to be approximately $3.1 trillion per year in the United States. Approximately one third of this amount, $910 billion per year, is estimated to be waste. Numerous studies over the past thirty years have reported that approximately 30% of all laboratory tests ordered on hospitalized patients are unnecessary.
Beyond costs, unnecessary laboratory testing is an important patient safety issue. Incidental findings result in unnecessary follow-up testing and potentially harmful interventions. Daily, early morning blood draws cause iatrogenic anemia and interfere with patient sleep.
Hospitalists at the University of Utah, a 500 bed academic medical center, recently implemented a multifaceted quality-improvement initiative to reduce laboratory testing. They utilized a Value Driven Outcomes (VDO) tool that allowed providers to understand the costs of health care by providing actual cost data down to the patient level. In this study VDO included the actual cost paid by the hospital to the university-owned laboratory vendor (ARUP Laboratories, Salt Lake City, UT) for laboratory testing.
The laboratory reduction intervention incorporated education, process change, cost feedback, and financial incentives. Baseline data was collected between July 1, 2012 and January 31, 2013. The intervention period was February 1, 2013 to April 30, 2014 and included the following interventions:
- Education of all providers at the start of their hospitalist rotation about laboratory overuse, costs associated with laboratory overuse, previous interventions and their success, and current intervention with goals. Each resident was provided a pocket card with the most common lab tests and associated charges.
- Standardization of rounds including a checklist review of labs, telemetry, pain, central lines, nursing presence, communication with family and needed follow-up. Decisions about lab tests had to be discussed with senior members of the team. Third-year medical students were responsible for ensuring that all items were covered daily for each patient.
- Monthly feedback at the hospitalist group meeting regarding laboratory costs using the VDO tool. Data were presented as a monthly group average and compared to pre-intervention baseline costs. Individual performance and peer group comparison were available.
- Financial incentive through a program that shared 50% of cost savings realized by the hospital with the Division of General Internal Medicine. The incentive could be used to support future quality improvement projects, but did not include individual physician incentive. ?
Using VDO, the hospitalists learned that common routine laboratory testing for their patients was costing University Hospital about $2 million a year. An intervention group of 6,310 hospitalist patient visits were compared to a control group of 25,586 non-hospitalist visits. The number of basic metabolic panel, comprehensive metabolic panel, and complete blood count test per day were reduced significantly more in the intervention group compared to the control group. Interventions reduced the mean cost per day for laboratory testing from $138 to $123 and the mean cost per visit from $618 to $558. It was estimated that applying this approach to all inpatient visits would have saved the hospital more than $1.3 million per year. Length of stay was unchanged and 30-day readmissions decreased in the intervention group.
A multifaceted approach to laboratory reduction demonstrated a significant reduction in laboratory cost per day and per visit, as well as common tests per day at a major academic medical center. The VDO tool provided physicians with valuable timely feedback so they knew how they were doing.
Yarbrough P, Kukhareva P, Horton D, Edholm K, and Kawamoto K. Multifaceted Intervention Including Education, Rounding Checklist Implementation, Cost Feedback, and Financial Incentives Reduces Inpatient Laboratory Costs, Journal of Hospital Medicine, March 2016
