Article Text

Reducing unnecessary testing: an intervention to improve resident ordering practices
2. Kristine M Thompson2,
3. Jed C Cowdell3,
4. Catalina Sanchez Alvarez3,
5. Ryan L Ung4,
6. Armando Villanueva3,
7. Kayin B Jeffers3,
8. Jaafer S Imam3,
9. Mario V Mitkov3,
10. Tasneem A Kaleem3,
11. Lewis Jacob3,
12. Nancy L Dawson5
1. 1 Division of Gastroenterology, Cleveland Clinic Florida, Florida, USA
2. 2 Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA
3. 3 Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
4. 4 Department of Cardiovascular Diseases, Mayo Clinic, Jacksonville, Florida, USA
5. 5 Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
1. Correspondence to Dr Nancy L. Dawson, Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA; dawson.nancy11{at}mayo.edu

## Abstract

Purpose of the study To reduce the number of unnecessary laboratory tests ordered through a measurement of effects of education and cost awareness on laboratory ordering behaviour by internal medicine residents for common tests, including complete blood cell count (CBC) and renal profile (RP), and to evaluate effects of cost awareness on hospitalisation, 30-day readmission rate and mortality rate.

Study design 567 patients admitted during February, March and April 2014 were reviewed as the control group. Total CBC, CBC with differential and RP tests were counted, along with readmission and mortality rates. Interventions were education and visual cost reminders. The same tests were reassessed for 629 patients treated during 12 months after intervention in 2015.

Results Data showed a significant increase in CBCs ordered after the intervention (mean number per hospitalisation changed from 1.7 to 2.3 (p<0.001)), a decrease in CBCs with differential (mean number changed from 1.7 to 1.2 (p<0.001)) and no change in RPs ordered (mean number, 3.7 both before and after intervention (p=0.23)). No change was found in mortality rate, but the decrease in the readmission rate was significant (p=0.008).

Conclusions Education in the form of cost reminders did not significantly reduce the overall ordering of the most common daily laboratory testing in our academic teaching service. We believe further research is needed to fully evaluate the effectiveness of other education forms on the redundant ordering of tests in the hospital setting.

• cost awareness
• daily laboratory testing
• resident education
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## Discussion

We found that our quality improvement project of education and cost reminders did not significantly reduce the overall ordering of the most common daily laboratory testing for patients in the hospital on an internal medicine teaching service. To bring the highest value to the current practice of medicine, healthcare professionals need to optimise resources with highest cost effectiveness without adverse effects on health outcomes and high-quality care. For several reasons, excessive laboratory testing may represent an economic burden for the hospital and an unnecessary risk for patients. The reasons include unnecessary cost to the healthcare system and unnecessary discomfort and blood loss to the patient.14 Although laboratory testing may deliver information to providers about a patient's internal body processes to help identify and treat a wide variety of medical conditions, repeated testing in the setting of clinical stability is not indicated. In addition, cost awareness should always be encouraged and test costs considered.

Studies have demonstrated poor awareness of cost by physicians and other healthcare professionals.15 One recent study showed that residents' cost awareness can be increased through comprehensive visual displays.14 However, that study did not specifically address whether increased awareness resulted in residents changing their clinical decision-making habits or their test ordering. Our study confirmed that awareness of laboratory test cost did not change overall ordering behaviour. Yet, we find it interesting that residents were able to significantly decrease the total number of CBCs with differential ordered per patient hospitalisation but appeared to compensate with a significant increase in total CBC orders. This outcome suggests that residents may have recognised that a more expensive CBC with differential may not add incremental value to a patient's medical management. However, the interventions did not improve overall total number of daily laboratory tests ordered.

Several studies have evaluated the effect of education on healthcare costs and test ordering behaviour.7 ,11 ,16 ,17 One study performed in Australia demonstrated a decrease in the number of inappropriate tests ordered by trainees after an educational intervention and a feedback strategy were applied.7 This change in behaviour was transient, and its effect waned by the end of the semester following the intervention. Two subsequent studies had conflicting results. Bates et al 11 showed that implementation of a computerised display of test costs failed to result in a statistically significant change in test orders at a teaching institution. In contrast, a separate study using the same strategy at a non-academic institution found a 9.1% reduction in tests ordered.16 Multiple other studies have shown a high variability in results after education strategies, demonstrating that other factors may also influence ordering behaviour.7 ,17

One explanation for the large number of laboratory tests seen in our study population is the fact that our institution uses an electronic health record, and this helps facilitate the ease of ordering. After an order for a daily laboratory test is placed in the computer, it is continued automatically until it is manually stopped. In this case, tests may not be reassessed daily to determine whether they are truly needed. Because our study showed that education and cost awareness were not sufficient to change this ordering practice in residents, an alternative solution could be to modify the ordering system to have an expiration date.8 ,18 A second explanation is the fact that most ordering in our teaching services is done by interns. Lack of experience has been found to affect ordering.7 Possible contributors are insecurity in practice, supervisor pressure and lack of awareness about adverse effects and costs. Residency programmes are an apt environment for effective feedback by more experienced attending physicians, which have been shown to reduce laboratory testing in other settings.10

Our study has limitations. Although Charlson Comorbidity Index is a validated tool to measure overall comorbidities of a population,19 we could not distinguish whether there was an increase in CBC ordering because the individual patients had more serious comorbidities that required more frequent monitoring and laboratory testing. In addition, we did not independently measure the effectiveness of the educational portion of our intervention with any independent evaluation. It may be that an alternative education could have been more effective. We also did not survey the residents for their opinions on the effectiveness of the intervention or whether they believed they had changed their practice because of the intervention. This information could have added to the understanding behind the failure of change. Finally, a small change occurred in the resident personnel between the baseline measurement and the postintervention measurement, because the intervening time crossed the graduation date of the academic year. Therefore, the outgoing third year residents were no longer followed in the data, and the incoming intern class was a part of the intervention. However, the basic processes of ordering and patient care, as well as team attendings, did not change. This likely had minimal effect.

Our results support the hypothesis that a programme of education and cost awareness has no significant impact on ordering behaviour of medical residents. Future research should focus on alternative interventions if significant effect is to be made.

### Main messages

• Neither education nor cost awareness is an effective intervention to reduce automatic ordering of daily laboratory tests by residents. Further studies should be undertaken to find tactics that reduce unnecessary test ordering.

### Current research questions

• Does eliminating automatic daily orders change ordering behaviour in medical residents?

• What combination of interventions are more likely to produce behavioural changes?

• Do incentives have an impact on medical residents’ laboratory ordering behaviour?

View Abstract

## Footnotes

• Contributors All authors were involved in the quality improvement project and contributed to the writing of this manuscript.

• Competing interests None declared.

• Provenance and peer review Not commissioned; externally peer reviewed.

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