Does Everyone Need Daily Labs? Choose Wisely And Reduce The Overuse: A High Value Care Project

Introduction:One of the ABIM Foundation’s Choosing Wisely campaign recommendations by the Society of Hospital Medicine is to avoid repetitive lab testing in clinically stable patients. In 2014, an EMR upgrade at our... [ view full abstract ]

Introduction:

One of the ABIM Foundation’s Choosing Wisely campaign recommendations by the Society of Hospital Medicine is to avoid repetitive lab testing in clinically stable patients. In 2014, an EMR upgrade at our institution removed the “daily labs” order. A 1-year post-change audit showed no change in lab volume done at our institution. A provider workaround of ordering labs several days in a row by creating separate daily orders was found to be the cause. Our High Value Care (HVC) committee aimed to reduce lab overuse via provider education, peer champion advocacy, and team-based feedback on lab ordering. We planned to reduce ordering of “routine” labs ordered >24 hours in advance by 25% over the first 6 months of our intervention. 

Methods:
We obtained baseline lab ordering patterns for three medicine units staffed by housestaff. Baseline data was collected from March–July of 2016. At baseline, 20 percent of routine labs were ordered >24 hours in advance. At the start of each 4-week block, from August – November 2016, a presentation based on the Choosing Wisely recommendation and our baseline data was given to IM residents and hospitalists to discuss a thoughtful approach to lab ordering. The percentage of labs ordered >24-hours in advance was fed back to house staff teams every two weeks.

Results:
The percent of labs ordered >24 hours in advance fell from a baseline of 20% to 13% at the end of the fourth month (Table 1), equivalent to a relative reduction in lab ordering >24 hours in advance of up to 37%. 

Discussion:
Educating residents and hospitalists on HVC recommendations for appropriate lab testing coupled with team-based feedback reduced lab overutilization. Although we have obtained short-term success, we know that culture change takes time and plan continued intervention with monitoring for sustained change.