Blueprint Can Help Facilities Reduce Unnecessary Clinical Testing

A Special Communication from the Journal of the American Medical Association provides an "evidence-based implementation blueprint" for clinical testing based on recommendations from the American Board of Internal Medicine's 2012 Choosing Wisely campaign.

The Choosing Wisely campaign seeks to guide healthcare providers and facilities to reduce expenditures and eliminate unneeded testing, but, according to the article's lead author, Kevin P. Easton, MD, with the Department of Internal Medicine at Johns Hopkins School of Medicine in Baltimore, Maryland, and colleagues with the High Value Practice Academic Alliance, the "lack of a standardized approach" needed to meet the Choose Wisely initiative's goals has meant mixed results for implementation of testing recommendations.

Eaton and colleagues used data from 17 trial interventions to reduce clinical testing, and determined that a multimodal intervention plan focusing on education for healthcare providers, regular audits of testing orders, and limitations on testing could help facilities meet the goals and aims of the Choosing Wisely campaign.

Although Eaton's blueprint is designed for hospital use, it could be applied to a range of healthcare facilities, including primary care facilities, as a means to reduce unnecessary testing.

The Choosing Wisely Campaign was designed to help reduce healthcare costs by eliminating waste, reduce use of unnecessary and costly medical resources, and improve care by increasing communication between healthcare providers and patients. According to current 2017 data presented on the Choosing Wisely website, more than 75 healthcare societies and organizations have created 490 recommendations for healthcare improvement.

One of the campaign's focuses is the overuse of laboratory testing and diagnostic services. Testing recommendations have been offered from a variety of specialist societies including the American Society for Clinical Pathology, which offered up 20 recommendations on the use of laboratory testing to help guide clinicians and inform patients.

Eaton and colleagues state several reasons for the overuse of testing, including "insufficient knowledge of medical costs, fear of litigation, diagnostic uncertainty, absence of feedback on testing practices, and differing levels of health care professionals' training."

Although, as Eaton and colleagues claim, laboratory expenditures usually represent less than 5% of most hospital budgets. An overall reduction in the amount of laboratory testing using the study's blueprint can help reduce "testing cascade," where, perhaps harmless and low-cost unnecessary initial diagnostic testing leads to more extensive testing "downstream."

It becomes difficult to "measure the downstream consequences of the testing cascade," however some studies revealed an estimated cost savings from reducing routine phlebotomy testing from $91,793 to $163,751 per year.

Eaton and colleagues argue that reducing testing is about more than economics. According to the data presented, there are significant health risks associated with low-level testing. Frequent testing rather than optimizing patient care, can in fact lead to an increased risk of certain negative health consequences such as hospital-acquired anemia (HA) and blood-borne pathogens.

In 1 retrospective study of 17,676 patients by AC Salisbury published by the Archives of Internal Medicine in 2011, approximately 20% of hospitalized patients developed some form of moderate to severe HA. Furthermore, Eaton and colleagues point to several studies that show reductions of laboratory testing have no effect on readmission rate or mortality. This data should, according to Eaton's study, ease some clinician's fears about limits to routine testing.

In order to reduce cost, eliminate the risk associated with unnecessary tests, and provide a simple means of bringing healthcare facilities in-line with the Choosing Wisely recommendations, the High Value Practice Academic Alliance, a group of academic medical centers in the US and Canada, are working to advance high-value health care through collaborative quality improvement, research, and education and positioned their blueprint as a practical guide to implementing Choosing Wisely recommendations.

Their blueprint is a tripartite multimodal intervention plan in which a facility's clinicians receive regular education on the costs and risks of over-testing and regular feedback/audits of test ordering, and where electronic medical record (EMR) systems restrict ordering tests by adhering to a set criteria and alerting for duplicate testing.

The implementation blueprint Eaton and colleagues provide is simple, yet effective, however, Eaton warns, it’s only as strong as the readiness to change within an institution.

Designing hospital-wide educational initiatives to outline and standardize best practices for health care providers at all professional levels, to providing clinicians with data on ordering patterns in comparison to institutional benchmarks, and placing limits via EMR on multiple daily laboratory tests could have a substantial effect on providers, facilities, and patients, resulting in improved safety, satisfaction, and cost-effectiveness for all stakeholders.

"Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing" appeared on Oct. 16, 2017 in JAMA Internal Medicine.

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