Major reductions in unnecessary aspartate aminotransferase and blood urea nitrogen tests with a quality improvement initiative

2019 ◽  
Vol 28 (10) ◽  
pp. 809-816 ◽  
Author(s):  
Rachel Strauss ◽  
Alex Cressman ◽  
Mark Cheung ◽  
Adina Weinerman ◽  
Suzanne Waldman ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Blood Urea Nitrogen ◽  
Aspartate Aminotransferase ◽  
Cost Savings ◽  
Absolute Number ◽  
Choosing Wisely ◽  
Audit And Feedback ◽  
Quality Improvement Initiative ◽  
Urea Nitrogen ◽  
Hospital Days

Background/contextUnnecessary laboratory testing leads to considerable healthcare costs. Aspartate aminotransferase (AST), commonly ordered with alanine aminotransferase (ALT) and blood urea nitrogen (BUN), commonly ordered with creatinine (Cr), often add little value to patient management at significant cost. We undertook a choosing wisely based quality improvement initiative to reduce the frequency of testing.ObjectivesTo reduce the ratio of AST/ALT and BUN/Cr to less than 5% for all inpatient and outpatient test orders.MeasuresAbsolute number and ratio of AST/ALT and BUN/Cr; AST, ALT, BUN and Cr tests per 100 hospital days; projected annualised cost savings and monthly acute inpatient bed days.ImprovementsWe created guidelines for appropriate indications of AST and BUN testing, provided education with audit and feedback and removed AST and BUN from institutional order sets.Impact/resultsThe ratios of AST/ALT and BUN/Cr decreased significantly over the study period (0.37 to 0.14, 0.57 to 0.14, respectively), although the goal of 0.05 was not achieved due to a delay in adopting the choosing wisely strategies during the study time period by some inpatient units. The number of tests per 100 hospital days decreased from 20 to 7 AST (95% CI 19 to 20.5, 5.6 to 8.7, p<0.001) and from 72 to 17 BUN (95% CI 70 to 73.4, 16.6 to 22.9, p<0.001). The initiative resulted in a projected annualised cost savings of C$221 749.DiscussionA significant decrease in the AST/ALT and BUN/Cr ratios can be achieved with a multimodal approach and will result in substantial healthcare savings.

Results of a Regional Effort to Improve Warfarin Management

2016 ◽  
Vol 51 (5) ◽  
pp. 373-379 ◽  
Author(s):  
Adam J. Rose ◽  
Angela Park ◽  
Christopher Gillespie ◽  
Carol Van Deusen Lukas ◽  
Al Ozonoff ◽  
...  
Keyword(s):  
Quality Improvement ◽  
New England ◽  
Audit And Feedback ◽  
Quality Improvement Initiative ◽  
Veterans Health ◽  
Health Administration ◽  
Process Of Care ◽  
Processes Of Care ◽  
Anticoagulation Control

Background: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. Objective: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). Methods: Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. Results: VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. Conclusions: A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.

scholarly journals Doctor Who? A Quality Improvement Project to Assess and Improve Patients' Knowledge of Their Inpatient Physicians

2016 ◽  
Vol 8 (2) ◽  
pp. 197-201 ◽  
Author(s):  
Kathleen Broderick-Forsgren ◽  
Wynn G Hunter ◽  
Ryan D Schulteis ◽  
Wen-Wei Liu ◽  
Joel C Boggan ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Audit And Feedback ◽  
Quality Improvement Initiative ◽  
Clinical Learning Environment ◽  
Improvement Project ◽  
Business Card ◽  
Quality Patient Care ◽  
White Board ◽  
White Boards ◽  
The Impact

ABSTRACT  Patient-physician communication is an integral part of high-quality patient care and an expectation of the Clinical Learning Environment Review program.Background  This quality improvement initiative evaluated the impact of an educational audit and feedback intervention on the frequency of use of 2 tools—business cards and white boards—to improve provider identification.Objective  This before-after study utilized patient surveys to determine the ability of those patients to name and recognize their physicians. The before phase began in July 2013. From September 2013 to May 2014, physicians received education on business card and white board use.Methods  We surveyed 378 patients. Our intervention improved white board utilization (72.2% postintervention versus 54.5% preintervention, P &lt; .01) and slightly improved business card use (44.4% versus 33.7%, P = .07), but did not improve physician recognition. Only 20.3% (14 of 69) of patients could name their physician without use of the business card or white board. Data from all study phases showed the use of both tools improved patients' ability to name physicians (OR = 1.72 and OR = 2.12, respectively; OR = 3.68 for both; P &lt; .05 for all), but had no effect on photograph recognition.Results  Our educational intervention improved white board use, but did not result in improved patient ability to recognize physicians. Pooled data of business cards and white boards, alone or combined, improved name recognition, suggesting better use of these tools may increase identification. Future initiatives should target other barriers to usage of these types of tools.Conclusions

scholarly journals Biochemical Effects to Toxicity of CCl4 on Rosy Barbs (Puntius conchonius)

Our Nature ◽  
1970 ◽  
Vol 3 (1) ◽  
pp. 20-25 ◽  
Author(s):  
H. Bhattacharya ◽  
L. Lun ◽  
G.D. Gomez R.
Keyword(s):  
Alkaline Phosphatase ◽  
Lactate Dehydrogenase ◽  
Enzymatic Activity ◽  
Blood Urea Nitrogen ◽  
Aspartate Aminotransferase ◽  
Alanine Aminotransferase ◽  
Target Organ ◽  
Biochemical Changes ◽  
Urea Nitrogen ◽  
Biochemical Effects

Biochemical changes in the liver, kidneys and gills of rosy barbs due to toxicity of CCl4 were measured after 96 hour exposure. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), lactate dehydrogenase (LDH), blood urea nitrogen (BUN) and creatinin (CRN), levels were measured. Significant increase in ALP, ALT, LDH and BUN activities were observed in the liver in the treated groups compared to controls (P < 0.05). AST level was significantly higher in the kidneys. This study indicates that the enzymatic activity was comparatively higher in the liver than kidneys or gills, suggesting that the liver is the target organ of CCL4 toxicity to rosy barbs.Keywords: Toxicity, Rosy Barb, CCl4doi:10.3126/on.v3i1.330Our Nature (2005)5:20-25

A comprehensive Choosing Wisely quality improvement initiative reduces unnecessary transfusions in an Academic Department of Surgery

2017 ◽  
Vol 214 (4) ◽  
pp. 571-576 ◽  
Author(s):  
Caitlin W. Hicks ◽  
Jing Liu ◽  
William W. Yang ◽  
Sandra R. DiBrito ◽  
Daniel J. Johnson ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Academic Department ◽  
Choosing Wisely ◽  
Quality Improvement Initiative

Impact of an Interprofessional Collaborative Quality Improvement Initiative to Decrease Inappropriate Thyroid Function Testing

2020 ◽  
pp. 001857872092079
Author(s):  
Alyssa B. Bradshaw ◽  
Alex K. Bonnecaze ◽  
Cynthia A. Burns ◽  
James R. Beardsley
Keyword(s):  
Quality Improvement ◽  
Thyroid Function ◽  
Medical Center ◽  
Cost Savings ◽  
Thyroid Stimulating Hormone ◽  
Quality Improvement Initiative ◽  
Published Data ◽  
Free T4 ◽  
Potential Cost ◽  
Before And After

Background: Published data show that thyroid function laboratory tests are often ordered inappropriately in the acute care setting, which leads to unnecessary costs and inappropriate therapy decisions. Pilot data at our institution indicated that approximately two-thirds of the thyroid-stimulating hormone (TSH) laboratories were unnecessary, correlating to a potential cost avoidance of more than $20,000 annually. The purpose of this study was to improve the appropriateness of thyroid function test ordering with a multipronged initiative. Methodology: This controlled, single-center, before and after study included inpatients or emergency department (ED) patients at Wake Forest Baptist Medical Center who were at least 18 years of age and had a TSH level ordered during the study period. Patients with a history of thyroid cancer were excluded. The initiative included an electronic ordering intervention, direct education of providers (medical residents, attendings, and clinical pharmacists), and distribution of pocket information cards with appropriate ordering criteria. The primary outcome was the number and percentage of inappropriate TSH tests ordered before and after implementing the 3 interventions. Secondary outcomes included cost savings, inappropriate changes in thyroid therapy based on improperly ordered tests, and the number of free T4 lab tests ordered on patients with a TSH within the therapeutic range. Results: All 3 interventions were implemented, except for education of ED residents and faculty, who chose to forgo the direct education component. Inappropriate ordering of TSH levels decreased from 63 to 50 (13% reduction, P = .062) after implementation. Inappropriate TSH ordering decreased across all services, except in the ED. Inappropriate Free T4 orders decreased from 191 to 133 (30% reduction, P = .01). There were no therapy changes based on inappropriate TSH orders. Extrapolated annual cost savings were approximately $6,000. Conclusion: This multipronged interprofessional collaborative quality improvement initiative was associated with a nonstatistically significant reduction in inappropriate TSH orders, statistically significant reduction in inappropriate free T4 orders, and cost savings. There was a reduction in inappropriate ordering across all services except the ED, which may have been due the ED not participating in the direct education component of the initiative.

scholarly journals Effect of a multimethod quality improvement intervention on antipsychotic medication use among residents of long-term care

2021 ◽  
Vol 10 (2) ◽  
pp. e001211
Author(s):  
Heather M Hanson ◽  
Tova Léveillé ◽  
Mollie Cole ◽  
Lesley JJ Soril ◽  
Fiona Clement ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Antipsychotic Medication ◽  
Long Term Care ◽  
Medication Use ◽  
Implementation Fidelity ◽  
Audit And Feedback ◽  
Quality Improvement Initiative ◽  
Term Care ◽  
Antipsychotic Medications

BackgroundAntipsychotic medications are used to address neuropsychiatric symptoms associated with dementia. Evidence suggests that among older adults with dementia, their harms outweigh their benefits. A quality improvement initiative was conducted to address inappropriate antipsychotic medication use in long-term care (LTC) in the province of Alberta.MethodsWe conducted a multimethod evaluation of the provincial implementation of the project in 170 LTC sites over a 3-year project period incorporating a quasi-experimental before–after design. Using a three-component intervention of education and audit and feedback delivered in a learning workshop innovation collaborative format, local LTC teams were supported to reduce the number of residents receiving antipsychotic medications in the absence of a documented indication. Project resources were preferentially allocated to supporting sites with the highest baseline antipsychotic medication use. Changes in antipsychotic medication use, associated clinical and economic outcomes, and the effects of the project on LTC staff, physicians, leaders and administrators, and family members of LTC residents were assessed at the conclusion of the implementation phase.ResultsThe province-wide initiative was delivered with a 75% implementation fidelity. Inappropriate antipsychotic medication use declined from 26.8% to 21.1%. The decrease was achieved without unintended consequences in other outcomes including physical restraint use or aggressive behaviours. The project was more expensive but resulted in less inappropriate use of antipsychotics than the pre-project period (incremental cost per inappropriate antipsychotic avoided of $5 678.71). Accounts from family, organisational leaders, and LTC staff were supportive of the project activities and outcomes.ConclusionThis quality improvement initiative was successfully delivered across an entire delivery arm of the continuing care sector. Quality of care in LTC was improved.

Choosing Wisely in Georgia: A Quality Improvement Initiative in 25 Adult Ambulatory Medicine Offices

2018 ◽  
Vol 44 (12) ◽  
pp. 699-707 ◽  
Author(s):  
Scott Pugel ◽  
John L. Stallworth ◽  
Leslie B. Pugh ◽  
Carlee Terrell ◽  
Zuwere Bailey ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Choosing Wisely ◽  
Quality Improvement Initiative ◽  
Ambulatory Medicine

Myeloid growth factor utilization in a commercial and Medicare population: Phase 1 of a quality improvement initiative.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 242-242
Author(s):  
Edward C. Li ◽  
Barry A. Peterson ◽  
Cecilia Tran ◽  
Michael Sturgill ◽  
Dudley Gill ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Phase 1 ◽  
Cost Savings ◽  
Cost Effective ◽  
Secondary Prophylaxis ◽  
Quality Improvement Initiative ◽  
Curative Intent ◽  
Medicare Population ◽  
Concurrent Use ◽  
Chemotherapy Dose

242 Background: Some clinical practice guidelines encourage the judicial use of myeloid growth factors (MGFs) in the prevention of chemotherapy-induced febrile neutropenia (FN) because of efficacy and safety concerns. For example, the ASCO guidelines state that a dose reduction of myelosuppressive chemotherapy in patients with incurable disease rather than prescribing a MGF for secondary prophylaxis is a reasonable alternative. Because there is wide variation in MGF prescribing, New Century Health (NCH) conducted a quality improvement analysis of MGF requests in a commercial and Medicare population. The objectives are to: (1) describe the cohort demographics, (2) identify areas of improvement to promote cost-effective use, and (3) measure the economic impact from interventions. Methods: MGF authorization requests for oncology indications to NCH in 2013 were analyzed for cohort demographics: age, weight, tumor diagnosis, and treatment intention (e.g., metastatic/palliative, curative, etc.). Requests were analyzed for concurrent use with chemotherapy, approval status of the request (including reason for withdrawal), and cost saving associated with interventions. Results: There were 7,958 requests for a MGF; 81% were for pegfilgrastim and 19% for filgrastim. Average age of the cohort was 66 years, weight-based dosing (>70 kg) was appropriate in 43% of patients receiving 300 mcg and 72% of patients receiving 480 mcg. MGFs were most commonly requested in: breast (18%), lung (17%), lymphoma (14%), and gynecologic (8%) tumors. 40% of requests were for metastatic/recurrent disease and 38% for curative intent. 6,724 (84%) of requests were authorized based on established-use criteria. The main reason for not authorizing was lack of compendia support for both primary and secondary prophylaxis; this resulted in approximately $3.5 million in cost savings. Conclusions: There is opportunity to improve efficiency of MGFs use in this population through a dose rounding protocol and by promoting chemotherapy dose reductions, as advocated by the ASCO guidelines. Further analysis will assess the concordance of MGF use with guidelines, specifically in regard to chemotherapy regimens and their risk of FN.

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