Effect of a price display intervention on laboratory test ordering behavior of general practitioners

Background Redundant use of diagnostic tests in primary care has shown to be a contributor to rising Dutch healthcare costs. A price display in the test ordering system of the electronic health records (EHRs) could potentially be a low-cost and easy to implement intervention to a decrease in test ordering rate in the primary care setting by creating more cost-awareness among general practitioners (GPs). The aim of this study was to assess the effect of a price display for diagnostic laboratory tests in the EHR on laboratory test ordering behavior of GPs in the Westelijke Mijnstreek region in the Netherlands. Methods A pre-post intervention study among 154 GPs working in 57 general practices was conducted from September 2019, until March 2020, in the Netherlands. The intervention consisted of displaying the costs of 22 laboratory tests at the time of ordering. The primary outcome was the mean test ordering rate per 1.000 patients per month, per general practice. Results Test ordering rates were on average rising prior to the intervention. The total mean monthly test order volume showed a non-statistically significant interruption in this rising trend after the intervention, with the mean monthly test ordering rate levelling out from 322.4 to 322.2 (P = 0.86). A subgroup analysis for solely individually priced tests showed a statistically significant decrease in mean monthly test ordering rate after implementation of the price display for the sum of all tests from 67.2 to 63.3 (P = 0.01), as well as for some of these tests individually (i.e. thrombocytes, ALAT, TSH, folic acid). Leucocytes, ESR, vitamin B12, anti-CCP and NT-proBNP also showed a decrease, albeit not statistically significant (P > 0.05). Conclusions Our study suggests that a price display intervention is a simple tool that can alter physicians order behavior and constrain the expanding use of laboratory tests. Future research might consider alternative study designs and a longer follow-up period. Furthermore, in future studies, the combination with a multitude of interventions, like educational programs and feedback strategies, should be studied, while potentially adverse events caused by reduced testing should also be taken into consideration.

Variation in Laboratory Utilization and Correlation with Hospital Bed Utilization: Experience of a Trauma-Care Hospital during the COVID-19 Pandemic

Objectives The present study was planned with the following objectives: (i) to calculate the difference in frequency of laboratory test ordered and use of consumables between the prepandemic and pandemic phases, (ii) to determine and compare the monthly average number of tests ordered per patient between the prepandemic and pandemic phases, and (iii) to correlate the monthly test ordering frequency with the monthly bed occupancy rate in both phases. Materials and Methods Records of laboratory tests ordered and use of consumables were collected for the prepandemic phase (1.8.2019 to 31.3.2020) and the pandemic phase (1.4.2020 to 31.10.2020). The absolute and relative differences were calculated. Monthly average number of tests ordered per patient and bed occupancy rate between prepandemic and pandemic phases was determined, compared, and correlated. Statistical Analysis The absolute and the relative differences between the two periods were calculated. The continuous variables were analyzed between groups using Mann–Whitney U test. Spearman correlation was used to correlate the monthly test ordering frequency with the monthly bed occupancy rate in both phases. Results A total of 946,421 tests were ordered, of which 370,270 (39%) tests were ordered during the pandemic period. There was a decrease in the number of the overall laboratory tests ordered (12%), and in the use of blood collection tubes (34%), and an increase in the consumption of sanitizers (18%), disinfectants (3%), masks (1633%), and gloves (7011%) during the pandemic period. Also, the monthly average number of tests ordered per patients significantly reduced (p-value < 0.001). Test ordering frequency had strong positive correlation with bed occupancy rate during pandemic (Spearman co-efficient = 0.73, p-value = 0.03). Conclusions An overall decline in laboratory utilization during pandemic period was observed. Understanding and correlating the trends with hospital bed utilization can maximize the productivity of the laboratory and help in better preparedness for the challenges imposed during similar exigencies.

Genetic Testing in Patients with Neurodevelopmental Disorders: Experience of 511 Patients at Cincinnati Children's Hospital Medical Center

Our institution developed and continuously improved a Neurodevelopmental Reflex (NDR) algorithm to help physicians with genetic test ordering for neurodevelopmental disorders (NDDs). To assess its performance, we performed a retrospective study of 511 patients tested through NDR from 2018 to 2019. SNP Microarray identified pathogenic/likely pathogenic copy number variations in 27/511 cases (5.28%). Among the 484 patients tested for Fragile X FMR1 CGG repeats, a diagnosis (0.20%) was established for one male mosaic for a full mutation, a premutation, and a one-CGG allele. Within the 101 normocephalic female patients tested for MECP2, two patients were found to carry pathogenic variants (1.98%). This retrospective study suggested the NDR algorithm effectively established diagnoses for patients with NDDs with a yield of 5.87%.

Understanding Factors Associated With Anaplastic Lymphoma Kinase Testing Delays in Patients With Non–Small Cell Lung Cancer in a Large Real-World Oncology Database

Context.— With multiple therapeutic options available for patients with advanced non–small cell lung cancer, the timely ordering and return of results to determine therapy are of critical importance. Objective.— To assess factors impacting anaplastic lymphoma kinase (ALK) test ordering and time to result delivery. Design.— A retrospective study using a de-identified electronic health record database was performed. Postdiagnosis ALK tests (n = 14 657) were analyzed from 14 197 patients with advanced non–small cell lung cancer diagnosed between January 2015 and May 2019. Time from non–small cell lung cancer diagnosis to ALK sample receipt in the laboratory was a surrogate for test order time. Test ordering was considered delayed if order time was more than 20 days. Turnaround time from sample received to test result was calculated and considered delayed if more than 10 days. Multivariable logistic regression was used to assess factors associated with order time and turnaround time delays. Results.— Median ALK test order time was 15 days, and 36.4% (5342) of all 14 657 orders were delayed. Factors associated with delays were non–fluorescent in situ hybridization testing, send-out laboratories, testing prior to 2018, nonadenocarcinoma histology, and smoking history. Median turnaround time was 9 days, and 40.3% (5906) of all 14 657 test results were delayed. Non–fluorescent in situ hybridization testing, tissue sample, and orders combining ALK with other biomarkers were associated with delayed ALK result reporting. Conclusions.— This study provides a snapshot of real-world ALK test ordering and reporting time in US community practices. Multiple factors impacted both test ordering time and return of results, revealing opportunities for improvement. It is imperative that patients eligible for targeted therapy be identified in a timely fashion.

The impact of medical scribes on emergency physician diagnostic testing and diagnosis charting

Objectives Since the widespread adoption of electronic medical records (EMRs), medical scribes have been increasingly utilized in emergency department (ED) settings to offload the documentation burden of emergency physicians (EPs). Scribes have been shown to increase EP productivity and satisfaction; however, little is known about their effects on the EP’s diagnostic process. We aimed to assess what effect, if any, scribes have on EP diagnostic test ordering and their documentation of differential diagnoses. Methods We conducted a retrospective cohort study utilizing a chart review to compare diagnostic practices of EPs working both with and without scribes. We analyzed the number of laboratory and radiologic diagnostic studies ordered per encounter as well as characteristics of differential diagnosis documentation. Results Scribes did not affect laboratory studies ordered per encounter (mean 6.31 by scribes vs. 7.35 by EPs, difference −1.04; 95% confidence interval [CI] −2.34 to 0.26) or radiologic studies ordered per encounter (mean 1.49 by scribes vs. 1.39 by EPs, difference 0.10; 95% CI −0.15 to 0.35). Scribes did not affect the frequency of documenting a differential diagnosis or the number of diagnoses considered in each differential, but they were associated with higher word counts in EP differentials (mean 72.29 by scribes vs. 50.00 by EPs, mean difference 22.79; 95% CI 6.77 to 38.81). Conclusions Scribe use does not appear to affect EP diagnostic test ordering but may have a small effect on their documentation of differential diagnoses.

Why is there variation in test ordering practices for patients presenting to the emergency department with undifferentiated chest pain? A qualitative study

IntroductionUp to one-third of laboratory tests ordered in the ED for adults presenting with undifferentiated chest pain are generally not indicated by current Australian guidelines. This study set out to undertake a qualitative investigation of clinician perceptions to identify the reasons for variations in pathology requesting.MethodsFor this study, we draw on data from semistructured interviews (n=38) conducted in the EDs and laboratories across three hospitals as part of a larger study on the test result management process from test request to result follow-up. Thematic analysis was conducted to determine what aspects of the clinical routines and environment might contribute to variations in pathology requesting. Informed by the findings from the analysis, targeted questions were developed and further focus groups (n=5) were held with clinicians, hospital management and electronic medical record (eMR) analysts to investigate in more detail the reasons for requesting outside of guidelines.ResultsParticipants cited four main reasons for ordering outside of guidelines. Clinicians requested tests outside of guidelines and the ED scope of practice to facilitate the patient journey along the broader continuum of care, including admission to hospital or transfer to another site. Clinicians were also faced with multiple and inconsistent guidelines regarding appropriate test selection. Limited access to in-house specialty and diagnostic services also influenced ordering patterns in smaller non-referral hospitals. Finally, certain features of the current electronic ordering framework within the eMR facilitated overordering and failed to impose any real restrictions on ordering inappropriately or outside of scope of practice.ConclusionBeyond the standardisation of pathology requesting advice across electronic decision support, order sets and guidelines, attempts to address issues related to the appropriateness and variation of laboratory test ordering should consider local and systemic factors which also shape the ordering process.

Clinical and healthcare improvement through My Health Record usage and education in general practice (CHIME-GP): a study protocol for a cluster-randomised controlled trial

Background There is an international interest in whether improved primary care can lead to a more rational use of health resources. There is evidence that educational interventions can lead to improvements in the quality of rational prescribing and test ordering. A new national platform for shared medical records in Australia, My Health Record (MHR), poses new opportunities and challenges for system-wide implementation. This trial (CHIME-GP) will investigate whether components of a multifaceted education intervention in an Australian general practice setting on rational prescribing and investigation ordering leads to reductions in health-service utilisation and costs in the context of the use of a national digital health record system. Methods The trial will be undertaken in Australian general practices. The aim of the research is to evaluate the effectiveness of components of a web-based educational intervention for general practitioners, regarding rational use of medicines, pathology and imaging in the context of the use of the MHR system. Our target is to recruit 120 general practitioners from urban and regional regions across Australia. We will use a mixed methods approach incorporating a three-arm pragmatic cluster randomised parallel trial and a prospective qualitative inquiry. The effect of each education component in each arm will be assessed, using the other two arms as controls. The evaluation will synthesise the results embedding qualitative pre/post interviews in the quantitative results to investigate implementation of the intervention, clinical behaviour change and mechanisms such as attitudes, that may influence change. The primary outcome will be an economic analysis of the cost per 100 consultations of selected prescriptions, pathology and radiology test ordering in the 6 months following the intervention compared with 6 months prior to the intervention. Secondary outcome measures include the rates per 100 consultations of selected prescriptions, pathology and radiology test ordering 6 months pre- and post-intervention, and comparison of knowledge assessment tests pre- and post-intervention. Discussion The trial will produce robust health economic analyses on the evidence on educational intervention in reducing unnecessary prescribing, pathology and imaging ordering, in the context of MHR. In addition, the study will contribute to the evidence-base concerning the implementation of interventions to improve the quality of care in primary care practice. Trial registration ClinicalTrials.gov ACTRN12620000010998. Registered on 09 January 2020 with the Australian New Zealand Clinical Trials Registry

Reducing vitamin test ordering in primary care; the effectiveness of professional and patient oriented strategies in a Cluster randomized Intervention Study

BackgroundVitamin tests are increasingly ordered by GPs, but a clinical and evidence based indication is often lacking. Harnessing technology, ie, decision support tools and redesigning request forms, have been shown to reduce vitamin D requests.AimCould the number of vitamin tests also be reduced by providing a multi-level intervention programme based on training, monitoring and feedback?Design & SettingIn a Cluster Randomised Intervention Study performed in 26 primary care health-centres (200.000 patients) the relative reduction in ordered vitamin D and B12 tests was determined after introduction of two de-implementation strategies (may 2017-may 2018).MethodHealth-centres randomised to de-implementation strategy one received education and 3-monthly benchmarking of their own vitamin test ordering behaviour. Health-centres in de-implementation strategy two received the same education and benchmarking but supplemented with educational material for patients.ResultsThe number of vitamin D tests decreased 23% compared to the one-year pre-intervention period. For vitamin B12 tests an overall reduction of 20% was found. Provision of patient educational information showed additional value over training and benchmarking of GPs alone, but only for vitamin D test ordering (10% extra reduction, OR 0.88, 95% CI 0.83–0.92, compared to 4% extra reduction for vitamin B12, OR 0.96, 95% CI 0.91–1.02). Nationwide, this would result in over € 3.200.000 saving on healthcare expenditure per year.ConclusionA structured intervention programme, including training and benchmarking of GPs regarding their diagnostic test ordering resulted in a significant reduction in ordered vitamin tests. Additional information provision to patients resulted in a small but still relevant additional reduction. If implemented on a national level, a substantial cost saving can be achieved.

Use of diagnostic and antimicrobial stewardship practices to improve Clostridioides difficile testing among SHEA Research Network hospitals

We surveyed acute-care hospitals on strategies to reduce inappropriate C. difficile testing and treatment of colonized patients. Decision support during C. difficile test ordering was common, but “hard stops” to prevent placement of inappropriate orders and active intervention of antimicrobial stewardship programs on positive C. difficile test reports were infrequent.

Does admission order form design really matter? A reduction in urea blood test ordering

IntroductionLaboratory blood testing is one of the most high-volume medical procedures and continues to increase steadily with instances of inappropriate testing resulting in significant financial implications. Studies have suggested that the design of a standard hospital admission order form and laboratory request forms influence physician test ordering behaviour, reducing inappropriate ordering and promoting resource stewardship.Aim/methodTo redesign the standard medicine admission order form-laboratory request section to reduce inappropriate blood urea nitrogen (BUN) testing.ResultsA redesign of the standard admission order form used by general internal medicine physicians and residents in two large teaching hospitals in one health zone in Alberta, Canada led to a significant step reduction in the ordering of the BUN test on hospital admission.ConclusionsRedesigning the standard medicine admission order form-laboratory request section can have a beneficial effect on the reduction in BUN ordering altering physician ordering patterns and behaviour.