Interventions to change test ordering practices

(Credit: this post was adapted from a clinical information summary authored by Julie Beauregard, MLIS, Library Fellow, Eskind Biomedical Library, Vanderbilt University Medical Center, Nashville TN)

In the April case study, the team's next step after reading the literature provided by the librarian will likely be to start figuring out how to share the information and how to begin changing the way amylase and lipase are ordered in the Emergency Department. A logical follow-up question from the team would be: What does the literature tell us about how to change physician test ordering behavior, and are there any benefits in terms of cost and clinical outcomes associated with such interventions?

There are several studies investigating the cost savings associated with interventions to reduce the number of unnecessary laboratory tests that are ordered; however, there are very few that evaluate the clinical outcomes associated with this change of test-ordering behavior.

Two articles (Hampers 1999; Neilson 2004) address the clinical outcomes associated with reducing the number of laboratory tests. Based on a telephone survey conduced 7 days after the ED visit, Hampers et al found that there is no significance difference in clinical outcome between the control and intervention groups. A study conducted by Neilson et al also found no significant changes in regards to readmission rates, transfers to intensive care unites, length of stay and mortality in pre- and post-intervention groups.

According to the literature, there are various methods employed to influence changes in physician test-ordering behaviors, including care provider order entry (CPOE); computer-based decision support system (CDSS); providing the physicians with pricing information for each test; feedback reports; and guidelines developed in-house. The article list included below provides representative articles on these intervention methods.

A Dutch study by Verstappen et al (2004) compared the cost effects of feedback only and a newly developed strategy of combining feedback reports, education on evidenced-based guidelines, and quality improvement meetings and found that both interventions reduced the number of tests ordered, but the combined intervention was more successful. Another Dutch study (Poley, 2007) implemented CDSS and found that the cost of blood testing was significantly reduced with the use of CDSS compared with the control group.

Furthermore, guidelines developed by an emergency department (ED) to aid in limiting the number of tests ordered, were associated with a $50-100,000 reduction of charges to insurance companies. Hampers et al (1999) provided physicians with the pricing information for each test and also noted a 27% reduction in testing charges compared with the control group. Neilson et al (2004) implemented 2 interventions; the 1st one reduced open-ended test ordering and the 2nd intervention developed specific ordering constraints. The authors found that ordering rates were significantly reduced with the 1st and 2nd intervention 32% and 52%, respectively.

All of the studies included here found a reduction in laboratory test orders by physicians as a result of an intervention. It should be noted, that there is the potential for publication bias for this topic, in that there may be a tendency to publish studies that show a reduction in cost and/or unnecessary tests.

Selected References
Verstappen WH, van Merode F, Grimshaw J, Dubois WI, Grol RP, van der Weijden T. Comparing cost effects of two quality strategies to improve test ordering in primary care: a randomized trial. Int J Qual Health Care. 2004 Oct;16(5):391-8. PMID: 15375100.

Poley MJ, Edelenbos KI, Mosseveld M, van Wijk MA, de Bakker DH, van der Lei J, Rutten-van Molken MP. Cost consequences of implementing an electronic decision support system for ordering laboratory tests in primary care: evidence from a controlled prospective study in the Netherlands. Clin Chem. 2007 Feb;53(2):213-9. PMID: 17185371.

Sucov A, Bazarian JJ, deLahunta EA, Spillane L. Test ordering guidelines can alter ordering patterns in an academic emergency department. J Emerg Med. 1999 May-Jun;17(3):391-7. PMID:10338227.

Hampers LC, Cha S, Gutglass DJ, Krug SE, Binns HJ. The effect of price information on test-ordering behavior and patient outcomes in a pediatric emergency department. Pediatrics. 1999 Apr;103(4 Pt 2):877-82. PMID: 10103325.

Neilson EG, Johnson KB, Rosenbloom ST, Dupont WD, Talbert D, Giuse DA, Kaiser A, Miller RA; Resource Utilization Committee. The impact of peer management on test-ordering behavior. Ann Intern Med. 2004 Aug 3;141(3):196-204. PMID: 15289216.

MLA President's blog

Mark Funk, the new president of the Medical Library Association, has launched a blog, Only Connect!.

Mark comments in his inaugural post:

Like my predecessors, I will probably write about my travels and adventures. I’ll also be playing around with WordPress plugins for photos and other cool things. But I hope that this form of communication can be more than reportage. Can we actually develop some kind of dialog? This is as new to me as it is to you. I want to hear from the MLA membership. What do you want in a blog by the MLA president?

(Thanks to David Rothman for the link)

Announcing the July case

The July 2007 issue of the Journal of the Medical Library Association is now available in PubMed Central, and it includes the next installment in our case study series.

This month's case "Organ preservation in a brain dead patient: information support for neurocritical care protocol development," explores a role for the librarian in shaping the organ donation and procurement process.

An excerpt from the case:

You serve as the liaison to your hospital's [Neurocritical Care Unit] committee, which is charged with identifying and implementing guidelines to assist care providers in using appropriate management strategies for patient care in the unit. This multidisciplinary team also includes physician intensivists, critical care nurses, pharmacists, respiratory therapists, ethicists, and hospital epidemiologists. Given the complexity of the organ donation process, the NCU committee turns its attention to verifying and implementing best practices for organ donor management.

The main concerns during the committee's initial discussion of organ procurement practices center around standardizing different aspects of donor care, including appropriate interventions to maintain organs prior to removal for transplant and to ensure effective and timely communication with family members. The team's goal is to achieve appropriate management of the body from the point at which brain death is perceived to be imminent to the time when organs are removed for transplantation. They hope that by optimizing the unit's practices, they will also ultimately increase the number of viable organs available for transplant. Discussion among group members during the first meeting also indicates that no one is aware of guidelines or studies examining the recommended methods to ensure organ preservation in a brain dead patient.

During the discussion, the team comments that organ preservation in this setting may need to be addressed by literature that evaluates medical, family-based, or staff training strategies to increase the number of successful transplants or improve quality of the organs removed from potential donors. Noting the daunting potential volume and complexity of literature that is needed to guide them in developing a care protocol for brain dead cadaver care, they ask you, as the group's librarian, to aid them in identifying, summarizing, and appraising guidelines and articles addressing these issues.

Reference: Todd PM, Jerome RN, Jarquin-Valdivia AA. Organ preservation in a brain dead patient: information support for neurocritical care protocol development. J Med Libr Assoc. 2007 July; 95(3): 238–245.