Thursday, July 26, 2007

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.

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.


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