Analysis of Daily Laboratory Orders at a Large Urban Academic Center: A Multifaceted Approach to Changing Test Ordering Patterns

Abstract

Objectives: We sought to address concerns regarding recurring inpatient laboratory test order practices (daily laboratory tests) through a multifaceted approach to changing ordering patterns.

Methods: We engaged in an interdepartmental collaboration to foster mindful test ordering through clinical policy creation, electronic clinical decision support, and continuous auditing and feedback.

Results: Annualized daily order volumes decreased from approximately 25,000 to 10,000 during a 33-month postintervention review. This represented a significant change from preintervention order volumes (95% confidence interval, 0.61-0.64; P < 10-16). Total inpatient test volumes were not affected.

Conclusions: Durable changes to inpatient order practices can be achieved through a collaborative approach to utilization management that includes shared responsibility for establishing clinical guidelines and electronic decision support. Our experience suggests auditing and continued feedback are additional crucial components to changing ordering behavior. Curtailing daily orders alone may not be a sufficient strategy to reduce in-laboratory costs.

Keywords: Clinical decision support; Daily laboratory orders; Utilization management.

Figure 1

Total daily orders by services for 2014. A, Orders volume. B, Orders volume/admissions.

Figure 2

A, Daily orders grouped by test code. B, Top 500 indications for daily orders grouped by category. Data span January 2, 2012, to August 3, 2015. aPTT, activated partial thromboplastin time; LDH, lactate dehydrogenase; PT-INR, prothrombin time + international normalized ratio.

Figure 3

A, Changes in frequency of total daily orders benchmarked to hemoglobin (HGB) order volume. Arrow indicates start of order indication solicitation, and arrowhead indicates initiation of email feedback. B-D, Changes in frequencies of daily orders for CBC, CBC with differential (DIFF), magnesium (MG), and international normalized ratio (INR), including (B) number of daily orders, (C) total orders placed, and (D) total results issued. Results are displayed in annualized weekly rolling averages.