Impact of an electronic decision support rule on ESR/CRP co-ordering rates in a community health system and projected impact in the tertiary care setting and a commercially insured population

Abstract

Introduction: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are common laboratory assays used as markers of inflammation. ESR suffers from higher false positive and false negative rates than CRP. To that end, the American Board of Internal Medicine's (ABIM's) Choosing Wisely campaign has recommended against ESR testing for those with undiagnosed conditions in favor of CRP testing. This study describes the impact of a computerized provider order entry (CPOE) decision support rule against ESR/CRP co-ordering within a community health system that predates the ABIM's Choosing Wisely national guidance. To demonstrate the potential impact of such a CPOE rule within other healthcare settings, ESR/CRP ordering data from a multi-site tertiary care practice and from the commercially insured population in the OptumLabs® Data Warehouse (OLDW) were analyzed and the relative reduction in ESR/CRP co-ordering achieved within the community health system was projected onto these populations.

Materials and methods: ESR and/or CRP orders from a community health system were assessed from 2012 to 2016. Co-ordering and test concordance rates between ESR and CRP were compared before and after CPOE decision support rule launch. Similarly, ESR/CRP co-ordering across three tertiary care sites from 2015 to 2016 and the OLDW from 2009 to 2013 were assessed and the co-ordering rate reduction achieved in the community health system was mathematically projected onto these populations. Estimated payer savings from the rule's effect were calculated within each population using Medicare reimbursement rates.

Results: The CPOE decision support rule realized an unadjusted 42% relative rate reduction in ESR/CRP co-ordering within the community health system yielding an annual payer savings of $15,000 with a modest increase in ESR/CRP concordance rates. Projecting a 40% relative reduction in ESR/CRP co-ordering rates from a similarly effective CPOE rule, annual payer cost reductions exceeding $100,000 within a multi-site tertiary care setting and $1,000,000 within the OLDW would be expected.

Conclusion: ESR/CRP co-ordering represents an opportunity to eliminate testing waste and reduce payer costs. A CPOE decision support rule stably reduces ESR/CRP co-ordering rates. Similar results may occur as one component of new commercially available decision support platforms.

Keywords: C-reactive protein; Clinical decision support; Erythrocyte sedimentation rate; OptumLabs.