Choosing Wisely and reducing the simultaneous ordering of erythrocyte sedimentation rate and C-reactive protein testing in a large safety net system

Abstract

Objectives: C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are commonly used inflammatory markers. C-reactive protein is more sensitive and specific for monitoring acute inflammation. However, it is commonly co-ordered with ESR despite recommendations against this. Our objective was to reduce unnecessary ESR orders and ESR/CRP co-ordering rates across a large safety net health system.

Methods: This was a quality improvement project that used a quasi-experimental pre- and postintervention interrupted time-series regression analysis. Patients with a positive COVID-19 test were excluded. We designed a nonintrusive, normative nudge within the ESR order that recommended against co-ordering ESR and CRP. In addition, a best practice advisory triggered when ESR and CRP were simultaneously ordered. The outcome measures were ESR order rates per 1000 patient days in the inpatient setting and per 1000 patient encounters in the outpatient setting, as well as ESR/CRP co-ordering rates.

Results: Inpatient ESR orders decreased from 12.02 preintervention to 5.61 per 1000 patient days (-53.3%, P < .001). Outpatient ESR orders decreased from 6.09 to 4.07 per 1000 patient encounters (-33.2%, P < .001). Relative co-ordering rates decreased by 50%.

Conclusions: This electronic health record initiative successfully reduced ESR testing across 11 hospitals and 70 ambulatory centers in a safety net setting.

Keywords: Choosing Wisely; ESR/CRP co-ordering; clinical decision support; overuse; safety net hospital system.