Reduction in the Concomitant Ordering of Erythrocyte Sedimentation Rate and C-Reactive Protein Within a Large Academic Medical Center

Abstract

Background: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are two laboratory tests often ordered simultaneously to assess for inflammation. Studies show that CRP is superior to ESR, and co-ordering ESR and CRP increases expenditures and phlebotomy without demonstrable patient benefit.

Objective: Our quality improvement project aimed to reduce ESR/CRP co-ordering and total ESR orders in a safety-net health setting (health system 1) and a university setting (health system 2) within an academic medical center.

Design/interventions: Using plan, do, study, act (PDSA) methodology, we developed education and electronic health record (EHR) interventions, which included education to all rheumatology providers, targeted education to rheumatology providers with the highest ESR/CRP co-orders, removal of ESR from the rheumatology order set at health system 2, and implementation of a non-intrusive clinical decision support (CDS) change at both hospitals.

Main measures: We compared ESR/CRP co-orders, ESR-only orders, and CRP-only orders between pre- and post-intervention periods, as well as weekly average orders per 1000 patient days in the inpatient setting and per 1000 patient encounters in the outpatient setting and rheumatology clinics.

Key results: In health system 1, average weekly ESR/CRP co-orders decreased by 25%, ESR-only orders decreased by 26%, and CRP-only orders increased by 11%. In health system 2, average weekly ESR/CRP co-orders decreased by 36%, ESR-only orders decreased by 47%, and CRP-only orders increased by 65%. Most of the change was seen in the outpatient setting, with >80% reduction in ESR/CRP co-ordering by the rheumatology division in both health systems. Using ESR and CRP Medicare reimbursement rates, estimated payer savings system-wide were $59,354.33 over 1 year.

Conclusion: Specialty-led and targeted educational interventions and non-intrusive simple EHR CDS changes are effective in reducing redundant laboratory testing to provide higher value care.

Keywords: CRP; Choosing Wisely Campaign; Clinical decision support; ESR; Ordering practices.