Background: It is estimated that 30-50% of laboratory testing ordered on hospitalized patients is unnecessary, which contributes to healthcare waste and may cause harm. A University Health System Consortium 2011 analysis indicated that the University of Utah General Internal Medicine hospitalist service had a higher average direct lab cost per discharge compared to top performers nationally. Recognizing laboratory cost as a problem, the hospitalist service implemented a multifaceted quality‐improvement initiative with a goal to reduce unnecessary laboratory testing. At the time of this project, University of Utah Health (UUH) developed a Value Driven Outcomes (VDO) tool to provide direct data related to costs of care, including the actual cost paid by the hospital to the university‐owned laboratory vendor for testing. The hospitalist group successfully incorporated VDO into the initiative for routine cost feedback which resulted in a 19% reduction in daily labs. In order to sustain and further reduce unnecessary lab ordering and cost, a new tool, LORCA (Lab Ordering Reduction and Cost Accountability), was developed by UUH hospitalists, value engineers and data specialists. This tool, which was derived from VDO using advances in technology, was launched in 2016 with the new capability to monitor and provide provider-specific and timely feedback on lab utilization. In this study, we report the impact of LORCA on lab utilization and cost.
Methods: The hospitalist service consists of 4 teaching teams with Internal Medicine (IM) residents and medical students, and 2 teams with Advanced Practice Providers (APP). LORCA monitors inpatient laboratory utilization by attending physician and medical team and provides a screen shot of the count and cost of labs per patient per 24 hours. APP teams have consistent exposure to LORCA feedback, while teaching teams have less consistent exposure due to residents’ rotations. LORCA can compare an individual provider’s lab use to colleagues’ use as well as demonstrate team lab use and trends over time. LORCA’s impact was assessed by comparing lab ordering between hospitalist and other subspecialty services (cardiology, pulmonology, oncology, and hematology). The subspecialty services functioned as a control group who did not receive feedback. Ordering behavior was also compared among the different hospitalist teams (teaching vs. APP).
Results: Data was collected from January 2016 through December 2017 on inpatients discharged by any IM service. A total of 19,296 visits (12,851 unique patients) were reviewed. Outcome measures included lab counts of basic metabolic panels (BMP), comprehensive metabolic panels (CMP) and complete blood counts (CBC). Results were adjusted for Medicare Severity-Diagnosis Related Group and length of stay. The mean lab ordering per visit between hospitalist and IM subspecialty teams was significantly different with hospitalist ordering less (BMP (-0.77, CI: -1.11 to -.43, p<0.001), CMP (-0.41, CI: -0.66 to -0.15, p=0.002) and CBC (-0.88, CI: -1.25 to -0.52, p<0.001)).
A total of 8,935 visits (6,936 unique patients) were discharged by a hospitalist. Average monthly lab costs among the hospitalist teams were not significantly different from one another (p=0.21). However, when looking at the rate of decrease in lab use among hospitalist groups, APC teams decreased usage at a significantly faster rate when compared to resident teams. (BMP (95% CI: -.04 to -.007, p<0.01), CMP (95% CI: -.02 to -.005, p<0.01) and CBC (95% CI: -.07 to-.03, p<0.01)).
Conclusions: The implementation of the LORCA tool and the value culture established by the hospitalist service may have contributed to lower lab ordering and cost by hospitalist teams. In addition, the APPs’ consistent exposure to LORCA’s specific and timely feedback may have had an impact in decreasing usage. By reducing laboratory testing, quality and value of care may be improved.
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