Multifaceted Approach Cuts Unnecessary Inpatient Lab Testing, Reduces Costs

Amultifaceted intervention is able to cut inpatient lab costs per day by reducing the number of commonly ordered, but unnecessary, routine tests, according to a study published Feb. 4 in the Journal of Hospital Medicine. The intervention incorporates education and cost feedback to change the culture of routine test ordering into a "thoughtful process," the authors say.

Laboratory tests, while a small percent of the total health care spend, are documented to contribute to waste, with an estimated 30 percent to 50 percent of tests for hospitalized patients being unnecessary, the authors say. A University Health Systems Consortium 2011 analysis indicated that The University of Utah General internal medicine service compared their costs to 2011 University Health Systems Consortium's data and determined it had a higher average direct lab cost per discharge compared to top performers. In addition to the potential cost savings, potential anemia from phlebotomy during long hospital stays, negative patient experience from frequent, early morning blood draws, and a cascade effect from false positives that lead to further testing and monitoring all contributed to the hospital's interest in quality improvement efforts.

University of Utah Health Care developed a Value Driven Outcomes (VDO) tool to give direct data related to costs of care, including the actual cost paid by the hospital to the university-owned laboratory vendor (ARUP Laboratories) for testing. The VDO provided routine cost feedback. Additionally, the intervention included education for all hospitalist group providers on laboratory overuse and costs and standardization of the rounding process to include a checklist review that ensured discussion of lab testing. Lastly, a shared savings program would provide 50 percent of realized cost savings back to internal medicine to support future quality improvement projects, but physicians did not personally benefit financially.

The baseline period (July 1, 2012 to Jan. 31, 2013) was compared to the intervention period (Feb. 1, 2013 to April 30, 2014). This study included 6,310 hospitalist patient visits (internal medicine; intervention arm) and 25,586 non-hospitalist services (surgical services, pulmonary, cardiology, hematology, and oncology services; control arm).

The researchers found that in the intervention group, unadjusted mean cost per day was significantly reduced from $138 before the intervention to $123 after the intervention and unadjusted mean cost per visit decreased significantly from $618 to $558. The number of tests per day significantly decreased for all specific tests (basal and comprehensive metabolic panels and complete blood chemistry tests) in the intervention group. The authors projected that the decreased cost in the intervention group amounts to approximately $251,427 savings over the first year and could have led to an additional cost savings of $1,321,669 if the intervention was used and had similar impact in the control group. In addition to the cost savings, readmission rates decreased significantly by 3 percent in the intervention group, but length of stay was unchanged.

"Prior to this intervention, the least experienced person on this team, the intern, ordered any test he or she wanted, usually without discussion," write the authors led by Peter Yarbrough, M.D., University of Utah, Salt Lake City. "The intervention focused on this issue through standardized supervision and explicit discussion of laboratory tests. … The incorporation of process change in this intervention was felt to likely contribute to the sustained reduction seen at 15 months."

Takeaway: A multifaceted intervention targeting unnecessary inpatient hospital testing could save $1.5 million a year in an academic medical center setting.