Riddhi
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Dissertation proposal
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Week 4 of 4
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My Commitment Journal
 Riddhi
March 23, 2015, 10:46 AM
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| 0 hrs again!! | |
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Riddhi
March 16, 2015, 11:32 AM
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| 0 hrs! | |
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James_Willig
March 2, 2015, 6:40 PM
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Come on Riddhi! You can do this! |
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March 2 to March 9
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James_Willig
- Referee approval report
Keep going Riddhi! One more week to go!
Riddhi
- Committed user success report
Initial draft for background and rationale sent for review.
Draft:
Background and significance
Laboratory testing is an essential tool for disease diagnosis, monitoring and management across all medical settings and specialties (Zhi, 2013; Laxmisan, 2011; Futrell, 2014; Atalli, 2006; Robinson 1994; Catrou, 2006). It is estimated to play a role in up to 70% of the clinical decisions made (Badrick, 2013; Cola white paper; Jackson, 2007; Forsman, 1996). In the United States, approximately 7-10 billion tests were ordered in 2014 (Futrell, 2014; Cola white paper). Lab tests contribute to 5% of the total health care cost (Song, 2011; Forsman, 1996) and are predicted to rise in the future (Pilsczek, 2005; Dada, 2011). On an average, unnecessary lab tests account for about 1.7 million per year hospital loss (Futrell, 2014). In 2014, a study conducted by Khalifa et. al, report a case study of Saudi Arabia were laboratory test orders were found to increase 5-10% each year.
Overutilization defined as unnecessary ordering of tests (Catrou, 2006) that are not indicated (Zhi, 2013) (is a growing concern among health care organizations and health care providers worldwide (Baird, 2014; Smellie, 2012; Weydart, 2005; Van Walveran, 2003). Overutilization can occur in the form of repeat tests ordered earlier than specified testing time intervals or tests ordered during initial evaluation. (Zhi, 2013; Futrell, 2014; Robinson, 1994; Jones, K www.medindia.net/news/three-in-10-laboratory-blood-tests-unnecessary-127916-1.htm). Prior studies indicate that the maximum misuse of the laboratory tests is unnecessary repetition (Zieve, 1966; Eisenberg, 1977). A study conducted by Bates DW (1998) in Brigham and Women’s Hospital, a tertiary care hospital on high volume lab tests, shows that for around 80,000 lab tests performed during a 3-month study period, 28% of the tests were repeated. They further randomly selected performed about 400 medical chart reviews of repeated tests and found that 91% of these repeated tests occurred prior to specified testing intervals and about 42% followed an initial normal result. A study conducted by Neilson, et.al suggest that about 25% of high volume laboratory testing, electrocardiograms, and radiographs are repeated unnecessarily and may be eliminated nationwide . Several other studies indicate that repeat tests are often unwarranted in delivering quality care to patients (Miyakis, 2006; Neis, 2010). Results from Beth Israel Deaconess Medical Center (BIDMC) indicate that among 50 most commonly ordered tests, 30% were unnecessary (Futrell, 2014; Zhi, 2013; Baird, 2014). A meta-analysis conducted by Zhi et.al., for studies published from 1977-2012 indicate that the overall mean rate of overutilization of lab tests is 20.6%.
The higher number of tests conducted, the greater the chance of false positive results (Grossman, 1983; Yeh, 2014) leading to further unnecessary tests and treatments, prolonged hospital stays, additional clinic visits, surgeries etc (Walraven, 1998; Rang, 1972; Jones, K http://www.medindia.net/news/three-in-10-laboratory-blood-tests-unnecessary-127916-1.htm ; Yeh, 2014; Atalli, 2006; Bates DW 1999; Bates DW 1991). Braid and his colleagues estimates that if for one patient 14 tests were ordered, the chances of having one abnormal value for a normal patient is roughly 50% (Briad, 2014). The impact of these subsequent activities is very expensive (Zhi, 2013; Futrell, 2014; Hauser, 2014). Apart from raising health care costs, overutilization affects quality of care and causes patient dissatisfaction (Futrell, 2014; Eisenber, 1977; Yeh, 2014).
There are several factors attributed to lab test overutilization. As described above, false positive results can be an important contributor to further unnecessary testing. Ease of test ordering is also an essential cause of overutilization (Futrell, 2014). Panel tests are increasingly common. Bundling of several related groups of test in a panel allows providers to order multiple tests together resulting in overutilization of laboratory tests. For instance, among the most commonly ordered panels [complete blood count (CBC), basic metabolic panel(BMP) or chemistry panel, liver function tests (LFTs), blood coagulation tests, and arterial blood gases (ABG) (Yeh, 2014)]; even if single abnormal value is found, entire panels get repeated (Zieve, 1966). Sometimes these panels are continued as standing orders repeated until patients are discharged (Zieve,1966). Several studies have reported unbundling of tests reduced laboratory test orders and costs (Yeh, 2014; Attali 2006; Emerson, 2001). However, some studies propose that blanket test orders may reduce hospital length of stay and health care costs by reducing waiting time for initial results (Robinson,1994; Spencely, 1980). Physician’s experience has been consistently shown to influence test ordering (Yeh, 2014). Studies suggest that experienced physicians tend to order less number of tests compared to young physicians (Weydart, 2005). Some studies found that older and experienced physicians ordered more tests compared to young physicians with less experience. But the tests ordered were more relevant and targeted compared to those ordered by young physicians. Test ordering patterns are highly variable among health care providers depending on clinic culture and medical training (Kwok, 2004) on similar diagnosis (Yeh, 2014). A 17 fold variation in number of tests ordered by physicians is demonstrated (Kwok, 2004; Epstein, 1985). Testing patterns also differ in regions within the United States (Yeh, 2014 – Ref 8) and among different clinical care settings - outpatient, inpatient or emergency department (Larsson, 2000; Yeh, 2014). Prior studies indicate that lab test overutilization is widely prevalent in academic care settings (Weydert, 2005). About 68% of the tests ordered in the internal medicine academic settings can be avoided without compromising quality of care (Miyakis, 2006). Additional factors include patient demand, free tests with insurance coverage, care fragmentation, medico-legal factors, availability of lab services, and financial benefits, (Bakarman, 1996; Neilson, 2004; Robinson, 1994; Vidyarthi, 2014).
Unnecessary repeat testing and better patient outcomes have shown no correlation (Yeh, 2014; Garland, 2006; Weydert, 2005), however, if tests are repeated at appropriate intervals, patients can benefit (Braid, 2014). Several other studies support the idea that lab tests should be ordered in appropriate time intervals and in a logical sequences to achieve optimal patient care and reduce hospital resources (Murphy, 1978; (Neison, 2004; Robinson, 1994; Futrell, 2014). However, there is lack of agreement on what constitutes appropriate lab testing (Khalifa, 2014; Hauser, 2014). Prior studies have used locally defined definitions of appropriate lab tests and this heterogeneity in outcome ascertainment makes it difficult to compare individual study outcomes (Hauser, 2014).
With wide variation in physician testing practices and limited guidelines available (https://www.clinlabnavigator.com/why-are-too-many-laboratory-tests-are-ordered.html ), it is important to define boundaries for appropriate testing (Epstein, 1985) within an institution to provide quality care and conserve hospital resources. Repeat laboratory testing which is a modifiable factor has not been studied for this academic institution previously and will be informative to develop future interventions. It is more valuable to quantify laboratory test overutilization for specific lab tests than providing and overall numbers for all unnecessary tests (Eisenberg,1977). In the present study we will, a) assess baseline laboratory utilization at UAB hospital in 2013-14 and using evidence based guideline define appropriate testing intervals for commonly over used laboratory tests and evaluate the epidemiology of lab test overutilization ; b) using qualitative methods (focus groups) and surveys, assess provider attitudes regarding factors associated with overutilization of laboratory tests (i.e., panel based ordering), evaluate test ordering behavior in different clinical settings (clinics, hospital, etc.), and cost awareness) c) Measure the impact of new ordering modalities (panel based ordering via “powerplans”) with transition to new EMR at UAB, assess impact of utilization of these tests pre and post transition.
February 23 to March 2
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