title: A multifaceted hospitalist quality improvement intervention: Decreased frequency of common labs.
abstract: OBJECTIVE
  Common labs such as a daily complete blood count or a daily basic metabolic panel represent possible waste and have been targeted by professional societies and the Choosing Wisely campaign for critical evaluation. We undertook a multifaceted quality-improvement (QI) intervention in a large community hospitalist group to decrease unnecessary common labs.
  
  
  METHODS
  The QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered as daily within the hospitalist group. We performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the 7-month intervention period. Demographic and clinical data were collected from the electronic medical record. The primary endpoint was number of common labs ordered per patient-day as estimated by a clustered multivariable linear regression model clustering by ordering hospitalist. Secondary endpoints included length of stay, hospital mortality, 30-day readmission, blood transfusion, amount of blood transfused, and laboratory cost per patient.
  
  
  RESULTS
  The baseline (n = 7824) and intervention (n = 5759) cohorts were similar in their demographics, though the distribution of primary discharge diagnosis-related groups differed. At baseline, a mean of 2.06 (standard deviation 1.40) common labs were ordered per patient-day. Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared to baseline (95% confidence interval [CI], 0.34 to 0.11; P < 0.01). There were nonsignificant reductions in hospital mortality in the intervention period compared to baseline (2.2% vs 1.8%, P = 0.1) as well as volume of blood transfused in patients who received a transfusion (127.2 mL decrease; 95% CI, -257.9 to 3.6; P = 0.06). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618).
  
  
  CONCLUSIONS
  Implementation of a multifaceted QI intervention within a community-based hospitalist group was associated with a significant, but modest, decrease in the number of ordered lab tests and hospital costs. No effect was seen on hospital length of stay, mortality, or readmission rate. This intervention suggests that a community-based hospitalist QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care.
authors: Department of Hospital Medicine, Swedish Medical Center, Seattle, Washington.
authors: Adam H
authors: http://orcid.org/0000-0003-0913-733X
authors: AH
authors: Corson
authors: Division of Pulmonary and Critical Care Medicine, University of Washington, Harborview Medical Center, Seattle, Washington.
authors: Vincent S
authors: VS
authors: Fan
authors: Department of Hospital Medicine, Swedish Medical Center, Seattle, Washington.
authors: Travis
authors: T
authors: White
authors: Pharmaceutical Outcomes Research and Policy Program, School of Pharmacy, University of Washington, Seattle, Washington.
authors: Sean D
authors: SD
authors: Sullivan
authors: Department of Hospital Medicine, Swedish Medical Center, Seattle, Washington.
authors: Kenji
authors: K
authors: Asakura
authors: Department of Quality & Value, Swedish Medical Group, Seattle, Washington.
authors: Michael
authors: M
authors: Myint
authors: Department of Quality & Value, Swedish Medical Group, Seattle, Washington.
authors: Christopher R
authors: CR
authors: Dale
mesh_terms: D003363:Cost Control / Q000379:methods; D003953:Diagnosis-Related Groups / Q000191:economics; D003955:Diagnostic Tests, Routine / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data*; D004469:Economics, Hospital; D057286:Electronic Health Records / Q000706:statistics & numerical data; D005260:Female; D020445:Hospitalists / Q000592:standards*; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D017063:Outcome Assessment, Health Care / Q000191:economics / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000191:economics; D058996:Quality Improvement / Q000191:economics / Q000592:standards*; D013548:Sweden; D019564:Unnecessary Procedures / Q000191:economics* / Q000706:statistics & numerical data